AccountId: 011433970860
ContactId: bdf7960d-a835-46db-8f54-61c6b12c129d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 790700 ms
Total Talk Time (AGENT): 257262 ms
Total Talk Time (CUSTOMER): 331494 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/10/bdf7960d-a835-46db-8f54-61c6b12c129d_20250210T16:21_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hey, this is [PII]. I'm a broker in [PII]. How are you doing?
[AGENT][NEUTRAL] I am fine, Mr. [PII], and yourself?
[CUSTOMER][POSITIVE] Doing great, doing great. I'm just calling to see if I could check on a claim for one of our customers.
[AGENT][NEUTRAL] OK, and what's that policy number, please?
[CUSTOMER][NEUTRAL] Policy number is 2489179.
[AGENT][NEUTRAL] OK, thank you. And do you have a callback number in case the call drops?
[AGENT][NEUTRAL] Excuse me
[CUSTOMER][NEUTRAL] Yes ma'am, it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and the patient's name, date of birth?
[CUSTOMER][NEUTRAL] Um, her name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] OK, and that date of service and amount of the charge if you have it.
[CUSTOMER][NEUTRAL] Um, I can tell you the claim number should end in 177.
[CUSTOMER][POSITIVE] That'll help you.
[AGENT][NEUTRAL] OK, I see.
[AGENT][NEUTRAL] 177.
[AGENT][NEUTRAL] T.
[AGENT][NEUTRAL] Oh, let's see.
[AGENT][NEUTRAL] OK, uh, I show a claim processed on [PII], last Thursday, and a check has been mailed to the, or no, direct deposit has been sent out to the insured.
[CUSTOMER][NEUTRAL] OK, can you let me know what was processed on there?
[AGENT][NEUTRAL] Uh, oh, as far as the, the amount or the different charges on there or the different benefits on it?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] The total is fine. I'll probably have a good idea what it was just by the total.
[AGENT][NEUTRAL] OK, I'm showing 2800 was paid.
[CUSTOMER][NEUTRAL] OK, so that's probably the surgery, the overnight stay, and the daily benefit, got it.
[AGENT][NEUTRAL] Yes, and the ER.
[CUSTOMER][NEUTRAL] That'll work.
[CUSTOMER][POSITIVE] Perfect, so 2800 on there and.
[CUSTOMER][NEUTRAL] Let me check one more thing just while I have you, OK?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] If that's all right. Let's see.
[AGENT][NEUTRAL] No, that's fine.
[CUSTOMER][NEUTRAL] Trying to keep up with all these people is uh is something else let me tell you it's uh.
[AGENT][NEUTRAL] I can imagine.
[CUSTOMER][NEUTRAL] Constant phone calls, you know, like it's constant phone calls.
[AGENT][NEUTRAL] No, I get it, or emails probably too.
[CUSTOMER][NEUTRAL] Yes, everything, yes, it's uh.
[CUSTOMER][NEUTRAL] But it's, you know, it's the nature of the business.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Of course, my APL system, whenever I, it goes fast all the time, but whenever I need it to go fast, it's like, hold on, we're gonna take our time here, you know, it's
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Did y'all enjoy the Super Bowl, being in [PII] yesterday?
[CUSTOMER][POSITIVE] Yes ma'am. Well, we have a [PII] normally we'd have been down there walking around and enjoying all the festivities, but we have a [PII], so we decided to sit this one out, but, uh, a lot of people we know were down there and they had a great time.
[AGENT][NEUTRAL] Oh, I don't blame you.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Oh, I bet.
[AGENT][POSITIVE] I love [PII]. It's just, it's just, I love the culture, the food. It's always great when I go.
[CUSTOMER][NEUTRAL] Yes, ma'am. Yes ma'am. I grew up there, uh, for most of my life, and we actually live about 30 minutes outside the city right now because it was uh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's a, um, we live on the North Shore, which is basically, it's, it's basically just like a calm down [PII], you know, it doesn't have all the party and it's more just like suburbs, but we go into the city whenever we want to. We just kind of lay our head at night away from the city where it's not so wild, you know?
[AGENT][NEUTRAL] Oh no, I understand. Yeah, I had a, I have a friend or friends that live right there in the [PII] and uh we used to go and go to concerts and everything and stay with them, so it's not that far from the, the main part and then go and shop around and everything before going back home.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, ma'am. Yeah, I have some groups in the [PII], so I'm uh I'm all over the city all the time.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] It is nice. Everyone is really sweet.
[CUSTOMER][NEUTRAL] Let's see here, hold one second.
[CUSTOMER][NEUTRAL] Oh yeah, a lot of, a lot of good people in [PII], of course, we always get a bad rap because of crime, but a lot of good people there who work hard and you know.
[AGENT][POSITIVE] Oh, absolutely.
[AGENT][POSITIVE] Exactly.
[CUSTOMER][NEUTRAL] Now this one I don't know that it's processed but uh I'm just double checking because this was the CEO of one of our groups and just want to make sure that we have it and everything's in line if that's OK um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Popping up now sorry it took so long.
[AGENT][NEUTRAL] No, you're fine. I'm here all day.
[CUSTOMER][NEUTRAL] OK, it looks like it's.
[CUSTOMER][NEUTRAL] Policy number 227-0249.
[AGENT][NEUTRAL] 49. OK, give me one moment.
[AGENT][NEUTRAL] Sorry, I'm having to type in a note real quick.
[CUSTOMER][POSITIVE] No problem, take your time.
[AGENT][NEUTRAL] OK. And that uh patient's name?
[CUSTOMER][NEUTRAL] Should be um [PII]. Date of birth [PII].
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Well, I don't show any claims have been received for her.
[CUSTOMER][NEUTRAL] You know what it's show it's saying insured her dad's name so they might have it says received but they probably haven't um.
[CUSTOMER][NEUTRAL] Like typed it in the system yet, you know what I mean like because I'm showing received on [PII] I see now so it's only 210.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK. Yeah, cause I see one in front of Rusty. Uh, give me half a moment. Let me make sure.
[CUSTOMER][NEUTRAL] That's probably what's going on. It's showing the dad's name instead of hers.
[AGENT][NEUTRAL] Oh this computer is slow. OK, let's see.
[AGENT][NEUTRAL] OK, I see it's supposed, yeah, you're right, it's supposed to be for [PII]. I'll put a note on the claim so they make sure they process it under her.
[CUSTOMER][POSITIVE] Thank you so much I appreciate it and um.
[AGENT][NEUTRAL] Yes, I.
[CUSTOMER][NEUTRAL] It's actually, I just realized there was one person.
[CUSTOMER][NEUTRAL] There was one person that a claim got held up on and uh they sent in some medical records from a provider but I, I can't see that on my side. I can only see what I upload it if I gave you one more person, could you tell me that if y'all receive the records?
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Sure. What's that policy number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, policy number is.
[CUSTOMER][NEUTRAL] 244-622-2
[AGENT][NEUTRAL] Let's
[AGENT][NEUTRAL] OK. And that uh patient's name?
[CUSTOMER][NEUTRAL] That should be for Ms. [PII].
[AGENT][NEUTRAL] And we were needing medical records?
[CUSTOMER][NEUTRAL] What happened was I sent a diagnosis and an itemized bill, which normally if I send the claims, they're pretty clean, but Miss [PII] said she needed more information because of, I guess, um, the way the diagnosis came through.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So we got the doctor to send some medical records over to
[CUSTOMER][NEUTRAL] To APL, but I can't see that on my side that medical records were received, but apparently we received them, and I'm trying to see if they process them.
[AGENT][NEUTRAL] OK, let me see.
[AGENT][NEUTRAL] It looks like it did, um, press, let's see.
[AGENT][NEGATIVE] And the claim was processed on the [PII] as this loss does not meet the provision of coverage on the benefit.
[AGENT][NEUTRAL] What is 4.
[CUSTOMER][NEUTRAL] OK, so that's after they received the medical records?
[AGENT][NEUTRAL] Uh, yes, sir. Uh, it was processed on the [PII].
[CUSTOMER][NEUTRAL] I wonder
[CUSTOMER][NEUTRAL] I wonder what happened there, cause the records say that she fell and the diagnosis was an injury to the um to the leg or knee. I wonder what was showing up different, you know what I mean?
[AGENT][NEUTRAL] Yeah, uh, sometimes if it says like bodily injury, like it doesn't, uh, specifically state like due to an accident that could
[AGENT][POSITIVE] OK, yeah, this is an excellent yeah.
[CUSTOMER][NEUTRAL] Because we even included the report and everything that said she had an accident, but every now and then I gotta work a little harder on one if it's the employee doesn't give me the best information, you know.
[AGENT][NEUTRAL] No, I understand.
[AGENT][NEGATIVE] They're only given so much information and
[AGENT][NEUTRAL] We require more.
[AGENT][NEUTRAL] But, yeah, looks like the medical records were received and
[AGENT][NEUTRAL] Diagnostic test for so.
[AGENT][NEUTRAL] See
[AGENT][NEGATIVE] Oh, my system is super slow this morning.
[CUSTOMER][NEUTRAL] That's OK. I'm just looking at all the stuff we scanned in while you're looking at that to see what I'm missing here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But this lady, for some reason, I always have fits with her claims. She had a bee sting and claims that they needed a copy of the drug test they took when she went to the doctor.
[CUSTOMER][NEUTRAL] Because her company, no matter what, if you have an accident at work, they automatically do a tox screen, just because that's what they have to do for their thing. So they fought me on getting a drug test, and she had a bee sting at work.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] So this particular lady I've had bad luck with, uh, but that's just how it goes sometimes, you know.
[AGENT][NEUTRAL] Yeah, and I'm looking on the, the records and it just says leg pain, patient reports pain.
[AGENT][NEUTRAL] In their leg
[CUSTOMER][NEGATIVE] You know what happens a lot too is I feel like these doctors or, or rushed through something and they'll put a bunch of diagnosis codes on there. A lot of times they'll mess up.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] It can happen though. Yeah.
[CUSTOMER][NEUTRAL] I see it all the time. I'm like, wait.
[CUSTOMER][NEUTRAL] I see it all the time and I'm like, wait a minute, you went there for this. I have all the proof that you had an injury this, and the doctor puts unspecified.
[CUSTOMER][NEUTRAL] Something of leg or pain or injury of leg. I'm like, no, it is specified. She fell here. Here's the, the medical report from work where she fell, you know what I mean? So, it's just, uh, a lot of times it can be used in error at these doctor's offices and you have to go fight to get them to change their record, you know what I mean?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Oh yes. Oh yes. And I'm looking at hers and it's just says uh leg pain. It doesn't, and it gives a description saying that she fell downstairs. No bruising or deformed, noted, but it doesn't really.
[AGENT][NEUTRAL] The diagnosis, it just says pain in the left leg.
[CUSTOMER][NEUTRAL] Yeah, perfect example. The doctor writes out what happened and uh puts a different diagnosis. I'm like, wait, what?
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] You know what I mean? Like, what, so I now have to go chase you down just to put your correct code in, you know what I mean? So it's just, it just makes it all harder on all of us when they uh when they don't do what they're supposed to do, you know.
[AGENT][NEUTRAL] Exactly. And then if we look back because we're going by what we received and.
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] It's like, well,
[AGENT][NEUTRAL] Doesn't indicate injury per the notes or medical records, you know, but she can always uh submit an appeal, um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And if she has any other documents, uh, submit that to us and they can review.
[CUSTOMER][POSITIVE] OK, I'll keep you posted on that. I appreciate your time this morning. I hope you have a good day.
[AGENT][POSITIVE] Oh, you too, Mr. [PII]. Thanks for calling APL. You have a great rest of your day.
[CUSTOMER][POSITIVE] Thank you, take care.
[AGENT][NEUTRAL] Mhm, bye.
[CUSTOMER][POSITIVE] Thanks bye bye.