AccountId: 011433970860
ContactId: b79f7505-c4da-4fb8-961e-f4cbea42e57a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 864099 ms
Total Talk Time (AGENT): 368603 ms
Total Talk Time (CUSTOMER): 405638 ms
Interruptions: 4
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/23/b79f7505-c4da-4fb8-961e-f4cbea42e57a_20250123T13:20_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name's [PII]. I'm calling about, um, my policy number is 2558036.
[AGENT][NEUTRAL] OK, Ms. [PII], what is your callback number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] What were the last 4 numbers?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you. And how can I help you today, Ms. [PII]?
[CUSTOMER][NEUTRAL] I'm calling because I submitted a claim on.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Um, it was claim 354-8962.
[CUSTOMER][NEGATIVE] And it was rejected because.
[CUSTOMER][NEUTRAL] There were like 3 different reasons. Um, one of those was that my EOB from my um.
[CUSTOMER][NEUTRAL] Health insurance had to be submitted.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] So I printed that out and, and the other one was, I believe the diagnosis code. So I printed that out. I called my doctor's office and asked them if they were willing to file it for me. They're not.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] I printed out the EOB and I asked them to give me the diagnosis codes. They said the diagnosis codes are on the bill and there are codes like there's like 5 digit code on the bill that I submitted to you guys.
[CUSTOMER][NEUTRAL] So now, so I submitted the EOBs from my insurance.
[CUSTOMER][NEUTRAL] To you and on the top of them I wrote um.
[CUSTOMER][NEUTRAL] I referenced the previous claim number.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And so now it's saying.
[CUSTOMER][NEUTRAL] It appears to be a duplicate of a previously submitted expense of course it is because you guys asked for additional information.
[CUSTOMER][NEUTRAL] And it asked me for diagnosis codes again and I like, and it said I can obtain them from my doctor's office, which I did.
[AGENT][NEUTRAL] OK, so, oh.
[CUSTOMER][NEUTRAL] And I, I don't know what else to do. My health insurance paid these claims and I'm trying to get my.
[CUSTOMER][NEUTRAL] Gap, like that's how this plan was sold to me was the health insurance covers it, then the gap will pick up the difference.
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEGATIVE] And, and it's just turned into a nightmare.
[AGENT][NEUTRAL] Oh I'm so sorry. So you do have a, OK, so your questions are about a claim that you filed.
[AGENT][NEUTRAL] And the review. OK, so yes, ma'am. I, we can take a look at that. I can help you with this. But first, what I'll need to do is to verify several things with you for security purposes, Ms. [PII], and also any information I provide would be a verification of benefits and not a guarantee of payment. OK? Um, so first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. Your home mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. The phone number we have for you is the same as the one that you gave me, so that is your best contact number, is that correct?
[CUSTOMER][POSITIVE] That's correct.
[AGENT][NEUTRAL] That we should have on file. OK, thank you. And lastly, your email address, please.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. Alright, so give me a moment to look at your two claims that we received, so just a moment please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Is this for McInnis dermatology?
[CUSTOMER][NEUTRAL] Yep
[AGENT][NEUTRAL] So let me just look at the first one.
[AGENT][NEUTRAL] OK. So yes, I can see on there where one of the remarks, states office visits are not covered under your policy, which that is, they are not. And the other ones are for treatment. Did you have some type of procedure done in the office?
[CUSTOMER][NEUTRAL] Yeah, I had a, a surgery for a skin cancer and that's the only thing that I submitted to you were the charges associated with that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Because I see two dates of service, [PII] and [PII].
[AGENT][NEUTRAL] On that one claim, on the initial claim that [PII] is the date that I see the one of the codes for the office visit and then yes, there were two other.
[CUSTOMER][NEUTRAL] OK, yeah, and the, the um.
[CUSTOMER][NEUTRAL] Yeah, they're bill that I mean that's how they billed me so the 12th floor.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] I still don't understand.
[CUSTOMER][NEGATIVE] Why that wouldn't be covered because it's way above my office visit co-pay which is $75.
[CUSTOMER][NEUTRAL] But, and, and they did a procedure then they actually did the biopsy while I was there then.
[AGENT][NEUTRAL] That was on [PII]. OK. So that is the, that is the one that this, I'm just looking again at the remarks on the first claim. That's the, we needed the diagnosis code and the explanation of benefits from the primary insurance for that date.
[CUSTOMER][NEUTRAL] Uh huh
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And [PII].
[CUSTOMER][NEUTRAL] And they're saying that
[CUSTOMER][NEUTRAL] They're saying that um that five digit code that's listed on the bill the like so I don't know I'm looking at first page of the original bill I sent you date [PII] is the very first item listed and it's diagnosis code 14,060.
[CUSTOMER][NEUTRAL] It's a tissue transfer.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And that's all that I, you know, can.
[CUSTOMER][NEUTRAL] But my limited medical.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] But that are you saying that those those are not diagnosis codes because that's what they told me that they were.
[AGENT][NEUTRAL] No, that, the code that you just gave me is a procedure code. That is what they did.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, we need to, we need to know the why, essentially, I mean, and just breaking it down. That's, that, that's the why.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so you need to basically know from [PII] when they took the biopsy what that diagnosis was.
[AGENT][NEUTRAL] Yes, ma'am. Uh-huh. What they, and they would have, right, and that's the same as far as the 1218 data service, that is the code for each of those line items. It doesn't reference, you know, an office as a charge for that date. It's strictly procedure.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Codes.
[CUSTOMER][NEUTRAL] OK, what's the code that um.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEGATIVE] The part that um you're denying.
[AGENT][NEUTRAL] If you.
[CUSTOMER][NEUTRAL] Um, that's saying it's an office visit.
[AGENT][NEUTRAL] OK, just one moment and let's see that was for 12, let's see, let me pull up that information.
[CUSTOMER][NEUTRAL] What part of it is that?
[AGENT][NEUTRAL] The 99213 is your office visit.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK and then what I see additional documentation that I submitted.
[CUSTOMER][NEUTRAL] Um, just yesterday or day before I can't remember, but, but those three pages.
[CUSTOMER][NEGATIVE] And none of that is showing.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] As an office visit, oh it is.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, that's, yeah, that's just your office visit code and then the other codes are like what they did, but we need to know the why.
[CUSTOMER][NEUTRAL] OK, so, so basically all that you guys are, are disputing on this specific charge though is like $51 and I'm sorry I'm trying to read it sideways on my screen $5105.
[AGENT][NEUTRAL] That is hard to do. Uh, let's see. Yeah, reading sideways can be difficult.
[AGENT][NEUTRAL] OK, um, we're looking at claims ending in 62, the initial one.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Is that the one you're looking at?
[CUSTOMER][NEUTRAL] No, I'm looking at the the additional documentation like the claim detail that I um submitted.
[CUSTOMER][NEGATIVE] Um, like I said, it was either yesterday or day before that I submitted it. I, I thought it was yesterday, but they weren't together.
[AGENT][NEUTRAL] Let's see, let me just look at the remarks. OK, one of those for 124 was a duplicate. One of those line items was a duplicate.
[AGENT][NEUTRAL] On that claim. That was the.
[CUSTOMER][NEUTRAL] Uh when did you pay me?
[AGENT][NEUTRAL] That was the 12th floor where the office visit was on there again, it looks like.
[CUSTOMER][NEGATIVE] OK, yeah, and there's no way for me to print that page of my, I guess I could have drawn a Sharpie through it or something, um.
[AGENT][NEUTRAL] And then the
[AGENT][NEUTRAL] Yeah, anything, anything you submit, Ms. [PII], we're gonna review so that any benefits that are payable we, we can review. So if you, you know, if you in the future, if you're having to submit your own claims, if there's something that you know is not covered or don't want us to consider, you know, then you could do that. You could just mark out other dates of service.
[AGENT][NEUTRAL] For example, maybe you submitted an EOB for this 124, but then there's also a, you know, another data service on there and which appears that that's the case with this that you don't want us to review or that we've already reviewed. Yes, ma'am, you can just mark that out or just mark the area that you want reviewed.
[CUSTOMER][POSITIVE] OK perfect.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I'll do that going forward.
[AGENT][NEUTRAL] Mhm. So yes, ma'am, really, and it's the same thing on this most recently received information. We're just needing the diagnosis code for this data service.
[AGENT][NEUTRAL] And your
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So you can just when you get that information just upload it.
[CUSTOMER][NEUTRAL] So if I looked up.
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] If well if I log into my United Healthcare account I get the EOB from 124.
[AGENT][NEUTRAL] I it
[CUSTOMER][NEUTRAL] Should that have the diagnosis code on it?
[AGENT][NEUTRAL] No, ma'am. Probably not. Most primary insurance is due to, you know, for security purposes and HIPAA privacy. It's not gonna have your diagnosis on there.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] That would be something to get from your doctor.
[CUSTOMER][NEUTRAL] OK, so I need the diagnosis code.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That tells the why.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I had to get the surgery.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yeah, we have the procedure codes, it appears, but we just need the diagnosis code.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Along with your primary insurance explanation of benefits, or you already, cause it looks like on this most recently information you updated Ms. [PII], you, did you
[CUSTOMER][NEUTRAL] That is from United Healthcare.
[AGENT][NEUTRAL] Yeah, you included your primary EOB with these, correct? Is that right?
[CUSTOMER][NEUTRAL] OK, so I'll.
[CUSTOMER][NEUTRAL] Yeah, that's um that that file that I submitted hold on let me close this again.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] I submitted it on the [PII], so Tuesday.
[AGENT][NEUTRAL] And that one is
[CUSTOMER][NEUTRAL] That file is my EOB from United Healthcare.
[AGENT][NEUTRAL] OK. Right, because all of those remarks, aside from the one stating it was a duplicate, it does not reference needing the EOB now. It just only all of those state that we need the diagnosis codes.
[CUSTOMER][NEUTRAL] OK, so if I just write.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, on a piece of paper I'll call the doctor's office right now and write.
[CUSTOMER][NEUTRAL] In reference to claim number 354-8962 and 3554239, here is the diagnosis code or the codes and submit that.
[AGENT][NEUTRAL] You can or you can just print you or you can just print that EOB that you see in your portal and write it on there and then upload that back into your portal.
[CUSTOMER][NEUTRAL] OK, so that exact same EOB that I just that I already submitted?
[AGENT][NEUTRAL] No, ours, where you have your remarks on there as to what we need.
[CUSTOMER][NEUTRAL] Got you OK, OK, so that, um, the one where you rejected it that says this is not a bill. OK, the above reference appears to be a duplicate. OK, all right, so I'll just print that and um reupload that with the diagnosis codes.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] I appreciate your help.
[AGENT][POSITIVE] Oh, you're certainly very welcome. So, do you have any other questions, um, that I can help you with?
[CUSTOMER][NEUTRAL] No
[AGENT][POSITIVE] Well, OK. Well, if that's all then, Miss [PII], I can help you with at the moment anyway. Thank you again for calling APL and I hope that you have a very nice day.
[CUSTOMER][POSITIVE] Alright you too thank you.
[AGENT][POSITIVE] Yes, ma'am, and thank you very much as well.
[CUSTOMER][NEUTRAL] Mhm bye bye.
[AGENT][NEUTRAL] Ah