AccountId: 011433970860
ContactId: b6fd0962-1d6b-4681-9424-d28004f3be9b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 588369 ms
Total Talk Time (AGENT): 300428 ms
Total Talk Time (CUSTOMER): 277079 ms
Interruptions: 5
Overall Sentiment: AGENT=0.6, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/b6fd0962-1d6b-4681-9424-d28004f3be9b_20250429T20:27_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII]. How are you?
[AGENT][POSITIVE] I'm good, thank you. How about you, Miss [PII]?
[CUSTOMER][NEUTRAL] Good thanks. I am trying to get some clarity on this. I've, I've called a couple times and I'm just being really dumb when it comes to this policy. Like I just think I've left things on the table and I'm just, I, I don't think I submitted things correctly. um, so can you tell us, uh, if I give you the policy number, can you tell me what benefits and like can I get like a summary of claims for like all time on this thing? I just can't go back that far on the internet, so.
[AGENT][NEUTRAL] OK, sure. Um, let me have a uh callback number just in case we get disconnected.
[CUSTOMER][NEUTRAL] Yeah, um, my cell is [PII].
[AGENT][NEUTRAL] And this is your personal policy?
[CUSTOMER][NEUTRAL] It's my husband, yeah, it's a family policy, yeah.
[AGENT][NEUTRAL] Oh, it's fine. What is the policy number if you have it, Ms. [PII]?
[CUSTOMER][NEUTRAL] OK, yeah, it's uh 21048002.
[AGENT][POSITIVE] Thank you and let's see one moment.
[AGENT][NEUTRAL] OK, for security, may I have your date of birth and mailing address on file?
[CUSTOMER][NEUTRAL] Yeah, it is um [PII] and then you want mine or [PII]. Mine's OK, OK, and it's [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, yours, yeah.
[AGENT][POSITIVE] OK, thank you.
[AGENT][POSITIVE] All right. Here we go.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So basically where we're at is I didn't realize that we had benefits for urgent care um and like I, yeah, and so I didn't really put 2 to 2 together I think the benefits for like uh imaging and so I started this and then I got like really overwhelmed by things you guys needed and then I just wanna make sure I can just submit it one time and be done.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so like I know that the prior claims you guys needed more information like just to make sure that I'm giving the right information, like do you need the paid in full receipt from us? Can I give you the EOB and the doctor's IDC codes? Like I just don't think I'm doing it very organized and like once I get organized I can, you know, knock it out, but I just don't think I'm doing it right.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It's OK. I can assist you with that. Um, if, if you're ready, I can go ahead and it's, it's really simple. It's just 33 documents. That's all we need. It's just 3 documents. Um, so as long as you have those 3 documents, you have a claim.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so if you have, yeah, OK, so if you're ready to write it down, I can tell you which one is the first one.
[CUSTOMER][POSITIVE] OK good alright so let's let's start there.
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] All right. OK. So the first document we're gonna need is the claim form.
[AGENT][NEUTRAL] Which the claim form, you can find it on our website at [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Um, the second document is an itemized bill with diagnosis code.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so that one you get from the provider, itemized bill with diagnosis codes.
[CUSTOMER][NEUTRAL] So if the diagnosis code is not on the bill, can we send like a copy of like the doctor's summary, like for instance, the, like the, like the bill for the, for the X-ray of my daughter's hand probably won't have the diagnosis code. It may or may not, but can I send the summary from the doctor's office as well?
[AGENT][NEUTRAL] Yes, uh-huh. If, if you wanna send both of them, that will help to at least find that diagnosis code because we really need that diagnosis code.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So in that case, you will send both of them the itemized bill and you will send the doctor's notes as well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So we have both.
[AGENT][NEUTRAL] And then, OK, and then you need uh the copy of the explanation of benefits for that date of service. Um, the copy of the explanation of benefits from the primary insurance, it needs to have the amount applied towards the deductible co-payment and co-insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, um, what I can tell you just by looking at the policy and looking at what we have done in the past is that you have submitted some office in office treatment and office um benefits. It doesn't look like we covered that.
[CUSTOMER][NEUTRAL] Yeah, because they don't break down the EOB. That's the trick that sorry, it doesn't break our EOBs don't split out the other claims, so it's gonna take everything on the EOB and then throw it onto one document so I can't split them out. That's the tricky part.
[AGENT][NEUTRAL] Oh, got you.
[AGENT][NEUTRAL] Gotcha. OK. OK. All right.
[CUSTOMER][NEGATIVE] So that's why you guys are gonna get all that crap from me.
[AGENT][NEUTRAL] OK, it's fine. I just, I just saw a lot of them and I, I just don't want you to get confused about why we're not paying those, but I guess you are, you're aware, so we're good.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] All right, so yes, um, whenever you get the explanation of benefits, and I see that the last time you submitted claims was back for [PII] or back in [PII], [PII]ically, um, so yeah, you can, we don't have timely filing limits.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And um the, I think that the one that I saw, like there's some that were asking for the EOB but it looks like we already paid that one. But I saw some that were asking for the diagnosis code. Um, the diagnosis code is really, really important for us to process the claim, um.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So,
[AGENT][NEUTRAL] So if you can find the diagnosis code for the ones that that we deny because we still need diagnosis codes, you can still submit those, OK? So um you can go ahead and just ask, um, it looks like it was for [PII]. Um, let me see. No, that was not it. It was for Quest Diagnostics. That, that's it. OK, for Quest Diagnostics, [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So where do we get that from, from like, yeah.
[CUSTOMER][NEUTRAL] So like on the labs, is that gonna come from the daughter?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's gonna come from the quest. So
[CUSTOMER][NEUTRAL] Uh the the the the the doctor I mean sorry.
[AGENT][NEUTRAL] No, it's gonna come from Quest. Unless the doctor has the copy of that bill and it has the diagnosis code, you can use it, but if um they don't have a copy of it, then you need to call Quest and get an itemized bill with the diagnosis code for that date of service.
[CUSTOMER][NEUTRAL] OK, so itemized bill, um, OK, so here's my, here's my question for you too like is it does like let's say they're routine labs, is that covered or no?
[AGENT][NEUTRAL] If it's part of preventative, like, you know, the yearly checkups and preventative, no, we do not cover preventive.
[CUSTOMER][NEUTRAL] Like, let's say like if it was like for thyroid, like would that be covered if it's not like I mean it's they have to check it annually. So are they saying yes or no? should I send it anyways and let you guys decide?
[AGENT][NEUTRAL] If it's thyroid to, to make sure that you don't get thyroid, then that's preventative. Now, if it's because you already have thyroid and they're just um wanna make sure that it's not, you know, this hasn't gone worse than it was already.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Or something like that, then that more than likely is a sickness. Anything that is related to a sickness, that is something they've been treating you for, that's a sickness, or anything that you're just trying to prevent, like make sure that you don't have it, that's preventative.
[CUSTOMER][NEUTRAL] OK, OK, so sickness is what I need to remember here.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, sickness. We only cover sickness.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And just in case, sickness includes pregnancy.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] OK, no, I had to, we got this policy after I had both. That was actually one of the key things that I was like, so and what I'm having trouble with now is getting the EOBs from 21. I'm, I'm having a difficult time getting those from Aetna, so that's where I, that's where this has become kind of a pain, um, OK, so I think that more or less that makes a little more sense to me on what we're trying to determine here, um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEGATIVE] So basically I just need to download all of these EOBs that I've already done and then cross reference what I need to add back I think I just got really overwhelmed by all the EOBs but I panicked and was like I just don't even know what I'm supposed to be doing OK um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] understand.
[CUSTOMER][POSITIVE] OK, alright, perfect. That is what I need to do and so I have one that I need to submit from [PII], um, I for a procedure so like do you want, um, so I just need to send the claim form, the itemized bill, the diagnostic code, and the EOB. OK, perfect. That is what I will submit back over. OK, alright, thank you so much. Have a good day.
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] USL, is there anything else I may help you with? Any other questions or concerns?
[CUSTOMER][NEUTRAL] I don't think so. Have a good one.
[AGENT][POSITIVE] You as well thank you for calling APL. Have a good afternoon, Ms. [PII]. Bye-bye.
[CUSTOMER][NEUTRAL] All right, bye-bye.