AccountId: 011433970860
ContactId: c1e1d299-cf1c-453f-9adc-d0841bf990b8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 778500 ms
Total Talk Time (AGENT): 275884 ms
Total Talk Time (CUSTOMER): 363629 ms
Interruptions: 2
Overall Sentiment: AGENT=0.6, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/14/c1e1d299-cf1c-453f-9adc-d0841bf990b8_20250314T16:18_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I'm calling checking on a claim.
[AGENT][NEUTRAL] Sure, I can check on a claim for you. uh, what was your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and is this for your policy, [PII]?
[CUSTOMER][NEUTRAL] It's for my policy, but um I did it for my husband.
[AGENT][NEUTRAL] Sure, OK, um, can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you. And then do you have your policy number?
[CUSTOMER][NEUTRAL] I have the claim number.
[AGENT][NEUTRAL] Oh sure that'll work.
[CUSTOMER][NEUTRAL] 35716887
[AGENT][NEUTRAL] OK, thank you. One moment please.
[AGENT][NEUTRAL] OK, I'm just gonna verify some information really quick, [PII]. Can I get your date of birth, please?
[CUSTOMER][NEUTRAL] Sure it's uh [PII].
[AGENT][NEUTRAL] Thank you and then can I get your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect. Last thing I need is the email address we've got on file for you. Um, looks like it might be, yes.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect. OK, thank you so much for verifying that. Alrighty, give me just a moment, let me take a look here.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so yes, for this claim, uh, we would have sent it in the mail um for the medical records, um, that was the first part, uh, requesting the medical records, and then let me take a look at the second part here.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So um looks like we're just missing some additional information uh to support of course what the accident was and when it occurred, so that could've, I'm not sure what you, uh, did submit already for this claim, um, but definitely something like a hospital admission, uh, and or discharge dates. OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well I sent all that in and then today it's saying processed.
[CUSTOMER][NEUTRAL] Completed
[AGENT][NEUTRAL] OK, OK, so let's, let's go back and take a look because of course this is the original claim. So if you sent that information in it's probably got a a different claim number, uh, so let me check that.
[CUSTOMER][NEUTRAL] Well it says it says completed they completed today.
[AGENT][NEUTRAL] OK, let's take a look. Give me just a moment.
[AGENT][NEUTRAL] The sizes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh yes, OK, so what that just means that it had finished processing um and so that's why we have this, uh, they were able to determine the information that was missing so when it's just because it says completed or even if it says denied um that doesn't mean it's of course a hard no it just simply means that we need that additional information so once you're able to give that to us um of course you can upload it through.
[CUSTOMER][NEUTRAL] What do you need?
[AGENT][NEUTRAL] Right, so that's what it's stating um we are waiting for the medical records, but then it's also needing more supporting, uh, documentation, uh, regarding the actual accident and when it occurred. So again that would be things like um.
[AGENT][NEUTRAL] Um, statements, uh, any sort of billing statements or office notes, hospital admission and discharge summaries, and or diagnostic testing results. So what I would recommend doing is contacting the provider or facility wherever he went, uh, for treatment regarding the accident and just asking them for whatever kind of information they can give you.
[CUSTOMER][NEUTRAL] Well, he fell out the bed and, and bust his knee. And so, um.
[AGENT][POSITIVE] Oh goodness.
[CUSTOMER][NEUTRAL] I wonder because it wasn't saying completed yesterday it's saying they completed [PII], which is today.
[AGENT][NEUTRAL] Yes, that's when it had completed processing, yes.
[CUSTOMER][NEUTRAL] Right, but if it's completed processing because y'all, y'all got the medicals from the doctor. Let, can I talk to somebody in claims?
[AGENT][NEUTRAL] Sure, um, give me just a moment. I'm gonna put you on a brief hold.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Of course.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], this is [PII] over on the care team. How are you today?
[CUSTOMER][POSITIVE] I'm good how are you [PII]?
[AGENT][NEUTRAL] Doing good thank you. I've got a member on the line uh who was calling regarding an accident claim um I tried to just explaining it looks like we're just missing some information and requested medical records um and she just asked to speak with someone in claims so I think she's just a bit confused.
[CUSTOMER][NEUTRAL] OK, uh, what's the policy number?
[AGENT][NEUTRAL] It is 02545851.
[CUSTOMER][NEUTRAL] OK, let me get over there real quick.
[AGENT][NEUTRAL] Mhm we're speaking with part one, but the claim is for part two.
[CUSTOMER][NEUTRAL] Part 2, OK.
[CUSTOMER][NEUTRAL] Is it 357-1687?
[AGENT][NEUTRAL] Yes, that's it.
[CUSTOMER][NEUTRAL] OK and.
[CUSTOMER][NEUTRAL] Medical records.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] I think she's a bit confused because she saw that the status as of today is that it had completed, and I tried explaining that just means that it had completed processing and so now we see the information that's needed, um, that I don't think she quite understands when it says completed.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Got you OK.
[CUSTOMER][NEUTRAL] So we had.
[CUSTOMER][NEUTRAL] A failed knee replacement? Am I reading that right?
[AGENT][NEUTRAL] She said he fell off the bed and busted his knee.
[CUSTOMER][NEUTRAL] Oh [PII].
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] And I needed a knee replacement for that. That is awful.
[AGENT][NEUTRAL] Oh yeah, how high up is this bed?
[CUSTOMER][NEUTRAL] I'm right. Oh gosh, OK.
[CUSTOMER][NEUTRAL] I'm trying, I'm just trying to look at these records and figure out what.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] What would be requesting for.
[AGENT][NEUTRAL] Sure, yeah, that's where I was, you know, the, the note like I understand, but it is a bit vague. I wish I had something more particular or specific I could give her.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No yeah I understand where you're coming from on this because it's like mm.
[CUSTOMER][NEUTRAL] I mean we have a diagnosis code.
[CUSTOMER][NEUTRAL] Kind of what else?
[CUSTOMER][NEUTRAL] I guess would be needed.
[CUSTOMER][NEUTRAL] Other mechanic complication other.
[CUSTOMER][NEUTRAL] Let me just look this up because line abbreviates it and sometimes I can I know what I'm doing and sometimes I'm like I don't know what that is.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, OK, so.
[CUSTOMER][NEUTRAL] Mm, OK, other mechanical complication of other internal orthopedic device implants and grafts. OK, so there was a complication which is why I think his.
[CUSTOMER][NEUTRAL] His claim form says that he had a failed.
[CUSTOMER][NEUTRAL] Knee replacement.
[CUSTOMER][NEUTRAL] I think that's why, so.
[CUSTOMER][NEUTRAL] Because there's not really anything on here that indicates.
[AGENT][NEUTRAL] Oh, so we would just need like the supporting evidence of that.
[CUSTOMER][NEGATIVE] Yeah, like, yes, he had a failed knee replacement, but is, is the knee replacement not good because he just had it and he failed and.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You know, because she's saying he fell and busted his knee. So is it.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] The injury, the reason why this failed or is it just because if it's not accident related with with it being an you know an accident policy then.
[AGENT][NEUTRAL] I see. OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That then it's not gonna be, you know what I'm saying, yeah.
[AGENT][POSITIVE] Right. Yes, yes, that makes perfect sense.
[CUSTOMER][NEUTRAL] Plus we don't have her um.
[CUSTOMER][NEUTRAL] Or his claim form, this is just the attending claim form?
[CUSTOMER][NEUTRAL] Um, that I can see.
[CUSTOMER][NEUTRAL] I mean unless we've received something previously and just hadn't let's see.
[CUSTOMER][NEUTRAL] What is that 1 54 73? Let me see what that says. Oh, that's the record request.
[CUSTOMER][NEUTRAL] Oh hang on there it is.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Because I'm wondering like did she submit something before?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] What have we paid before?
[CUSTOMER][NEUTRAL] So many components here.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, that's a screening so that it's not gonna matter.
[CUSTOMER][POSITIVE] And that's a screening. OK, so what we've paid so far it's just been a screening so we haven't paid on anything, I guess that's good news.
[CUSTOMER][NEUTRAL] Um, so it's not like we've already paid for this accident and we're trying to see if there's something else. It's really just determining this accident, so let me look at one last thing and then I should be able to kind of explain what's going on here.
[AGENT][NEUTRAL] I see. OK.
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Uh, why is that doing that?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEGATIVE] Because it looks like we received something previously and we denied that for um.
[CUSTOMER][NEUTRAL] That we needed supporting documentation to evidence the accident and when it occurred which could be office notes, hospital admission and discharge summaries like all of that.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I did, yeah, I read, I read her that. I was just looking in the uh COREM, um, and I think she's, she must have had some experience with us before, because at that point she goes, can I just speak to someone in claims? I was like, OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Bless it.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] What we received previously was essentially something from her primary payer.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] An office visit on [PII] and that's pretty much it.
[CUSTOMER][NEUTRAL] Like there wasn't anything there, there were diagnosis codes, but they weren't accident related until, until we got the claim form from the physician.
[AGENT][NEUTRAL] Right, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] So he was complaining of pain.
[CUSTOMER][NEUTRAL] In both of his knees truly pain in left knee pain in right knee, that was, of course, if he fell, he like, I mean, I'm assuming he hit both. I don't know, I don't know how this pain but
[AGENT][NEUTRAL] I don't either.
[CUSTOMER][NEUTRAL] When he went on 23 it says presence of left artificial knee joint, so he already had the artificial joint it looks like.
[CUSTOMER][NEUTRAL] And then and now I don't know when that was in there and then this one says.
[CUSTOMER][NEUTRAL] Mechanical complication of like an implant or an orthopedic device.
[AGENT][NEGATIVE] Oh, what a mess.
[CUSTOMER][NEUTRAL] So it could be, yeah, so it could be he already had it, he fell, he went in for pain, looks like the something happened to the joint, but that's what the records are for. Uh, and I'm, I can explain that, but yeah, it's just piecing it all together and girl.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I see. OK.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] No kidding. Yeah, that's a lot. I'm finding those missing pieces. Um, all righty. Well, I sure appreciate your help. Are you ready to talk to her?
[CUSTOMER][NEUTRAL] It's everywhere. I know, I know.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I can take her.
[AGENT][POSITIVE] OK. All right. I will send her over. Thank you, [PII].
[CUSTOMER][POSITIVE] OK, you're welcome.
[AGENT][NEUTRAL] All right, bye.
[CUSTOMER][NEUTRAL] Bye.