AccountId: 011433970860
ContactId: c4b25f09-bcab-4bb9-8243-b66e81a088f3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 638630 ms
Total Talk Time (AGENT): 304994 ms
Total Talk Time (CUSTOMER): 192734 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/01/c4b25f09-bcab-4bb9-8243-b66e81a088f3_20250401T13:30_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], I need some assistance in regards to uh a claim.
[AGENT][POSITIVE] OK, well I can definitely help you with the claim and may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] 256.
[CUSTOMER][NEUTRAL] 453 2.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII] I mean [PII].
[AGENT][NEUTRAL] You're the patient?
[CUSTOMER][NEUTRAL] I am the patient, yes.
[AGENT][NEUTRAL] OK, you said the policy number was 256-453-2?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And I just need you to verify your date of birth and your mailing address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you and the email address on file.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, and all the information provided is a verification of benefits, not a guarantee of payment, and is the claim for you, your spouse or dependent?
[AGENT][NEUTRAL] All right, may I have the date of service for the claim?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Is it from integrated sleep care?
[CUSTOMER][POSITIVE] Yes, correct.
[AGENT][NEUTRAL] OK, here it is.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] I have the claim here. I'm just waiting for the um decision so I can see what it was. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, the claim was denied requesting additional information. So anytime you file a claim, um, you'll need your explanation of benefits from your primary insurance because we're second to them, and then you'll need the itemized bill from the provider, the doctor or hospital, wherever you went, um, that has the diagnosis codes on it, the procedure codes, and all the charges.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So that's what this is being denied for, it's asking for the explanation of benefits from primary insurance and the diagnosis.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so I don't know if you have access to the claim, but the claim has some a couple files attached and one is the explanation of benefits and the other one is the itemized bill.
[AGENT][NEUTRAL] OK, hold on one moment, let me pull the documents.
[AGENT][NEUTRAL] It's coming up now. Hold on one second.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, so those are the claim forms with this.
[AGENT][NEUTRAL] Hold on one moment. The pages are populating. It's quite a few.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Of the pages that you sent over, do you know what pages the explanation of benefits is and the itemized bill?
[CUSTOMER][NEUTRAL] OK, so the itemized bill.
[CUSTOMER][NEUTRAL] The file name
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] Um, integrated sleep care.
[CUSTOMER][NEUTRAL] It's the PDF?
[AGENT][NEUTRAL] Alright, I just need the page number because it's 103, so I'm just trying to get to the page. It doesn't show me the file names.
[CUSTOMER][NEUTRAL] 100
[CUSTOMER][NEUTRAL] 103?
[AGENT][NEUTRAL] Yeah, it looks like it might just be, yeah, this is just the claim form over and over.
[CUSTOMER][NEUTRAL] What?
[CUSTOMER][NEUTRAL] Can be
[CUSTOMER][NEUTRAL] A claim form, so how many documents did you attached?
[AGENT][NEUTRAL] So again, it's not attachments, it's like the actual imaging, um.
[AGENT][NEGATIVE] So I don't know how many files were attached. I, I just see the images of the pages and it's 103 pages, but it's the same thing over and over.
[AGENT][NEUTRAL] So let me see if I'm
[CUSTOMER][NEUTRAL] Oh no, it, it might be a system glitch because uh from my end I'm seeing one page and it says statement.
[CUSTOMER][NEUTRAL] And then I see another page it says policy.
[CUSTOMER][NEUTRAL] And I think that's not the policy I'm gonna change it instead of instead of uploading the.
[CUSTOMER][NEUTRAL] The explanation of benefits I uploaded the policy. I'll I'll change that right now.
[CUSTOMER][NEUTRAL] But the itemized invoices there. It says statement and it has a code.
[AGENT][NEUTRAL] So I would say to just
[AGENT][NEUTRAL] I would say to just resubmit it, um, resubmit the resubmit all you need is the claim form, the itemized bill, and the explanation of benefits from primary insurance, um, because I don't know what.
[AGENT][NEUTRAL] I would just resubmit it because this is 103 pages of the same thing over and over. I don't know where it got lost in translation, but I'm just trying to get you so we can process the claim.
[AGENT][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Alright, let me find out thank you.
[AGENT][NEUTRAL] Yeah, cause I, I just went through them again and yeah, it's, it's literally the same thing over and over.
[CUSTOMER][NEUTRAL] So what is, what is, what are you seeing right now?
[AGENT][NEUTRAL] So I see you actually, your actual policy certificate, so that's your your policy um with all your coverage. Correct.
[CUSTOMER][NEUTRAL] For APO, right?
[AGENT][NEUTRAL] And then, uh, what is this? This is the poli so this is all the policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I don't even see the.
[CUSTOMER][NEUTRAL] OK, scroll down. You're gonna see a, you're gonna see a you're gonna see a a colored.
[CUSTOMER][NEUTRAL] Um, they didn't tell me to, to submit a claim form. They just told me to upload those two documents, so I need to submit a claim form.
[AGENT][NEUTRAL] Right. Anytime you're submitting a claim, the claim form, explanation of benefits, and itemized bill are the only three things you need.
[CUSTOMER][NEUTRAL] OK, so where do I find the, the claim form?
[AGENT][NEUTRAL] So you can go to our website, [PII].
[CUSTOMER][POSITIVE] Yeah, I'm here I'm here right now.
[AGENT][NEUTRAL] At the top right corner, you'll see where it says claims and forms. You'll click on that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you're looking for the Medlink claim form. It's an alphabetical order. You're gonna have to scroll down until you see uh policy documents and forms.
[CUSTOMER][NEUTRAL] OK, what's the name again? [PII]?
[AGENT][NEUTRAL] I'm sorry. Medlink claim form.
[CUSTOMER][NEUTRAL] What's the name of the form? OK, let me see.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEGATIVE] Yeah, this is just the, yeah, I just went through it again. This is just the policy over and over.
[CUSTOMER][NEUTRAL] OK download form.
[CUSTOMER][NEUTRAL] OK, I got the form. I'll, I'll, I'll work on that now I submit it again.
[AGENT][NEUTRAL] All right, and on your itemized billing, are you, um,
[AGENT][NEUTRAL] Is it the patient bill that you have or is it the itemized bill from the provider?
[AGENT][NEUTRAL] Because the patient bill has coating on it too.
[CUSTOMER][NEUTRAL] If the item is built from the provider.
[CUSTOMER][NEUTRAL] And it has uh right now.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So it has uh uh check date, policy number, reference, insured, claim number, payment.
[CUSTOMER][NEUTRAL] Um, total charges from to patient.
[CUSTOMER][NEUTRAL] ACC action.
[AGENT][NEUTRAL] I just need to know if it had, do you see anywhere that says diagnosis code or it might say DX code?
[CUSTOMER][NEUTRAL] Patient action number?
[CUSTOMER][NEUTRAL] Mm, give me one second.
[AGENT][NEUTRAL] Or do you just see hick picks and CPT?
[CUSTOMER][NEUTRAL] Give me one second, I'll tell you right now what I see.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I see, uh, code says patient name date and then this and it says code.
[AGENT][NEUTRAL] Is it numbers and letters or just?
[CUSTOMER][NEUTRAL] And the code is 95.
[CUSTOMER][NEUTRAL] It's just numbers 95,800.
[AGENT][NEUTRAL] OK, do you see any other?
[CUSTOMER][NEUTRAL] And thenation action.
[CUSTOMER][NEUTRAL] Patient action number HF 512014253.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, do you see any other numbers that have like a DX next to it? So what you're looking at with the 9 number, that's the procedure code. I'm trying to see if there's a diagnosis code to let you know that's a good document or if you need to get something else, because it sounds like that's your patient bill.
[CUSTOMER][NEUTRAL] Yeah, so what's the, what's the ACCT number?
[CUSTOMER][NEUTRAL] Patient ACCT number.
[AGENT][NEUTRAL] That's account number. You're looking for either DX or CPT. If you see CPT or um Hick picks.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That's that 9 number that's on there. You'll just see numbers for that. The
[CUSTOMER][NEUTRAL] CPT or BX B as in boy?
[AGENT][NEUTRAL] D like dog.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So if you see that on your doc if you see that on your document, then the DX code, that's the diagnosis code. If it's not on there, then that's your patient bill and we need the hospital's version of the bill.
[CUSTOMER][NEUTRAL] And then X
[AGENT][NEUTRAL] They may call it a universal bill as well, um, depending on locations, itemized bill, universal bill is the same thing, but we just need their version because it shows the diagnosis, which is why the treatment, which is what you got for it and then how much you paid versus the patient bill just shows what you received and what you paid, not why.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][POSITIVE] OK, OK, let me ask for that, thank you.
[AGENT][POSITIVE] You're welcome. Was there anything else I can help you with today?
[CUSTOMER][NEGATIVE] No thank you.
[AGENT][POSITIVE] Alright, thanks for calling APL. Bye bye.