AccountId: 011433970860
ContactId: c070be99-8616-48e4-9233-78d9a3220ab5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1012520 ms
Total Talk Time (AGENT): 236834 ms
Total Talk Time (CUSTOMER): 363704 ms
Interruptions: 5
Overall Sentiment: AGENT=1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/10/c070be99-8616-48e4-9233-78d9a3220ab5_20250110T19:19_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], it's [PII]. I've got um Miss [PII], uh, I can't say her last name. Anyway, her policy number is 194.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 7648.
[CUSTOMER][NEUTRAL] She's calling about claim number 350.
[CUSTOMER][NEUTRAL] 68 I'm sorry 873.
[CUSTOMER][NEUTRAL] I read her the remarks on the claim and she wants further assistance.
[AGENT][NEUTRAL] Very
[AGENT][NEUTRAL] OK, um, 3506873, is that for her or somebody else on the policy?
[CUSTOMER][NEUTRAL] It's for her, uh, [PII]'s part two. I'm sorry, I should have told you that.
[AGENT][NEUTRAL] Is that part OK alright.
[AGENT][POSITIVE] No problem, no problem. OK, thank you so much. I'm ready thank you.
[CUSTOMER][NEUTRAL] She's part 2.
[CUSTOMER][POSITIVE] Thanks [PII]. Have a good weekend. Bye bye.
[AGENT][POSITIVE] OK, I'm ready. You're welcome you too thank you bye.
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes I was calling just transferred here um and I uh I I was speaking to someone about a question about a claim um and how it I guess needs to be submitted, OK.
[AGENT][NEUTRAL] You
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, yes ma'am. I was told it was for claim number 3506873 for [PII] for [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, yes ma'am, um, it shows that the claim was denied services were denied. Your policy does not cover for services or procedures inside the office, the doctor's office or clinic.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So, I was just wondering because it was like a, a surgery ablation under anesthesia done, I mean, it's at [PII], which is a hospital done by my doctor. I just didn't, I just am confused. Um, so I thought it would be, it was like an outpatient thing since we, I went to [PII].
[AGENT][NEUTRAL] Um, again, make sure that was [PII] and that was Women's Care.
[AGENT][NEUTRAL] Is that correct?
[CUSTOMER][NEUTRAL] Yes, that Women's Care is the name of my doctor, so I don't know, that's why I was so confused. I was like, are they just billing it?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Differently.
[AGENT][NEUTRAL] OK, let me just look at.
[AGENT][NEUTRAL] Let me just look how they it was submitted um one moment, [PII].
[CUSTOMER][POSITIVE] OK, thanks.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Right. OK. OK. OK, I think I kind of merged the call but just she's checking on something else right now so I might need you in a second. OK, sorry, the internal medicine person called me to schedule something and I didn't know that that's what they're calling for. OK, just wait until she.
[CUSTOMER][NEUTRAL] Figures out.
[CUSTOMER][NEUTRAL] That because I guess because you're over [PII] they can't look into it without me, OK.
[CUSTOMER][NEUTRAL] And maybe we can check on the status of the other dispute too. Remember how they weren't covering the urgent care thing and they said they did a dispute for it because of the same issue. Remember how we called like a few weeks ago?
[CUSTOMER][NEUTRAL] I remember the same thing they said they wouldn't cover it or this is not this is American Public Life. This is supplemental insurance. 00, so I was, I thought you're on the, I thought you're on the, sorry, hello.
[AGENT][NEUTRAL] I still
[AGENT][POSITIVE] I'm sorry, yes, hello? OK, thank you, um, so for you.
[CUSTOMER][NEUTRAL] Hey.
[AGENT][NEUTRAL] OK, for [PII] it shows it was billed at an office office setting, so that's why the charges were denied for women's care.
[CUSTOMER][NEUTRAL] OK, I'm OK again I was just like wondering since it was at [PII] like if they resubmit it a different way. I just didn't know if they submitted it incorrectly.
[AGENT][NEUTRAL] Um, I'm not sure if they submitted it incorrectly, but it comes from [PII].
[AGENT][NEUTRAL] Is the physician was a doctor and it was built from women's care and it shows um office settings so that's why it was denied.
[CUSTOMER][NEUTRAL] OK, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK, so I'll just call them and ask them why it was built that way, you know what I mean, why it was built that way. OK, Mom was that for you or for me? Yes, OK, and then I have my daughter [PII] on the phone, um, because I had a question too about something for her. Um, there's two MRI's that she had done that were denied one, is that Mayo Clinic, like Mayo Clinic Hospital, um, from [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so we're done with you, [PII], is that correct? Can I move to your daughter, right? OK, thank you. So alright.
[CUSTOMER][NEUTRAL] Yes, yes, yeah.
[CUSTOMER][NEUTRAL] Sorry.
[AGENT][NEUTRAL] And that day of service again was for [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment we'll get that pulled up as well.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Almost there.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] I apologize for the delay.
[CUSTOMER][NEUTRAL] You have
[AGENT][NEUTRAL] Let me, can I put you on a brief hold please please one moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] I'll just remove it if it's gonna keep having issues, yeah hey.
[AGENT][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Hi, thank you for your patience. So I have the one pulled up for [PII] uh for [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now for this particular one it does show it was.
[AGENT][NEUTRAL] M sorry, Mayo Clinic Hospital Florida Hospital.
[AGENT][NEUTRAL] You said it was an urgent care?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] It's, it's a, it's a.
[AGENT][NEUTRAL] You just
[AGENT][NEUTRAL] Hospital OK hospital. OK, alright, um.
[AGENT][NEUTRAL] I can send this back for review by the adjuster and that claim number shows 351263-9.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, that's fine.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And then um let me know when you're ready for that.
[AGENT][NEUTRAL] Did you have another date of service you want me to check for [PII]?
[CUSTOMER][NEUTRAL] Yeah, there was another data service from um 5.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] From uh orthopedic institute.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] to come up as well, bear with me.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, so the assistant orthopedic Institute and that was the office setting office visit, that's something that's not covered by the policy.
[AGENT][NEUTRAL] So that is not covered by the policy, um, Christian lady.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, so even if she, it was just like a, like she had like a separate MRI just set up, that's not you're saying because it was done at the orthopedic institute it's not allowed or?
[AGENT][POSITIVE] Yes, correct, uh, the place of service.
[CUSTOMER][NEUTRAL] I'm just trying to understand for.
[AGENT][NEUTRAL] The place of service where it was done is um.
[AGENT][NEUTRAL] Not a diagnostic testing facility. It's, it's an office setting, it's an office.
[AGENT][NEUTRAL] So it's the place of service.
[CUSTOMER][NEUTRAL] OK, so you're saying because like they have the MRI even though it's like just like done on a totally different day, like the MRI like she needs to, if she ever has them do an MRI, say, no, I don't want you doing it at your MRI facility.
[AGENT][NEUTRAL] For your benefits with your policy, it doesn't cover office visits. It doesn't cover any services or procedures inside a doctor's office or clinic.
[CUSTOMER][NEUTRAL] I guess.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] As far as the diagnostic testing, it has to be done in a diagnostic testing facility.
[CUSTOMER][NEUTRAL] OK. So like a separate, like a facility that doesn't have MRI's and doctors there, like just MRI's.
[AGENT][NEUTRAL] A diagnostic testing responsibility.
[CUSTOMER][NEUTRAL] Or something.
[CUSTOMER][NEUTRAL] OK. I just was trying to understand so she knows what to.
[CUSTOMER][NEUTRAL] Um, so, you know.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] So it doesn't count as a diagnostic testing facility even though like they take orders from people that aren't patients there like it was a they have a diagnostic testing facility like inside the.
[CUSTOMER][NEUTRAL] The institute that's unrelated to the doctors.
[AGENT][NEUTRAL] As far as how the claim was submitted, it was submitted as if you were in the office when that MRI took place, not a diagnostic testing facility.
[CUSTOMER][NEUTRAL] OK, alright, [PII], well, we'll just have to talk to them, um.
[CUSTOMER][NEUTRAL] About that.
[CUSTOMER][NEUTRAL] And then I guess I could call back. There's some other like MRIs that got denied. I just can't find the, I don't have the bills in front of me right now, but um like I know some MRIs that I had like last year that I had the same issue that got denied. And I don't know why for some reason, Mayo, like, I know you looked at [PII]'s too, but like,
[CUSTOMER][NEUTRAL] Just how Mayo works. I mean, it's not like I'm getting it done in the office or whatever. They're like, literally, my doctor's making me go to a totally different Mayo location, like at the hospital, you know, outpatient, to get these MRIs. And um I don't know, I just, I'm just trying to understand like how we get them to not be denied all the time, you know, or if we just need to, each team time call and.
[CUSTOMER][NEUTRAL] Get it reviewed or
[AGENT][NEUTRAL] Well, um, in regards to your, the policy benefits, um, it doesn't cover any services or procedures inside a doctor's office. It could be a PCP or specialist.
[CUSTOMER][NEGATIVE] Right, but they're not, like I said, like, like even with Mayo, for instance, it's like, I mean, it's like a huge Mayo clinic like it's just the freaking hot like we're walking in where they admit patients, you know.
[CUSTOMER][NEUTRAL] Facility that the only place that has that level of MRI, you know.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That they that they send you to not like an office is it?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, I, I apologize, um, it was processed as it was sent in and it was sent in with a place of service where it shows as a doctor's office. I'm sorry.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, got you. OK, well, um, we'll just wait for that one to be reprocessed and then I guess as soon as I have the other ones in front of me, do I just call back and ask to talk to you?
[CUSTOMER][NEUTRAL] Someone in claims.
[AGENT][NEUTRAL] Oh yes, you can or you can just call, talk to someone whoever answers the phone uh yes ma'am, that's fine. Now again that that claim for [PII], that claim number is 351-2639, it will be reviewed um by the adjuster, OK, but you can call back and check the status of it, of course.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much. All right, well thank you for looking into it.
[AGENT][POSITIVE] You're welcome. You're welcome, ladies. Thank you so much thank you bye bye.
[CUSTOMER][NEUTRAL] OK, bye bye.
[CUSTOMER][POSITIVE] Thanks bye bye.