AccountId: 011433970860
ContactId: ba08b7e8-60f7-4748-b352-4634d4a40e22
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 975159 ms
Total Talk Time (AGENT): 491696 ms
Total Talk Time (CUSTOMER): 293583 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/30/ba08b7e8-60f7-4748-b352-4634d4a40e22_20250530T13:19_UTC.wav
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[AGENT][POSITIVE] Good morning thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, I filed a claim for my husband for hospital admission.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And it was um denied saying they need additional information and I sent the itemized bill so I'm not sure exactly what they need.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so you had filed a claim for your husband, but we were needing some more information and you're just wanting to verify what you submitted.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] was sufficient. OK, yes ma'am, I can check claim status for you. And who am I speaking with?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Miss [PII], what is your callback number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, and your policy number, please?
[CUSTOMER][NEUTRAL] 2010635
[AGENT][NEUTRAL] OK, thank you, Miss [PII]. One moment, please.
[AGENT][NEUTRAL] And Ms. [PII], as you know, I will have to verify several things with you first for security and then also any information provided will be a verification of benefits and not a guarantee of payment. So first off, if you will please verify your date of birth and then your husband's name and date of birth.
[CUSTOMER][NEUTRAL] Mine is 629-72 and his name is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And then also your home mailing address, please.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. The phone number we have for you is the same as the one that you gave me, so that is the best contact number that we should have for you, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you and the last piece of information to verify is gonna be your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And Miss [PII], what is the data service for Mr. [PII] that you're calling about?
[CUSTOMER][NEUTRAL] Um, he was admitted on [PII] or [PII].
[AGENT][NEUTRAL] For [PII] of this year, correct?
[AGENT][NEUTRAL] OK, so let's see. I have multiple claims on here. Let me look at the most. So I do see that there was information submitted on [PII]. Is that correct?
[CUSTOMER][NEGATIVE] Those yeah those are all wellness claims and the hospital doesn't, I guess when I submit them for the cancer policy it transfers over to the hospital policy and it doesn't have wellness claims so they're of course gonna be denied. The one I'm calling about was submitted on the [PII] and that was for a hospital admission.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so yes. OK, so that's one of the claims that I see. So let me look to see what this was for Greenville Memorial Hospital. Is that correct?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So I can see that that one was denied and let me look at the remark.
[AGENT][NEUTRAL] OK, so I'm just gonna read this remark to you Miss [PII], and you can also see this in your portal, but the.
[CUSTOMER][NEUTRAL] Yeah, yeah, right.
[AGENT][NEUTRAL] OK. So it states that uh really what we're needing was the diagnosis code receipt if the claim is acknowledged, how in order, how, I'm so sorry. I'm falling all over my words this morning. I apologize. Let me try this one more time.
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] Receipt of your claim is acknowledged. However, in order to provide further consideration of this loss under this policy, we will need supporting documentation to evidence the accident or sickness. Supporting documentation may include, but is not limited to itemized bills with the diagnosis codes.
[AGENT][NEUTRAL] Supervis, office notes, hospital admission and discharge summaries, and or diagnostic testing results.
[AGENT][NEUTRAL] So based on the information I'm reading, it appears that maybe it's a diagnosis code that is missing.
[CUSTOMER][NEUTRAL] OK, so were they not on there?
[CUSTOMER][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Now
[AGENT][NEUTRAL] It may have the procedure codes, but it looks like it's the diagnosis code.
[AGENT][NEUTRAL] That is not on there.
[CUSTOMER][NEUTRAL] OK, so that last page.
[CUSTOMER][NEUTRAL] So they want the hospital account diagnosis code.
[CUSTOMER][NEUTRAL] Did that last page cut off?
[CUSTOMER][NEUTRAL] With
[AGENT][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] Can you see him?
[AGENT][NEUTRAL] Give me just a moment to see if I can get them to load.
[CUSTOMER][NEUTRAL] I think it may have a friend shot.
[CUSTOMER][NEUTRAL] So let me ask you this, um.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] I understand the diagnosis codes for some things like the surgery or whatever if it was for that but if it was for hospital admission, I mean is that not cut and dry he was admitted.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] No, we have to know why he was admitted.
[AGENT][NEUTRAL] The diagnosis is the why.
[CUSTOMER][NEUTRAL] But it should pay regardless, right?
[AGENT][NEUTRAL] Well, we can't review the claim until we have the complete information that's required for the review.
[CUSTOMER][NEUTRAL] I mean
[CUSTOMER][NEUTRAL] OK, and I understand that I can send that but my question is, no matter what, and it was for a heart attack, so I'm sure it's, you know, not a problem, but my question is, there should be no reason it should be denied since he was admitted, right?
[AGENT][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Again, I can't guarantee payment. We can't pay claims over the phone, Miss [PII]. We have to receive all of the required information, and I'm looking and I do not see a diagnosis on this information.
[CUSTOMER][NEUTRAL] I understand that
[AGENT][NEUTRAL] This shows some procedure codes.
[AGENT][NEUTRAL] But it doesn't have.
[AGENT][NEUTRAL] And, you know, medications.
[AGENT][NEUTRAL] But it does not have the actual diagnosis.
[CUSTOMER][NEUTRAL] OK, so hospital account diagnosis codes. Um, can, there's one page there that I think was.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] Cut off um
[AGENT][NEUTRAL] The very last page. Oh, I'm so sorry. Go ahead. I was just gonna tell you what the last page is that I can see.
[CUSTOMER][NEUTRAL] And it had like 26.
[CUSTOMER][NEUTRAL] Is there, yeah, is there a section that says hospital payments and adjustments and it's got date [PII]. Is that like a short page?
[AGENT][NEUTRAL] Mhm. That's on here. That's, yes, it is because it shows, it shows the service date. The very first thing on that page is the venna puncture.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] For 48 $28 there's that box with those charges, and then the second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Titled section is hospital payments and adjustments.
[AGENT][NEUTRAL] With that information regarding the Blue Cross payment and then the total, you know, gives the total payments and adjustments.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] So if I upload a document how quick can you see it?
[AGENT][NEUTRAL] Well, it will, we should be able, I mean, like, if you upload it right now, I should be able to see that it's been received and it will be in line for review.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] But that's the only, yes, you wouldn't have to submit a claim form or anything we just need that missing piece of information uploaded and then it's typically, you know, a 5 to 7 business day turnaround.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, so I'm just wondering if if you could see this page to see if this is what you needed.
[CUSTOMER][NEUTRAL] So it'll be another 5 to 7 days?
[AGENT][NEUTRAL] Mhm. Yes, ma'am. It can be, yes.
[CUSTOMER][NEUTRAL] OK, my next question is.
[CUSTOMER][NEUTRAL] Sending this in, there's a couple of things. um, there's the hospital admission.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] And then he was also in the emergency room. So, do I have to file a separate claim for that or do they?
[CUSTOMER][NEUTRAL] Go through everything that it qualifies for.
[AGENT][NEUTRAL] They would look at that on this limited benefit plan. I'm not, I would have to look to see if there are emergency room benefits on here because I'm not sure about that. So give me just one moment.
[AGENT][NEUTRAL] So actually that is part of the claim.
[AGENT][NEUTRAL] That same claim number?
[AGENT][NEUTRAL] It has the same exact mark for the emergency room. It's the diagnosis. I mean, it's the exact same code and everything.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I mean
[AGENT][NEUTRAL] That we're needing information.
[CUSTOMER][NEUTRAL] OK, and the last thing on, on that one is um he had a heart cath and I don't know, do they consider that surgery or no?
[CUSTOMER][NEUTRAL] I'm assuming if they didn't create a claim number for that, maybe not.
[AGENT][NEUTRAL] I don't see any indication on here. Um, let me look.
[AGENT][NEUTRAL] It would just be dependent upon.
[AGENT][NEUTRAL] The, you know, the information as far as how it was filed with the insurance.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Because there is the surgery, I mean, if it can fall up under this surgery, as far as hospital, whether that's surgery in a hospital or outpatient facility or freestanding outpatient surgery center, you know, there is a $1500 per day maximum of 1 day per calendar year benefit on your policy.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] But again, that would just be dependent on the claim and how it's reviewed. I mean, what has
[AGENT][NEUTRAL] What we received from the hospital for review.
[CUSTOMER][NEUTRAL] OK, so I just uploaded that whole sheet that has the diagnosis codes on the bottom, um.
[CUSTOMER][NEUTRAL] Will it then that I send it separate, will it connect to that claim?
[AGENT][NEUTRAL] No, it will because the system, it, there's not a way to actually, you know, upload to that existing claim number, but the system will know that this was some information that we did not have.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For this other claim when they see the date of service.
[CUSTOMER][NEUTRAL] Uh, can you see it?
[AGENT][NEUTRAL] And I can see, I can see that that was received.
[AGENT][NEUTRAL] Mhm. I can say that you did upload something.
[CUSTOMER][NEUTRAL] Can you see the document?
[CUSTOMER][NEUTRAL] OK, so you can't see the document to see if that's what you think I need to send?
[AGENT][NEUTRAL] Let me see if I can view it. I'm not sure if I can view it, but I will certainly try to see.
[CUSTOMER][NEGATIVE] I just hate for it not to be right. I have to wait 7 days and then come back and say, oh no, that's not what we needed.
[AGENT][NEUTRAL] Right. And again, I can just uh hm, let me try that again. It's not showing it to me.
[AGENT][NEUTRAL] OK, so I do see the I do see the diagnosis codes on here. I believe, you know, that that should be sufficient, but again, I am not one of the examiners on the claims. So they we'll just have to go, but I mean, I can see the diagnosis codes on this from where it was cut off on the page before.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So this does appear to be what we would, what we were needing.
[CUSTOMER][NEUTRAL] Alright, and it.
[CUSTOMER][NEUTRAL] OK, and there's no way to escalate it. It just has to sit and wait on them to pick it up again.
[AGENT][NEUTRAL] Yes. Uh-huh. It does. And
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Just for future reference, um, on these types of claims, Ms. [PII], the claim form, the hospital indemnity claim form, page one on that claim form gives you all the instructions for what documents if you're gonna be submitting the claim if the facility is not filing them for you, um, it does tell you everything that you would need to submit.
[AGENT][NEUTRAL] So I would just recommend kind of using that as a checklist in the future. So hopefully, you know, maybe avoid.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Having to get additional information.
[CUSTOMER][NEUTRAL] Yeah, I just saw, yeah, I just saw the itemized bill. I didn't pay attention to where I had to have this diagnosis codes.
[AGENT][NEUTRAL] Right, right. Sure.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] What about the wellness claims that have been submitted for the cancer policy? Do you know?
[CUSTOMER][NEUTRAL] How long they normally take because they've been on here, well, I hadn't been that long, but I submitted one before and it was fairly quick and these are just sitting here.
[AGENT][NEUTRAL] Yeah, typically, I, um, I don't have that policy information pulled up. I can look to see when we received them, but let me finish making the note on this one policy cause I have to look at them separately.
[CUSTOMER][NEUTRAL] Yeah, they were just send in on the [PII].
[AGENT][NEUTRAL] Oh, yes, ma'am. So it, it's the same review time on all the claims.
[AGENT][NEUTRAL] It's typically 5 to 7 business days.
[AGENT][NEUTRAL] For those.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Alright, is that all you need from me?
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Yeah, that, well, that's all I, I need. Is there anything else that I can help you with, Ms. [PII]?
[CUSTOMER][POSITIVE] That's it. I appreciate it.
[AGENT][POSITIVE] Well, you are certainly very welcome and thank you for calling APL. I hope that you have a wonderful weekend.
[CUSTOMER][POSITIVE] You too. Thank you. bye.
[AGENT][POSITIVE] Yes, ma'am, and thank you. Bye-bye.