AccountId: 011433970860
ContactId: b80e6ccb-c704-401a-a4ff-3852350c1dbb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 848500 ms
Total Talk Time (AGENT): 429274 ms
Total Talk Time (CUSTOMER): 369622 ms
Interruptions: 3
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/24/b80e6ccb-c704-401a-a4ff-3852350c1dbb_20250124T19:35_UTC.wav
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[AGENT][NEUTRAL] This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] on the care team. How are you?
[AGENT][POSITIVE] I'm pretty good. How are you?
[CUSTOMER][POSITIVE] I'm doing OK. I have an insured. We're going over claim status. I went through everything with her.
[CUSTOMER][NEUTRAL] Um, she still wants to speak with someone though. Um, can I give you the, the, um, you want the policy number? I like the claim number?
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Oh, the policy number is great.
[CUSTOMER][NEUTRAL] OK, it's 255-1253.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, basically, of the 3 claims that we've processed for her.
[CUSTOMER][NEUTRAL] This last claim here, 53561 has the documents from the things that were denied on the other claims.
[CUSTOMER][NEUTRAL] So she's, I explained everything to her, the denial reasons was needed, but she's saying I already submitted all of that on [PII]. They just have to look through those documents like the diagnosis code is being asked for.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] An emergency room visit, um.
[CUSTOMER][POSITIVE] And the detailed explanation of benefits.
[AGENT][NEUTRAL] OK, uh, cause I think I'm looking at the wrong one. The one that I, I'm sorry, I, I must have pulled up the wrong one, the one that I had, uh, it looks OK. So it's the one ending in 6333, is that what she's asking? Because the others, um, and they, they look like they're just
[CUSTOMER][NEUTRAL] Well, so the 6333 was the original claim, but she's saying she, she submitted the documents for the
[AGENT][NEUTRAL] Oh, I see.
[CUSTOMER][NEUTRAL] Basically, she submitted all the documents from everything that we asked for in this last claim she sent.
[AGENT][NEUTRAL] This last claim, the one that was denied uh as office visits and stuff like that, right? OK.
[CUSTOMER][NEUTRAL] Right. Mhm.
[AGENT][NEUTRAL] OK, OK. All right. OK.
[CUSTOMER][NEUTRAL] Cause at first I was like, well, it's the place of service and then she's like, but I sent the, the documents in this last claim. I said, oh, you sent the, so then everything connected and I'm like,
[AGENT][NEUTRAL] Diagnosis codes and things. OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, yeah, sure. I can, um, I'll go ahead and look at it. Yes, yeah, I can help her. Thanks.
[CUSTOMER][NEUTRAL] OK, thank you, [PII], hold on one moment, OK?
[AGENT][POSITIVE] OK, uh-huh, thanks.
[CUSTOMER][NEUTRAL] Hello [PII]?
[CUSTOMER][POSITIVE] Yes, hello. Thank you so much for holding. I apologize for that wait. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] Thank you so much for your help I appreciate it. You're very welcome and thanks for calling APL.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, [PII], what I'm looking for now are dates of service, uh [PII].
[AGENT][NEUTRAL] And uh [PII] for an ER visit.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let me just see what I can find. OK, so this is, OK, so let's just see.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, there's a bit of paperwork here to get through, so let's just get through it.
[CUSTOMER][NEUTRAL] Oh, trust me, I know.
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] On your end and mine.
[AGENT][NEUTRAL] OK, I'm just waiting for my computer to come up. It's, it's, uh, OK, so.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, so the last one that you sent in was for Doctor [PII] and that's, so that's what I'm going through right now to see there, OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So she's the one that gave me the diagnosis and called the emergency room to have me go to the emergency room. So I, I've already, I, I called a couple of weeks ago, um, APL, um, regarding the emergency room visit and I'm trying to get a claim for that. And I submitted it, you know, the bill, the EOB, they needed a detailed diagnosis code from the doctor of why I was admitted to the emergency room. So I got the detailed codes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, I know a lot of this stuff is already covered by my insurance or not covered by you by my secondary insurance. The main charge was that I was looking to help get coverage for was the actual emergency room stay, um, at the facility. I also had to do a CT scan there, um.
[CUSTOMER][NEUTRAL] And so that's when I recently submitted the diagnosis code from my primary care doctor who sent me to the emergency room.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So what I'm
[CUSTOMER][NEUTRAL] I know that was a mouthful, [PII], I apologize.
[AGENT][NEUTRAL] Oh, no, that's fine, that's fine. Um.
[AGENT][NEUTRAL] Oh, let's see.
[AGENT][NEUTRAL] Waiting for this to come up here.
[AGENT][NEUTRAL] fillings.
[AGENT][NEUTRAL] That that's for the lab. OK. So let's go over the paperwork that we've got here. Um, this is the last one, the last claim that you submitted, um.
[AGENT][NEUTRAL] Uh, beginning with 12:10, uh, 0 wait, excuse me, I'm sorry. The last one that you submitted, um, for [PII]. OK, let me see what we've got here. So what I'm looking for right now, it looks like what we're looking for was the um diagnosis code.
[AGENT][NEUTRAL] Uh, for that, for, um, and particularly for the ER which was on the, uh,
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] On the [PII], so let me just see what we've got here. So let's see, the 9 documents here and so let's just go through them. So the very first one,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] It's OK, so this
[AGENT][NEUTRAL] There's [PII] on it. Uh, this is.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Now, where am I, where would uh would be the diagnosis code on here because I see um the CPT codes, uh.
[AGENT][NEUTRAL] I see that the, um.
[AGENT][NEUTRAL] Uh, the charges, I see what went to your deductible, co-payment or co-insurance. I'm looking at, uh, um,
[AGENT][NEUTRAL] Sharp Coronado Hospital. It's, it, you're, now you're saying that the, that the uh that the um that the diagnosis code is on here. Could you give me an idea of where it is because what I'm seeing is the explanation of benefits, but I'm not.
[CUSTOMER][NEUTRAL] Let's
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] I'm not actually seeing anything that shows, yeah.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] At the very top it does it say 1:17 [PII] summary?
[AGENT][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] Cause that's the document that has the diagnosis codes on it.
[AGENT][NEUTRAL] That might be the
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] And that is attached to.
[CUSTOMER][NEUTRAL] That's attached to.
[AGENT][NEUTRAL] See, OK, I've got summary of, oh, I'm sorry, sorry, please go ahead.
[CUSTOMER][NEUTRAL] I was gonna say um it says summary at the very top and at the top left hand corner it says [PII].
[AGENT][NEUTRAL] OK. That's not it.
[CUSTOMER][NEUTRAL] Do you have that document?
[AGENT][NEGATIVE] Uh, no.
[CUSTOMER][NEUTRAL] OK, it's attached
[CUSTOMER][NEUTRAL] It's it's attached to 3553561.
[CUSTOMER][NEUTRAL] From my end, if I look at my claims uploaded and I say you file that's where I attached the diagnosis codes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] See if I can find it.
[CUSTOMER][NEGATIVE] And it's 4 pages long.
[AGENT][NEUTRAL] OK. This is, OK, so it's a summary, uh, visit ending in 7725.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, so right at the very top it has the diagnosis codes.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So that is, oh, please go ahead.
[CUSTOMER][NEUTRAL] That when I, when I called previously they said they just needed this summary but they gave me like 4 pages of stuff. I don't know what all this other stuff means so I apologize.
[AGENT][NEUTRAL] Oh, no, that's fine, that's fine. So what we're, what we're looking for from the previous claims, so let's look at the, um, because not only do the not only do the, the, um, uh, we're looking at the service date, so this is the date that you actually went in.
[CUSTOMER][NEUTRAL] Look
[AGENT][NEUTRAL] So what we're looking for for the outpatient um hospital visit that was [PII], the ER visit is [PII]. OK, so what we're, what's, um, the only problem that we, the reason that we didn't use this is because this shows the service date [PII]. So what we were looking for was the.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And that was
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But that
[CUSTOMER][NEGATIVE] That's not the right date. Um, that was my follow-up visit with the [PII] with my doctor.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That was my last visit with her.
[AGENT][NEUTRAL] Do we have
[CUSTOMER][NEUTRAL] So I had, so after I went to the emergency room, I had to go back to her. And that was the [PII] I went back to her. So they just need to change the date on here.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] Right, exactly.
[AGENT][NEUTRAL] Well, we need, what we need are the, the, the diagnosis codes for [PII] and [PII].
[AGENT][NEUTRAL] Um, [PII]. So that's, that's the reason they didn't use it is because it's a, it's a different date and it, whenever we use those documents, and I know it sounds incredible, but they, but they have to have the DX for that or the diagnosis code for that particular day, and that's why it didn't, they didn't take it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I, I totally get it. OK, so here's, I, I know I'm like uploading a ton of stuff now, um.
[CUSTOMER][NEUTRAL] Um, what do I do so I can easily call them and ask them.
[CUSTOMER][NEUTRAL] For um the diagnosis codes for those two dates, do I just upload them again or?
[CUSTOMER][NEUTRAL] And just keep adding to this um to this claim like I don't know is that confusing or is that what I?
[AGENT][NEUTRAL] No, not at all. No, what we can do is we can reference, we can reference the claim, um, and, and the claim number is the one that ends in 9137, and then you can just say this is the diagnosis codes for um [PII] and [PII].
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then what we do is uh we will use that and then uh um as our uh is our final um documentation, so to speak, and we'll look up the codes ourselves. If you just put down that it was for this, it was for that, you know, I sprained my ankle. It was a sore throat. It was, you know, uh, hypertension where we'll be glad to look up the diagnosis, um, if you didn't want to have to call Doctor [PII] back up again.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, but we just need you to, uh, write down so that we film these things. It becomes part of your permanent record and, um, so that we, so we show that you're the ones who actually told us that, you know, not that we're just not coming up with stuff, and, uh, then we will go ahead and figure.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No, I, I will.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I will call them and get an itemized bill for those dates, um.
[AGENT][NEUTRAL] You can just write it down.
[AGENT][NEUTRAL] OK, well, yeah, and just.
[CUSTOMER][NEUTRAL] You want me, yeah, I, I can.
[CUSTOMER][NEUTRAL] That way it's, it's official. I can get because I do see what you're saying because the date does have that date on it which I didn't realize before which is not the date that I went to the emergency room. I went a week before, um, and she's the one that did admit me, so I think when I called the billing department they probably just pulled my last visit I was there, which was the [PII], not the [PII] or the [PII]. Does that make sense? Um, so.
[AGENT][NEUTRAL] Right. Yes, yes, it does, it does. It's.
[CUSTOMER][NEUTRAL] I will, so if, if they give me um a new one of these summaries with the correct service date of [PII] and it has these diagnosis codes and and.
[AGENT][NEUTRAL] And and [PII]:13, [PII] and [PII]. Yes.
[CUSTOMER][NEUTRAL] And [PII].
[CUSTOMER][NEUTRAL] OK, um, and then, um, and then I can just upload them again to the site and just move forward from there?
[AGENT][POSITIVE] Yes, if you would please, and then uh just reference that that claim number um uh 354-9137, and we'll know what we're talking about that way it will get, it'll get us to, if you put your policy number and the claim number on there, it just means means a world of difference in in us being able to get this out to you as quickly as possible because that's, that's what we're trying to do is is to get these out quickly rather than trying to search through our system for your for your uh file. So if you will put your um.
[CUSTOMER][NEUTRAL] No, I
[CUSTOMER][POSITIVE] I appreciate that.
[AGENT][NEUTRAL] Uh, your, uh, claim number on there and your um policy number, then what we can do is we can just zip through there, we can finish finish it out and um then get this, this stuff to you.
[AGENT][NEUTRAL] Get the payment out to you.
[CUSTOMER][NEUTRAL] All right perfect I will yeah and I think I'm only allowed to upload files I can't put a note in the system when I upload my file so um I will just call back to verify like a couple of days after I submitted to see where it's at.
[AGENT][NEUTRAL] OK, well, also when you're uploading files, if you, I don't know whether you can scan something into the system. Sometimes you can actually put in a note on there before you scan it. Um, you can also do that as well, um, if you wanted to. Now, I would just add that I don't know if you've seen it or not, but there is a direct deposit, uh, form. Let me just see that whether you have one of those or not. You do not. OK, there's a direct deposit form on the system if you wanted to look that up as well, and then that way we're not sending you a check through the mail, um, but, but I don't know if you don't want it, you know.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] Um, so, uh, yes, if you wanted to do that as well.
[CUSTOMER][POSITIVE] No, that would be very helpful. That would, that would be very helpful because the bill is $6000. So any, any way I can.
[AGENT][NEUTRAL] Ouch.
[CUSTOMER][NEUTRAL] Uh, yeah, yeah, I mean, it's pretty rough, so I will, I will get um some itemized um documentation diagnosis codes for those two dates, upload them, um, I will try to find the um the form for the ACH, um, and get that going to, um, and then I will call back if I, if I have any, if I need any other help, OK?
[AGENT][NEUTRAL] OK, yes, yes, and then, and what we'll do is we'll look at it and if there's everything should be fine, but if it's not, then we can just let you know that, you know, in case we just need a little extra something, we can do it while you're on the phone and then that way it just makes the process a lot faster rather than waiting for you, you know, the mail to get back and forth, which is normally the way that we have to do that. OK, well, just so there's nothing else I can help with and just um thank you for contacting APL. You have a very good afternoon, have a very good weekend, and we'll try and get this uh resolved as soon as you get those documents in.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][POSITIVE] I appreciate it thank you so much [PII] have a nice day.
[AGENT][NEUTRAL] Mhm. You too.