AccountId: 011433970860
ContactId: c49eb2b1-1c52-4084-8b9f-f2f354e9fb46
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 653179 ms
Total Talk Time (AGENT): 401073 ms
Total Talk Time (CUSTOMER): 155286 ms
Interruptions: 6
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/23/c49eb2b1-1c52-4084-8b9f-f2f354e9fb46_20250523T22:04_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][POSITIVE] Hey Ms. [PII], this is [PII] in my care team. How are you today?
[AGENT][POSITIVE] I'm good how are you [PII]?
[CUSTOMER][POSITIVE] Being good ready for this long weekend.
[AGENT][NEUTRAL] I know it
[CUSTOMER][NEUTRAL] Girl, alright, well I've got an insured on the line. He's calling regarding a um Medlink claim and the denial notes simply state that it's not a covered loss, um, and she stated that there's been multiple claims filed that are identical and she doesn't know what's so different about this one.
[AGENT][NEUTRAL] OK, what's the policy?
[CUSTOMER][NEUTRAL] It is 982-081.
[AGENT][NEUTRAL] OK, um, which claims specifically are we looking at?
[CUSTOMER][NEUTRAL] It is, yes, um, it's uh 355-623-2.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see, it looks like it was.
[AGENT][NEUTRAL] Mm, OK, hang on.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] I think I might know what's going on here, but I'm gonna double check.
[AGENT][NEUTRAL] Looks like she was in there for treatment for cancer.
[AGENT][NEUTRAL] I'm gonna look at her policy and
[CUSTOMER][NEUTRAL] Yeah, I think she said it was some kind of infusion.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm gonna look at her policy, sir, to see.
[AGENT][NEUTRAL] What it says.
[AGENT][NEUTRAL] For outpatient, let's see.
[AGENT][NEUTRAL] Yeah, I don't see cancer treatment included in her outpatients.
[AGENT][NEUTRAL] Let me double check myself.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Outpatient hospital.
[AGENT][NEGATIVE] Please tell me you can't hear my children in the background.
[CUSTOMER][NEUTRAL] Oh no, I can't. I'm trying not to laugh. I'm sorry. That sounds just like my son.
[CUSTOMER][NEUTRAL] Yeah, but I'm sitting here biting my lip trying not to just start cracking up because it sounds just like my son like.
[AGENT][NEUTRAL] Oh.
[AGENT][NEGATIVE] Oh, they're so loud.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Oh my gosh.
[CUSTOMER][POSITIVE] No, it's it's not that bad, trust me, it's just makes me think of my kiddo, that's it just wild as can be.
[AGENT][NEUTRAL] It was like summer just started, you guys like I need you to simmer.
[CUSTOMER][NEUTRAL] Uh yeah, this was his last day and he's already I'm like, oh man, it's gonna be a long couple of months.
[AGENT][NEUTRAL] Yup, yup. OK, so I don't see treatment for cancer covered in outpatient services. So I feel like this was actually denied appropriately. However, I would have to review her history to review what's been paid in the past and why it may have been paid then and not paid now, um, because as far as.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, that's what I was wondering if she had something similar because she said it's paid before but she can didn't give me anything exact and you know I'm not gonna argue with her so it's like mm let's take a look.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Right. So 623-2, that was processed back in January and the claim before that that was paid was like.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Over a year ago.
[AGENT][NEUTRAL] And I don't even see, well, I say it was paid, let's see.
[AGENT][NEUTRAL] 623-2 we paid something after that.
[AGENT][NEUTRAL] Also in a facility, let me see what that one looks like.
[AGENT][NEUTRAL] Because that may be the confusion is like for data service 116.
[CUSTOMER][NEUTRAL] It, yeah.
[AGENT][NEUTRAL] And this was for 19.
[AGENT][NEUTRAL] We pay but.
[CUSTOMER][NEUTRAL] Oh yeah, maybe that's what she saw it.
[AGENT][NEGATIVE] Yeah, like, oh we all paid this one. Why didn't you pay the other one? And that could be that actually 116 shouldn't have been paid.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So let me see.
[AGENT][NEUTRAL] I don't even know what this. Oh, that looks like surgery. That may be why.
[AGENT][NEUTRAL] Let's see 36598.
[AGENT][NEUTRAL] Nope, uh, it may be imaging that's also payable in an outpatient setting.
[AGENT][NEUTRAL] That's a contrast material.
[AGENT][NEUTRAL] Um.
[AGENT][NEGATIVE] Questionable.
[AGENT][NEUTRAL] Uh, don't know about that one.
[AGENT][NEUTRAL] Yeah, I'm gonna have to look at that one. I'm trying to figure out what the heck may have paid that would cause the confusion because it looks like she's had several yeah um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] That made her think that, right.
[AGENT][NEUTRAL] Like I said, the last thing I see is paid was 35 of 24, so a year ago.
[AGENT][NEUTRAL] And that was paid at 2800.
[CUSTOMER][NEUTRAL] Yeah, I think she might have got confused like you said from this most recent one that did pay because it is the same facility it's or the same provider rather.
[AGENT][NEUTRAL] It is the same facility right, but it looks like it's for different services um and the last thing we paid was for.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 12 of 24 and she had blood work and
[AGENT][NEGATIVE] It looks like she had several procedures, so she had surgery and anesthesia. She had a hysterectomy, like there was all kinds of stuff done on that one. So that would have been paid because surgery in an outpatient setting. So I feel like this was denied appropriately. I don't even truly know that the most recent one should have been paid because it doesn't, I don't see anything.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] If it's something related to that, yeah.
[AGENT][NEUTRAL] Yeah, because what was done 36598.
[AGENT][NEUTRAL] It's a contrast injection for evaluation of existing central Venus access device, so maybe because it's like.
[AGENT][NEUTRAL] I don't know.
[AGENT][NEUTRAL] Cause that would typically be like a surgical topcoat, but that doesn't, that's not surgery. That's an injection of contrast materials. So that is not, obviously.
[CUSTOMER][POSITIVE] Oh, you got me.
[AGENT][NEUTRAL] Yeah, so I'm just kinda like, uh, I don't know um I'm trying to even figure out.
[AGENT][NEUTRAL] If this was released by the examiner or by.
[AGENT][NEUTRAL] A auditor it was released by the examiner.
[AGENT][NEUTRAL] So, um, let me see what these revenue codes are, is she wanting to talk to me directly or she just wanting like what is she needing from us today?
[CUSTOMER][NEGATIVE] She didn't say exactly uh she wanted to of course more clarification as to what that meant or she did well when I read her, of course that it's saying that it was not a covered loss, that's when she said, but it is, and then she brought up that it paid before and so that's when I was like I'm not stepping on toes. I will get with someone else.
[AGENT][NEUTRAL] Oh, you know what?
[AGENT][NEUTRAL] I can I see where she may be saying that because we paid for the 36598 and that revenue code on that on that next claim for 116 and it has a revenue code of 361 and that revenue indicates a minor surgery so operating services and on this claim there's 36593.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it's the declotting of that same device that we paid for for 116.
[AGENT][NEUTRAL] So it's also indicating, I, it was hidden because all I was seeing was therapy and everything. So, uh, it may be qualifiable honestly because of that one code. So if you want to relay to her that I'm gonna have this reviewed.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] I can.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Because that code she may be right, but I don't wanna say yeah you're right just let her know that we're gonna review it yeah and um once I have that reviewed you know we're out Monday and nobody else is here so um I will I'm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yes, OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I probably say like Tuesday or something. I'll, I'll just blame the holiday.
[AGENT][NEUTRAL] Yeah tell her Tuesday because of the holiday at the earliest, but Wednesday could be a possibility so I would say give us until next week to get back to her but we are going to review it.
[CUSTOMER][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure, OK, I will let her know, um, do you want her to call back?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] OK, uh, that is [PII].
[AGENT][NEUTRAL] OK, um, the only thing that I, and you don't have to tell her this but just what I'm thinking is that it does leave responsibility but it's for everything and we may not because that was.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I don't know, it may be that we need a more detailed broken down like you'll be broken down by charge because we may only be able to pay for that charge. I'll have that's part of the review, so.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][POSITIVE] Sure, OK, I can just tell her we'll take a deeper look at it, um, and then we'll get back with her. I'll just try to keep it as vague as I can. All right, well I sure appreciate your help, [PII]. Have a good weekend.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] For sure. OK.
[AGENT][NEUTRAL] Yeah, yeah.
[AGENT][POSITIVE] No problem at all. You too.
[CUSTOMER][NEUTRAL] Alright, bye.
[AGENT][NEUTRAL] All right, bye.