AccountId: 011433970860
ContactId: b3d73a02-2a1c-4e78-808e-8d9c2fe2e582
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 2100000 ms
Total Talk Time (AGENT): 955818 ms
Total Talk Time (CUSTOMER): 770864 ms
Interruptions: 12
Overall Sentiment: AGENT=-0.2, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/b3d73a02-2a1c-4e78-808e-8d9c2fe2e582_20250213T17:14_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Yes [PII] I had filed um it's been a little while it's been a few months, a whole bunch of um things for my husband.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEGATIVE] None of them have came back with anything so I'm trying to figure out what is going on.
[AGENT][NEUTRAL] Alright, you're calling for claim status. I can assist you with that. May I have your name please?
[CUSTOMER][NEUTRAL] It's my name is [PII]. Last name is [PII] uh huh.
[AGENT][NEUTRAL] 50.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII], may I have a callback number please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And also I need your policy number please.
[CUSTOMER][NEGATIVE] Um, I'm gonna give you my cancer on 218-951-9.
[AGENT][NEUTRAL] Can you please verify your date of birth, address, and email address please?
[CUSTOMER][NEUTRAL] [PII] CC [PII].
[AGENT][NEUTRAL] Your mailing address, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], thank you so much for verifying the information. I have your cancer policy pulled up. You're stating you're calling for the claim status on claims that you submitted for your, your spouse. It's [PII].
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] OK, so the last thing that I saw we received was in.
[AGENT][NEUTRAL] Um, August of last year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Probably yeah and I did a bunch and I don't even know which.
[AGENT][NEUTRAL] And you
[CUSTOMER][NEUTRAL] What they were anymore or what what.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, you said a couple of months. I thought maybe like within the last 2 months. OK. So August sounds about right. OK, OK, that sounds about right. OK.
[CUSTOMER][NEUTRAL] No, it's probably, it's probably August.
[CUSTOMER][POSITIVE] Thank you right.
[AGENT][NEUTRAL] So, um,
[AGENT][NEUTRAL] We did receive those claims. Those were processed on.
[AGENT][NEUTRAL] 94 and this is for wellness, it was for um.
[CUSTOMER][NEUTRAL] Can you
[AGENT][NEUTRAL] PSA test.
[CUSTOMER][NEUTRAL] Probably
[CUSTOMER][NEUTRAL] I don't even remember what they were for.
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Anymore.
[AGENT][NEUTRAL] Well, we did, those were processed in August.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Do you see any of that.
[AGENT][NEUTRAL] And can you verify your, your mailing address again?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the city is [PII], because that check was mailed to the address we have on file and that was for um two covered PSA tests that um for the year [PII] and [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yep, that's it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK, so these are ones that like I wouldn't have gotten anything back on.
[CUSTOMER][NEUTRAL] It's the ones that I'm talking about, um, they would have been like um.
[CUSTOMER][NEUTRAL] Doctor's visits, things like that.
[AGENT][NEUTRAL] Oh, those aren't covered. Doctor's visits aren't covered, labs aren't covered.
[CUSTOMER][NEUTRAL] Yeah, they're covered under one of these plans.
[CUSTOMER][NEUTRAL] I don't know if it's the hospital plan, but one of the plans we we get doctor's office visits covered.
[AGENT][NEUTRAL] OK, so you must be talking about another plan, not cancer. OK, so, cause you said this was cancer. So let me look at your other policies because I will need to send you over there.
[CUSTOMER][NEUTRAL] We get
[CUSTOMER][NEGATIVE] Yeah, I sent in multiples. I don't know what plan it was I don't know if it was on the hospital, if it was under the critical if it was under the accident I don't remember because it's been so long. I don't really even remember what I sent.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So is there not a way that you can pull him up and see?
[CUSTOMER][NEUTRAL] What was sent and what was denied or not covered or something like that? I mean, is there a way to do that?
[AGENT][NEUTRAL] OK, so, OK. So, you're not sure.
[CUSTOMER][NEUTRAL] Oh well
[AGENT][NEUTRAL] What policies you're calling about. So you're not calling about your PSA, his PSAs, you're calling about office visits.
[CUSTOMER][NEUTRAL] I'm not sure what I'm calling about. I I sent in multiples on one day. I did a whole bunch. I don't remember what they were. I don't know if they were. They, I know they were doctors visits, but they were multiple for multiple different things, so I don't know what plan they're under.
[CUSTOMER][NEUTRAL] So, so what I'm saying is, is there not a way that you can.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, I, I just need to know, I just need to know which policies I need to go over, which department I need to send you to, um, that's why I'm trying to figure out so I mean you, you know that you submitted claims with us, you know that you're looking for a payment so I was wondering like um.
[CUSTOMER][NEUTRAL] Look up his name.
[AGENT][NEUTRAL] Which area. So we did the cancer, the PSAs, um, that was August. Now I'm looking at your hospital indemnity plan um and it looks like hospital indemnity was submitted as well in August, but there was no payment made because um
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see if I can help you. If not, I'm gonna have to send you over to the hospital indemity.
[CUSTOMER][NEUTRAL] OK, when you finish that though, you know I'm sitting here thinking, and I know one of them was, um, he had a a um a biopsy on his prostate, and I know I sent that one in and I haven't received anything on that.
[CUSTOMER][NEUTRAL] So that should have been under the cancer policy.
[AGENT][NEGATIVE] OK. Let me go back to cancer.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And she has a
[CUSTOMER][NEUTRAL] Matter of fact, he has been diagnosed with uh prostate cancer.
[CUSTOMER][NEUTRAL] And he's had another biopsy and he's had multiple surgeries since then.
[CUSTOMER][POSITIVE] Wow
[AGENT][NEUTRAL] OK. So it shows the last thing that we received from you, it shows that it was um
[AGENT][NEUTRAL] Some type of um procedure done in March, which, um, that, that procedure, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Show a negative um diagnosis. When was he diagnosed with the positive diagnosis of cancer?
[CUSTOMER][NEUTRAL] I don't remember the exact date.
[AGENT][NEUTRAL] OK. So, let me advise you.
[CUSTOMER][NEUTRAL] But I haven't sent that in. I haven't sent the new stuff in yet.
[AGENT][NEUTRAL] Let me advise you.
[CUSTOMER][NEUTRAL] But that one that but the one that you're talking about if you look at the report, it does have cancer on there.
[CUSTOMER][NEUTRAL] The results, if you look at the results, it does have it on there.
[AGENT][NEUTRAL] So let me, let me.
[AGENT][NEUTRAL] For, for, for March.
[CUSTOMER][NEUTRAL] But I mean, I, I guess it doesn't, I guess it doesn't really matter because I mean he has an official diagnosis but so do we not get paid for that biopsy though?
[AGENT][NEUTRAL] OK, let me go back to what you said because you state that it was um on there as a positive. So let me go pull up what you submitted since you said it was.
[CUSTOMER][NEUTRAL] That he had done
[CUSTOMER][NEUTRAL] OK, yeah, if you look at the, the results.
[CUSTOMER][NEUTRAL] You'll see it on there it says adenocarcinoma I believe is what it says.
[CUSTOMER][NEUTRAL] I can't really remember. I mean we've been going.
[AGENT][NEUTRAL] So this one says benign, OK, for the right, benign um prosthetic tissue, suspicious for benign, benign, there is no there is no positive diagnosis.
[CUSTOMER][NEUTRAL] OK hold on let me see if I can pull them up.
[CUSTOMER][NEUTRAL] The thing this is just it's hard for me to remember because we've been through so much in the past months that.
[AGENT][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] Let me see, OK, so what I'm looking at results let me find it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so this is on page one.
[CUSTOMER][NEUTRAL] OK, and on the narrative #2, it says atypical small.
[CUSTOMER][NEUTRAL] Ante prolification suspicious for adenocarcinoma.
[AGENT][NEGATIVE] That's not positive.
[AGENT][NEUTRAL] So did they do another biopsy? Did they do something else after? So that's what you would need to send.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes, he's had another biopsy and he's had multiple surgeries since then.
[AGENT][NEUTRAL] OK. OK, so let me advise you. OK, let's stop there. Let, let's, let's stop there. OK. So, are you at a computer?
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Can you get online?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, have you ever looked at our um claim forms online?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so, alright, on page one.
[AGENT][NEUTRAL] And I'm about to go online too.
[AGENT][NEUTRAL] So on page one of the claim form.
[AGENT][NEUTRAL] So what you would need to do is get that one that is a positive diagnosis because that's suspicious like um we can't pay any uh first term, first term um diagnosis of cancer off a suspicious 4. It has to be a positive diagnosis of
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Cancer, right? So, on page one of the claim form, right, it, um, so what you would do is submit that pathology report, first diagnosing the cancer, the surgery, including the biopsies, right? And so, um
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] So once you do that, make sure that you also send us the itemized billing.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For those surgeries because biopsies are considered surgeries. But we have to have the code. Um, if we don't have the code, then we don't know how to pay the surgery.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah, so, so I mean so I guess I understand what you're saying that you need, you know, a different.
[CUSTOMER][NEUTRAL] Diagnosis, but he still had a biopsy, so why are we not getting paid for the biopsy that he had that day?
[CUSTOMER][POSITIVE] Even if it came back normal, we should still be getting paid for the biopsy.
[AGENT][NEUTRAL] The biopsy is only covered. The surgery is only covered for a positive diagnosis. Surgeries, the only time you will, the only thing that will get paid.
[AGENT][NEGATIVE] That's not positive, it's for the preventative. Everything else has to be a positive diagnosis of cancer.
[AGENT][NEUTRAL] Now, this is under cancer, right? We're only talking about cancer. We're not talking about hospital indemnity. Hospi indemnity is a different animal. So this is the cancer department. I can only tell you how the cancer products work. This for a positive diagnosis of cancer, then that's when all of the surgeries and all of the other benefits apply. Now, hospital indemnity works different.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, I'm only talking to you about the cancer.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so you're saying the biopsy could be covered under the hospital and not the cancer.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah. For, for a diagnosis um that is not positive for cancer. Hospital indemnity plays for um
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Depending on the benefits that you choose, office visits, surgery in a physician's office, surgery at a hospital, office visits, all of those types of things. That's hospitality. Those are two different policies, two different departments. So, I'm gonna just.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Discuss with you at this time because I have your.
[CUSTOMER][NEUTRAL] So you don't see, but.
[CUSTOMER][NEGATIVE] But you don't see anything else under the cancer policy that was recently and when I say recently I mean in the past, you know, 6 months or so that was denied.
[AGENT][NEUTRAL] We only, we paid for um.
[AGENT][NEGATIVE] The, the denial was we paid for the preventatives. We denied because you're only allowed one preventative benefit per year. So we denied because you had two. So we denied that and we denied that um surgery because it was not a positive diagnosis of cancer that you submit. That is what was it under cancer.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, you state that there you have um a positive diagnosis of cancer. You have the itemized billing for cancer, so you would need to submit that under your cancer benefit to be reviewed for the cancer benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I guess I need to get over to the hospital section them for the rest of this.
[AGENT][NEUTRAL] Yeah, so now you, um.
[CUSTOMER][NEUTRAL] Cervical arthroplastic.
[CUSTOMER][NEUTRAL] Because you can't look at that that right that somebody else has to look at that.
[AGENT][NEUTRAL] I can look at it and I can kinda help you a little, but that's not my area. And so um if it's more in depth, I will have to transfer you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, it's up to you. I mean if you wanna look or if you wanna transfer me in whatever way it doesn't make a difference.
[AGENT][NEUTRAL] OK. So, while I pull up your policy, this is a verification of your coverage and not a guarantee for payment. So I do have your hospital indemnity plan pulled up and let me see. Outpatient accident and sickness treatment benefit. You have physician's office which is 2 visits per year, $50 per visit. Urgent care, emergency room, PT, occupational therapy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Then you have surgery in a hospital, outpatient facility, 1000, surgery in a physician's office, 500. OK. So now, let's look at what you submitted and let's see what they said too.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] just show up that's the module on all these.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so there's labs, labs.
[CUSTOMER][NEUTRAL] Can
[AGENT][NEUTRAL] So that was labs are not covered.
[AGENT][NEUTRAL] The labs aren't covered on.
[CUSTOMER][NEUTRAL] No, uh, we're doing all three.
[AGENT][NEUTRAL] One under the hospital name or the cancer policy. So.
[CUSTOMER][NEUTRAL] What kind of what kind of lab did I submit?
[CUSTOMER][NEUTRAL] When you say lab, what does that mean?
[AGENT][NEUTRAL] Like blood work.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see what else you submitted.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so you submitted an ER visit for
[CUSTOMER][POSITIVE] Good
[CUSTOMER][NEUTRAL] And when I come back today
[AGENT][NEUTRAL] [PII] and they denied that because you already submitted that and those were already paid, so they didn't pay that, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then you submitted labs for March.
[CUSTOMER][POSITIVE] If you think something's just back in the front end I can fight it.
[AGENT][NEUTRAL] Of [PII], those were covered cause blood work labs are not covered with the policy.
[CUSTOMER][NEUTRAL] What do you think.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Please, I'm serious. Make a consultant. We're gonna pre-populate everything. I, I, I specifically said about the iPad.
[AGENT][NEUTRAL] All right, let's look. I don't see where you submitted any office doctor's visits, but let me take a look. Um.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] [PII], this was [PII].
[CUSTOMER][NEUTRAL] Let me see if I.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, so that's the claim form.
[AGENT][NEUTRAL] And then this is a bill.
[AGENT][NEUTRAL] With only labs and a bed charge.
[AGENT][NEUTRAL] Observation for chest pain.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But that's for March.
[AGENT][NEUTRAL] So those was for March, so that's the reason why that was denied is because that was a duplicate of what we already processed.
[AGENT][NEUTRAL] Alright, so this next one is a bill.
[CUSTOMER][NEUTRAL] And what's the data service on that one?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] So those were duplicate that was submitted.
[AGENT][NEUTRAL] And then you submitted a wellness claim form.
[CUSTOMER][NEUTRAL] Star
[AGENT][POSITIVE] Another wellness.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So how to navigate.
[AGENT][NEUTRAL] Then you submitted the.
[CUSTOMER][NEGATIVE] The whole process is gonna be hard and we, we haven't, we haven't.
[AGENT][NEUTRAL] Technology.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][POSITIVE] We can give you the whole
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] You did not
[CUSTOMER][NEUTRAL] No, he never did look at.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, so under the hospital indemnity plan, there are no um bills um for any office visits or any covered hospital visits or anything that is covered under your hospital that you did not submit those.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And there is a claim form as well.
[AGENT][NEUTRAL] Um, let me go here. Let me see where it is.
[CUSTOMER][NEUTRAL] And she
[AGENT][NEUTRAL] Kinda, OK. So, there is a hospital indemnity claim form.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] the
[AGENT][NEUTRAL] Online as well. There's a cancer one and there's a hospitality plan one.
[AGENT][NEUTRAL] And um you will fill that out. It does say.
[CUSTOMER][NEUTRAL] Through the
[AGENT][NEUTRAL] An itemized bill with diagnosis from the provider must accompany the completed statement of assured. Um, so basically what you would need to do is submit um any itemized billing for office visits, any um type of.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][POSITIVE] And I can't wait
[AGENT][NEUTRAL] Hospital confinements and surgeries, you will need to submit those under your hospital indemnity plan.
[CUSTOMER][NEUTRAL] Hey.
[CUSTOMER][NEUTRAL] OK, so the one that says, uh, please provide a diagnosis, a diagnosis, what does that go with? Like what, what kind of visit is that?
[AGENT][NEUTRAL] Where are you at?
[CUSTOMER][NEUTRAL] right
[AGENT][NEUTRAL] Are you looking at something?
[CUSTOMER][NEUTRAL] Uh, yeah, I'm looking at an explanation of benefits.
[CUSTOMER][NEUTRAL] Um, I got a reference number or a claim number you want that?
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] What are, are, which, which one are you, are you under the hospitality plan?
[CUSTOMER][NEUTRAL] Um, I'm not sure.
[CUSTOMER][NEUTRAL] 2189537.
[AGENT][NEUTRAL] That's hospital Demi plan. OK, what's the claim number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 348-42883
[CUSTOMER][NEUTRAL] and me
[CUSTOMER][NEUTRAL] Because they don't
[AGENT][NEUTRAL] OK, so that was a claim submitted in [PII].
[CUSTOMER][NEUTRAL] but we didn't have that.
[CUSTOMER][NEUTRAL] yeah, they didn't mention.
[AGENT][NEUTRAL] The um did it tell you that um you're looking at the explanation of benefits? Did you read it?
[CUSTOMER][NEUTRAL] Yeah, it's uh yeah it says please provide a diagnosis code for this state of service. The information may be obtained from your physician, but it doesn't tell me a date of service or what it's for, so I have no idea what it goes with because it doesn't tell you that.
[AGENT][NEUTRAL] Yeah, the installation benefits definitely do tell you the date of service. This is something that you submitted to us for [PII].
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] they
[CUSTOMER][NEUTRAL] [PII] what?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, and, and what and what is it? Like what is it a hospital bill or?
[AGENT][NEUTRAL] Uh, you tell me. You tell me. That's what we're trying to figure out. [PII], you know, a Doctor [PII]?
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] I, I mean, I, it's my husband's doctor, so I don't really know what it is, but that's what it is. It's under [PII]. It's probably a doctor's office visit, I would suppose.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] a little bit I'm assuming like a wellness visit.
[AGENT][NEUTRAL] Oh, that's what it is? OK.
[CUSTOMER][NEUTRAL] But I don't know why it says please provide a diagnosis code.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Because you typically don't need a diagnosis code for a wellness visit.
[AGENT][NEUTRAL] Not too sure that I'm gonna transfer you to, to, to the hospital to do anything cause I, like I stated, you know, I can help you so far but
[CUSTOMER][NEUTRAL] not
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I say
[AGENT][NEUTRAL] I'm not too sure about.
[AGENT][NEUTRAL] By it's asking for.
[AGENT][NEUTRAL] What's the date? What's, what was the date that that was received? OK, that's [PII].
[AGENT][NEUTRAL] That was received [PII].
[CUSTOMER][NEUTRAL] And it's gonna be
[CUSTOMER][NEUTRAL] then that's the only one I had is that true.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEGATIVE] questionable number of iPads for patients with access.
[CUSTOMER][NEUTRAL] Adjustment to new um.
[CUSTOMER][NEUTRAL] you know.
[CUSTOMER][NEUTRAL] one by one.
[CUSTOMER][NEUTRAL] Like uh
[CUSTOMER][NEUTRAL] The health, the reviews, yeah, OK, so history, do we have to input if, um, question mark if they don't, um, do the.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] For history
[CUSTOMER][NEUTRAL] But also, so it might be.
[CUSTOMER][NEUTRAL] The first time, but if, if a patient is just being seen and there's nothing.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] O
[AGENT][NEUTRAL] It says office visit co-pay $20 patient responsibility 10.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] All right. So let's look at the policy.
[AGENT][NEUTRAL] Before I transfer you, I'm gonna look at the policy to see what the policy states, or what the claim form states.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so if you look at the claim form, so I noticed when you submit claims you just submit the bill that's it. There's no direction of what is for where it's supposed to go, so one thing um.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That should accompany what you submit is the um claim forms and those are online. So on the claim form, it for the hospital indemnity plan, it says an itemized bill with diagnosis from the provider must accompany the completed statement of insured. So that right there.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I just
[CUSTOMER][NEUTRAL] We're on any medication
[AGENT][NEUTRAL] That it was the only thing we received was this co-payment of $20.
[CUSTOMER][NEUTRAL] Or they tell you what they're taking.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that was it. It was um for Doctor [PII]. So that right there, it wasn't complete. The claim is not complete.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, and that was 12,120 for that one for [PII], OK.
[AGENT][NEUTRAL] Yes. Yes.
[CUSTOMER][NEUTRAL] OK, I've got one more like that if you can give me the date of that one, then I can go fix it and resend it.
[CUSTOMER][NEUTRAL] I'm gonna give you the claim number.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's 348-428-1.
[CUSTOMER][NEUTRAL] And it's the same thing it's diagnosis code under one and then under another one it says the medical test is not a covered.
[CUSTOMER][NEUTRAL] Benefit or something so I'm not sure what that is either.
[AGENT][NEGATIVE] I'm not understanding why you're not able to see the.
[AGENT][NEUTRAL] The
[CUSTOMER][NEUTRAL] Yeah, it doesn't, it doesn't tell. I'm looking at the form. It doesn't have any of that. It has, it has no date it has what it is, so you kind of like just in limbo trying to figure out what this goes with.
[CUSTOMER][NEUTRAL] All it has is it has the the policy number, the reference number, my name, his name, the claim number, and then that's what I just read to you and that's all that's on this paper.
[AGENT][NEUTRAL] OK. So they don't have from to the service description?
[CUSTOMER][NEUTRAL] That's it.
[CUSTOMER][NEGATIVE] Mm mm, no.
[CUSTOMER][NEUTRAL] No, none of that.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] But when you use that.
[AGENT][NEGATIVE] So the, the EOB is 2 pages and you're only seeing one page?
[CUSTOMER][NEUTRAL] Yeah, I have page 2.
[AGENT][NEUTRAL] OK, so you're missing page one. And is this something you're looking at online or is this something you have in your hand?
[CUSTOMER][NEUTRAL] All I have.
[CUSTOMER][NEUTRAL] No, it's paper that they sent me in the mail.
[AGENT][NEGATIVE] Oh, so you only have page 2 and not page 1.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But it's OK if I know what it goes with I can go back and redo it.
[AGENT][NEUTRAL] OK. What was that?
[CUSTOMER][NEUTRAL] I just don't know what it goes with.
[AGENT][NEUTRAL] That was um.
[CUSTOMER][NEUTRAL] The doctor had his own course.
[CUSTOMER][NEUTRAL] The 348-428-1?
[AGENT][NEUTRAL] And then
[CUSTOMER][NEUTRAL] And then on the remarks it's got two different remark codes.
[CUSTOMER][NEUTRAL] right.
[CUSTOMER][NEUTRAL] So you were saying
[CUSTOMER][NEUTRAL] E
[AGENT][NEUTRAL] Um, 1212 of 2019.
[CUSTOMER][NEUTRAL] OK, 1212 of 19, OK.
[CUSTOMER][NEUTRAL] And that's what, what doctor?
[CUSTOMER][NEUTRAL] I said they can
[AGENT][NEUTRAL] This, um,
[CUSTOMER][NEUTRAL] things
[AGENT][NEUTRAL] [PII] shows.
[CUSTOMER][NEUTRAL] OK, 2 of shoes. OK, got it. OK, and then the other one on there, it's um, must have been some kind of radiology because it's talking about MRI stress test, so it must be some kind of radiology that I submitted.
[AGENT][NEUTRAL] We must have had some type of testing done and um under the plan, only certain tests are covered and that the um remark code is telling you what tests are covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, but, but you can't see what tests I submitted?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] 342-81.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] I'm just trying to throw all these papers like if I already got an answer I'm throwing these papers away so I don't have to keep holding on all this stuff.
[AGENT][NEUTRAL] Echo heart, Doppler, something Doppler.
[CUSTOMER][NEUTRAL] An echo, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK and then um one last question that I have and then I think we're gonna be finished.
[CUSTOMER][NEUTRAL] I'm, I'm also looking at papers that I wanna get rid of if I've been paid for it, date of service and this should be on the hospital [PII].
[CUSTOMER][NEGATIVE] Was a hospital visit. If I got paid for that, I'm gonna get rid of this.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] I don't see uh office visits for that.
[CUSTOMER][NEUTRAL] No, it's not, it's a um it's a hospital visit.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Sorry,
[CUSTOMER][NEUTRAL] And it's [PII]. We spent the night.
[CUSTOMER][NEUTRAL] He went through the ER and then he spent the night.
[AGENT][NEUTRAL] OK, so they submitted to you under your explanation of benefits stating we need the closed claim forms completed by the insurer given a detailed description of the accident or diagnosis of sickness. So, um, once again,
[AGENT][NEUTRAL] The claim forms need to accompany anything that you submit.
[CUSTOMER][NEUTRAL] OK, so for that one they're saying that there was no claim form?
[AGENT][NEUTRAL] So that's what it stated, but.
[AGENT][NEUTRAL] It says that's a denial on it. When I put in that, it says it's um we need the enclosed claim form completed by the insured giving a detailed description of the accident or diagnosis of sickness.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] Um, let's see, 129.
[CUSTOMER][NEUTRAL] So, so I'm looking at the claim form that I that I sent, I sent it says accident health claimant statement.
[AGENT][NEUTRAL] 1129.
[CUSTOMER][NEUTRAL] And I sent it with it.
[AGENT][NEUTRAL] 1129.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] What's the 2325.
[AGENT][NEUTRAL] OK, so we have
[CUSTOMER][NEUTRAL] And the detailed bill is there.
[AGENT][NEUTRAL] Yeah, so let me see that, uh.
[CUSTOMER][NEUTRAL] Do you see the statement that I sent?
[AGENT][NEUTRAL] I see a bill.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That's for you.
[CUSTOMER][NEUTRAL] Maybe the statement come through or something I don't know.
[AGENT][NEGATIVE] Nope, the only thing we received.
[AGENT][NEUTRAL] Is
[AGENT][NEUTRAL] The bill, that's it.
[CUSTOMER][NEUTRAL] OK, alright, let me print this and resend this then.
[AGENT][NEUTRAL] Yeah, and it's the hospital indemnity plan um claim form.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, all right, well I guess that.
[CUSTOMER][NEUTRAL] Answers my questions.
[AGENT][NEUTRAL] All right, [PII], is there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, that'll do it thanks so much.
[AGENT][POSITIVE] You're so welcome. Thank you for calling APO have a great day bye bye.
[CUSTOMER][NEUTRAL] You too bye bye.