AccountId: 011433970860
ContactId: b6ae9dd4-3c4e-466d-8b9e-f18d81799ff9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1024290 ms
Total Talk Time (AGENT): 474857 ms
Total Talk Time (CUSTOMER): 195061 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/04/b6ae9dd4-3c4e-466d-8b9e-f18d81799ff9_20250304T21:12_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. Um, I submitted a claim, um, to you guys and I received a letter saying that you're requiring itemized detailed bill. Um, but we already submitted that [PII], so I was wondering if you could look into this for me, please?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Sure, I can definitely look into the claim for you. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, uh, my name is [PII] and my phone number is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have your policy number?
[CUSTOMER][NEUTRAL] The policy number on the letter from you guys or my number?
[AGENT][NEUTRAL] Um, the letter from us.
[CUSTOMER][NEUTRAL] OK, the policy on the letter from you is 024.
[CUSTOMER][NEUTRAL] 69967
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the members, um, I'm sorry, can you verify your first and last name and date of birth?
[CUSTOMER][NEUTRAL] My first and last name is [PII], and the date of birth is [PII].
[CUSTOMER][NEUTRAL] Um, the patient name is [PII].
[AGENT][NEUTRAL] Thank you for that and um [PII]'s date of birth and then the mailing address on file.
[CUSTOMER][NEUTRAL] [PII]'s date of birth is [PII] and the mailing address is [PII].
[AGENT][POSITIVE] Thank you for that and then just your email.
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And hold on one moment, let me go to [PII].
[CUSTOMER][POSITIVE] Thank you
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Do you need the claim number? I know there's multiple claims.
[AGENT][NEUTRAL] Um, is it the one ending in 3616?
[CUSTOMER][NEUTRAL] No, this is ending with 5913.
[AGENT][NEUTRAL] Oh, this one came in in February. OK. Sorry, I was looking for, I, I thought you said January. I'm sorry, I misheard you.
[CUSTOMER][NEUTRAL] No, we submitted the claim in December, but we, we submitted the itemized bill in January, but I just got a letter saying that they need to itemize.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Wait, let me go back. Hold on one second, let me look at.
[CUSTOMER][NEUTRAL] Bill.
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Oh, OK, they overlap. OK. Um.
[AGENT][NEUTRAL] So, let me look at both, um, I'm gonna look at both claims and the documents. I'm looking for the itemized bill and then I'll look at the other claim and see what that one is missing. Um, and I'm gonna look at the documents that was received and see what we um received. Do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] Uh, no, that's fine, thank you.
[AGENT][NEUTRAL] You're welcome. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Does she need
[AGENT][NEUTRAL] Oh, we just need the diagnosis code.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] OK, and then what was the other one, DH.
[AGENT][NEUTRAL] I was OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I'm gonna see what was received.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, Mr. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, thank you so much for holding. I apologize for that wait. So I looked at the documents that were received. Um, so this is a bill, but this is the patient bill. It doesn't have any of the coding on it. So,
[AGENT][NEUTRAL] What we're requesting is the bill from the facility that they generated your bill from. They may call it an itemized bill, they may call it a universal bill, but it has the diagnosis codes so that we can prove medical necessity. It has the procedure codes so that we can show the treatment given for that uh diagnosis and then it has all the charges, and that's what's being asked on both of these claims.
[CUSTOMER][NEUTRAL] OK, I, I, I sent that, so did you see the one that is labeled, um.
[CUSTOMER][NEUTRAL] Detailed itemized Henry Mayo bill.
[AGENT][NEUTRAL] Hold on one second.
[CUSTOMER][NEUTRAL] What's the name of the attachment and it has the codes and it has.
[CUSTOMER][NEGATIVE] The itemized
[AGENT][NEUTRAL] I don't see it for this one. Let me check the 2nd 1. Hold on 1 2nd.
[CUSTOMER][NEUTRAL] The claims for 18,872.
[AGENT][NEUTRAL] Hold on, let me see what this total bill is.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] You said 18,000. I see one that's 58,000 and but they're all the same date, like this one is June, this one is a date range, [PII] to [PII].
[AGENT][NEUTRAL] And then
[CUSTOMER][NEUTRAL] No, it's um the one I'm calling on is from [PII].
[CUSTOMER][NEUTRAL] Uh, the dates of service are [PII].
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] But the attachments labeled detailed itemizer [PII].
[AGENT][NEUTRAL] OK, hold on.
[AGENT][NEUTRAL] Hold on one second. You said [PII]?
[CUSTOMER][NEUTRAL] Not the
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] So there's
[AGENT][NEUTRAL] I'm hesitating because I'm flipping through screens. It's not all in one place, so I apologize for that. Um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so there's a total of
[AGENT][NEUTRAL] 123 claims here. Between these three claims, the date range is [PII] through
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, this one goes all the way to
[AGENT][NEUTRAL] [PII], like there's some that have the same dates on multiple, but there isn't one here for [PII]. Do you have the claim number from the explanation of benefits? I can try to look that way.
[AGENT][NEUTRAL] To see if it's different then.
[CUSTOMER][NEUTRAL] Yeah, the sorry, [PII], and [PII], OK, it's um 356.
[CUSTOMER][NEUTRAL] 5913.
[AGENT][NEUTRAL] Yeah, see, that's one of the ones, that's actually the one that I have up here now. Um, that one has [PII], and then [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] So like they overlap, so I'm not sure.
[CUSTOMER][NEUTRAL] OK, so for.
[CUSTOMER][NEUTRAL] OK, um, so we did send an itemized bill [PII], not with the original package, so that's what I'm looking for you to find.
[AGENT][NEUTRAL] So, hold on one second. Let me pull up the incoming, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So we have, so what you mailed in on [PII], it may, so we have something that came in on [PII] and then the HIPAA authorization form on [PII], and then we finished processing the claim on [PII] and it's the explanation of benefits. So do you want me to see what that [PII] is?
[CUSTOMER][NEUTRAL] I don't, I don't know when you received it. We sent it [PII].
[AGENT][NEUTRAL] OK, so let's look at that one because that's the closest date to when you sent it.
[CUSTOMER][NEUTRAL] And the label, like the name of the attachment is detailed itemized [PII].
[AGENT][NEUTRAL] See, it just came over as like images of all 9 pages, so I don't know what the name of what, you know, the attachments, I, I can't see that part. But um,
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm just gonna go through these pages and look for the billing so I can see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, it looks like it starts here.
[AGENT][NEUTRAL] Right, so, so like I was explaining to you, this is the treatment that was done for the
[AGENT][NEUTRAL] Whatever the diagnosis was, but from just looking at the treatment, we can't tell what the diagnosis is. We need the diagnosis codes. So that comes from the hospital itemized bill. This is just your portion so you can see what you received and what you paid for, not why. We need to know why.
[AGENT][NEUTRAL] And that comes from
[CUSTOMER][NEUTRAL] OK, so we need to
[CUSTOMER][NEUTRAL] So you need diagnosis code and procedure code or both or one or the other?
[AGENT][NEUTRAL] So the document is called an itemized bill or a universal bill. It's the same document, but different places call it one or the other. So, um, you're just, so when you call, you're going to ask them for an itemized bill for date of service, [PII], you know, the all the days, and then um you're gonna say and it needs to have the
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] ICD like igloo, Charlie, David, and then the number 10, which is the diagnosis code.
[CUSTOMER][NEUTRAL] OK, ICG is sent.
[AGENT][NEUTRAL] And then the sea
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then what else? I'm sorry?
[AGENT][NEUTRAL] And then the CPT like [PII], that's the procedure code, so you'll see this, that's what's on yours, and then it's gonna list all the charges.
[CUSTOMER][NEUTRAL] OK, I'll give them a call.
[AGENT][NEUTRAL] Alrighty, and then that's needed um for let me check my notes. Hold on one moment cause I'll.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] And then one of them, so the itemized bill or the universal bill is needed for all the claims that we've processed. We also need documents, um, so you see like um on this claim, we were just looking at 65913 on [PII], how it has that remark code of D1M.
[CUSTOMER][NEUTRAL] The I
[AGENT][NEUTRAL] 0400.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Let me look, hold on.
[CUSTOMER][NEUTRAL] I don't know which document you're looking at.
[AGENT][NEUTRAL] Um, that, um, this is, this will be on the explanation of benefits.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] For claim number 356-5913.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it should like where the grid is that that has all of the um services that were received, it shows a remark code.
[CUSTOMER][NEUTRAL] Um, is it like the 123 10,010?
[CUSTOMER][NEGATIVE] I don't see where it says remark code.
[AGENT][NEUTRAL] Um, hold on one second.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Let me pull up a copy, hold on one moment.
[AGENT][NEUTRAL] Um, do you have the paper ex? Well, it's the same copy. Is it, are you on the, um,
[AGENT][NEUTRAL] Is it digital or do you have the paper copy?
[CUSTOMER][NEUTRAL] Digital.
[AGENT][NEUTRAL] OK. So, on page one, like where it says explanation of benefits and then it shows the check date and all the policy number.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And then you see um where it says remarks and then it has like a 1.2 and then the rest have 2s.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That's what you were talking about?
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so then if you go to page 2, it tells you what those numbers mean.
[AGENT][NEUTRAL] So all of them need the itemized bill, which is the 22, all the twos you see there, but then for the one that had a number one, you'll need um
[AGENT][NEUTRAL] I said it backwards. For the one that needs the #1, that's the itemized bill. For all the ones that have a 2, it's just asking for any documents that show the diagnosis code. It could be, uh, diagnosis code is on the discharge papers, it could be um.
[CUSTOMER][NEUTRAL] Oh, on the discharge papers?
[AGENT][NEUTRAL] Yeah, it, it's on the discharge papers. It's on the itemized bill as well too. So if you get the itemized bill or the universal bill that will suffice for both, but you can also um submit, you know, like the clinical notes, discharge papers.
[CUSTOMER][NEUTRAL] I have that.
[CUSTOMER][NEUTRAL] OK, and then back to the same email that we sent it.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] But, so the discharge papers should cover it. I don't need to get the itemized?
[AGENT][NEUTRAL] No, no, no, the itemized bill will cover both. The discharge would only cover the ones that have a 2, but
[CUSTOMER][NEUTRAL] We need both.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] If anything, get the itemized bill or the universal bill because that has everything on it.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] OK, I'll give them a call. Thank you so much.
[AGENT][POSITIVE] You're welcome. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No, that's all.
[AGENT][POSITIVE] All right, thanks for calling APL. I hope you have a great day.
[CUSTOMER][NEUTRAL] And