AccountId: 011433970860
ContactId: c5102ce1-e621-47a4-bb51-b61729488888
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1156780 ms
Total Talk Time (AGENT): 515288 ms
Total Talk Time (CUSTOMER): 557146 ms
Interruptions: 13
Overall Sentiment: AGENT=0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/30/c5102ce1-e621-47a4-bb51-b61729488888_20241230T19:31_UTC.wav
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[AGENT][POSITIVE] Thank you for calling American Public Life. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], it's [PII]. How are you?
[AGENT][POSITIVE] Hi good how are you?
[CUSTOMER][NEUTRAL] I'm doing fine. I have, I'm not planning on transferring this lady. I'm trying to not do that, um, but she has uploaded a picture just now into her portal of a prescription.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Cause we have reviewed a claim for her back in October for a scan that she had done, but we denied it needing a diagnosis code.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I don't, I mean, this is not gonna have a code. I think it just has like.
[CUSTOMER][NEUTRAL] You know,
[CUSTOMER][NEUTRAL] Verbally, the diagnosis, not, it doesn't include a diagnosis code. No, but it's on a prescription. It is.
[AGENT][NEUTRAL] So the, the
[AGENT][NEUTRAL] But it is the wording.
[CUSTOMER][POSITIVE] It says CT OK, they're ordering CT, you know, doctor's writing, gotta love it, right.
[CUSTOMER][NEUTRAL] OK. 9:10 is when the prescription was written. She had her scan done at [PII], but it says CT scan, abdomen, pelvis without IV or PO contrast, diagnosis flank pain, questionable kidney stone.
[AGENT][NEUTRAL] OK. Uh, I mean, it, it would, we would be able to, if it's from the doctor and it's a, uh, a description of the diagnosis, uh, we can get a code for it. So as long as it's coming from a doctor, we can use that. But you said that's dated [PII].
[CUSTOMER][NEUTRAL] Is that
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII] and the scan was [PII].
[AGENT][NEUTRAL] Let me, what's her policy?
[CUSTOMER][NEUTRAL] 206-3960
[CUSTOMER][NEUTRAL] For [PII].
[AGENT][NEUTRAL] So [PII]:10 is the prescription.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I mean, I told her that I would make a note if that was sufficient, but I mean, I.
[AGENT][POSITIVE] It is sufficient.
[CUSTOMER][NEUTRAL] But with the dates not being on there that was like because the script is for.
[AGENT][NEUTRAL] Uh,
[AGENT][MIXED] Right, um, I mean, I would, I would tell her the description is OK. However, with the date not matching the service date.
[AGENT][NEGATIVE] Um, because that doesn't make sense. Why, why would they?
[CUSTOMER][NEUTRAL] Well, you know, he writes the prescription, but I'm sure it's just like with anybody else. I know with every scan that I've had done, you know, it's not like you can get it done that day. You've got to get approved that, you know what I mean so I don't know, uh uh.
[AGENT][NEUTRAL] Is the doctor
[AGENT][NEUTRAL] Uh, let me see.
[CUSTOMER][NEGATIVE] She, I'm just afraid to be down with her call.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] But let me just ask you this. The doctor on the.
[CUSTOMER][NEUTRAL] Uh, um.
[AGENT][NEUTRAL] Prescription. Does the name even match this Qualare Medical Group?
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Um, his name on this, oh, I just closed out of it.
[CUSTOMER][NEUTRAL] It has urology. Hold on, I'm trying to open back up. Give me just a second.
[AGENT][NEGATIVE] Let me see, let me look because that was denied as a dupe. Let me look at the first one and see what name we used on there.
[CUSTOMER][NEUTRAL] Yeah,
[CUSTOMER][NEUTRAL] Really?
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Why does it keep pulling back?
[CUSTOMER][NEUTRAL] [PII], let's see.
[CUSTOMER][POSITIVE] Nice.
[AGENT][NEUTRAL] OK. I mean, you can, it's not matching information. I mean, the, the date doesn't match and the doctor isn't matching what we originally received.
[CUSTOMER][NEUTRAL] So, yeah, because this [PII] is like the radiologist.
[CUSTOMER][NEUTRAL] Is what she's telling me.
[AGENT][NEUTRAL] OK, so he would read.
[CUSTOMER][NEGATIVE] Yeah, he's not gonna have the, he's not gonna be the one, yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] With a diagnosis, OK. This urology.
[AGENT][NEUTRAL] She needs to get a description from
[AGENT][NEUTRAL] The provider for the date of [PII]. Is she saying, is she explaining why it's not matching [PII]? Because the same way she got it, she can.
[AGENT][NEUTRAL] Contact the [PII] and ask for a description or the diagnosis code for her data service of [PII].
[CUSTOMER][NEUTRAL] Well, that's the radiologist.
[AGENT][NEUTRAL] OK, so even the doctor that
[AGENT][NEUTRAL] Supposedly ordered the, ordered it. Even his information should match.
[CUSTOMER][NEUTRAL] Mm. That that is.
[AGENT][NEUTRAL] That he's ordering X-rays to be done.
[AGENT][NEUTRAL] For the diagnosis, not a prescription. Like there should be matching information.
[CUSTOMER][NEUTRAL] [PII], can I join her in because I, I'm getting
[CUSTOMER][NEUTRAL] I don't, I don't
[AGENT][NEUTRAL] So what is she arguing the like what is her, what you can't join her in, but just update me on what, what's going on with her.
[CUSTOMER][NEUTRAL] Well, she just says.
[CUSTOMER][NEGATIVE] She doesn't, you know, I mean, she doesn't understand why it's not being denied, why there's never been a problem before. It's one of these where you try to tell her, you know, she's like, I'm the patient, I'm not the, you know, I'm not a coder, I'm not this, I'm not that. I can't.
[CUSTOMER][NEUTRAL] It's just that type of call.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Like she, you know, she doesn't understand and I said it's, it's just like with.
[CUSTOMER][NEUTRAL] Your provider filing your primary insurance, there are certain things that they have to provide them. A diagnosis code is one of those things and it's also one of the things that we have to have, but we don't have that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, so let go ahead and put her in it and see if I can simplify it, um.
[CUSTOMER][NEUTRAL] I mean, I don't
[AGENT][NEUTRAL] I don't know, she may just be argumentative, but or either way, we need the information so you can argue all day or just go get the information and ask for it and in a way that I'm telling you to request it. So let me try to tell her how you don't even have to stay on the call, you can transfer her over.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Well, that's OK because I didn't tell her I was gonna transfer so it just it would probably just be better if I just kinda conference her in um.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Yeah, just tell her you, you're bringing in an explanation like a exam examiner or something, yeah.
[CUSTOMER][NEUTRAL] And she's verified, yeah, I am, yeah, examiner, yep, yep, yep, I am. OK, so thank you very much. Hold on, and she's fully verified as well, OK? OK.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hi [PII]. Hi, hi, this is still [PII], and I also have one of our examiners, [PII] on the line who works in our review department and we were discussing uh the claim that you and I have been discussing and [PII]'s gonna give you a little additional information on that to see if she can make this a little um easier to understand on what we need, OK?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, sure. Alright, [PII], can you hear [PII]?
[AGENT][NEUTRAL] Yes, I can. Hi, [PII].
[CUSTOMER][NEUTRAL] OK. Bye.
[AGENT][NEUTRAL] Hi, let me pull up what you uploaded today and
[AGENT][NEUTRAL] Take a look at it really quick.
[AGENT][NEUTRAL] OK, [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so I'm taking a look here and I see that you uploaded a copy of a prescription.
[CUSTOMER][NEUTRAL] Yeah, with the DX, uh, the diagnosis that the doc, why the doctor ordered the CT scan, the diagnosis.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK. So I do see that, that, you know, there is a description of a diagnosis here. Uh, however, with the date,
[AGENT][NEUTRAL] Uh, because it is a prescription, we need more information that's matching. So, is the doctor not able to give you, um,
[AGENT][NEUTRAL] An actual code because you can request the code from him.
[AGENT][NEUTRAL] Uh, for the, um, X-ray, for the order of the X-ray. Was there no paperwork provided? Um,
[CUSTOMER][NEUTRAL] Well, I haven't, I, well, I had the paperwork that was provided to me. I gave to you all that I had. So I had um I had this prescription to go do the scan.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then after I did the scan, I got a bill and, and I sent you that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and in between I got an explanation of benefits, uh, showing payment from the primary insurer, and I gave him that and those are the three papers that I received as a patient.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me take a look at what you sent prior and so this is for the data service of [PII], correct?
[CUSTOMER][NEUTRAL] Yeah, and I'm sorry but the the primary insurance it was included with like 3 different things. So like the mini clinic was on there is on the same piece of paper. They just combined it, I guess they were saving paper, so it did lead to some confusion. I was not trying to get mini clinic again, but it was just on that page, so it's kind of messy, yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. So, yeah, sometimes we do get that in the future, if you have to submit a claim, just um cross through the dates that you do not want to be considered and that'll, uh, that way, you know, we're not asking for information, you know, that you're not trying to get those charges paid. Um, so let me see. Hold one moment. Let me just look at this and make sure before
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I ask you, you know, just before I say additional information is needed.
[AGENT][NEUTRAL] I'm sorry it takes a little time to load.
[CUSTOMER][NEUTRAL] Yeah, I mean, the, the, I, I, I was wondering, I was starting to doubt myself. I thought this policy was supposed to help with the deductibles, but the, the radiologist's office says I owe it because I have a deductible, and I'm like, well, wait a minute, I have this secondary policy that's supposed to help with that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And she wasn't really that aware of those things, you know, even though I asked her to please give you the diagnosis code it was denied because I didn't have it, um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] So you might get another thing from them. I don't know, they weren't really that well put together. I, cause I had trouble with them.
[CUSTOMER][NEGATIVE] Just scheduling the scan. It was hard.
[AGENT][NEUTRAL] OK, OK, so this is a, OK, so I'm, I'm, um.
[AGENT][NEUTRAL] I see that the procedure that we did receive, um, it does show uh the CAT scan of the abdomen and pelvis. I do believe um with the prescription that was written for, um, for you to get the CAT scan.
[AGENT][NEUTRAL] I think uh when I first talked to [PII], I was a little confused. I thought it was just like a, a prescription like from the pharmacy type of prescription. So, I feel that that would be, you know,
[AGENT][NEUTRAL] Uh, we will have problems with that, but I do believe this would work. Uh, if you don't mind holding really quick, I'll speak with the team lead, um, just to make sure. This may be enough information to pay the claim.
[CUSTOMER][POSITIVE] OK, OK, good. Great. Thank you. I'll hold.
[AGENT][NEUTRAL] OK, hold, hold one moment, [PII].
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, where is
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Well, the music loud, yeah it is.
[AGENT][NEUTRAL] OK. Thank you for holding. Sorry for the wait, guys. So this would be enough information for your particular charge. Um, just so there's not any issues, I'll go ahead and
[CUSTOMER][POSITIVE] Oh good, good, good.
[AGENT][NEUTRAL] Uh, take care of the charge myself. Go ahead and reprocess it, uh, myself and get, get this, this, uh, one paid. But your policy is definitely set up to help you with deductible, um.
[CUSTOMER][POSITIVE] Thank you very much. Thank you.
[CUSTOMER][NEUTRAL] Yeah, yeah, I mean.
[AGENT][NEUTRAL] In this instance, because it is the radiologist, I'm guessing um.
[AGENT][NEUTRAL] When you go, you may, the easiest thing is to, if you're going to have to file a claim yourself, if they're saying that they will not file the claim on your behalf.
[AGENT][NEUTRAL] The best thing to do is ask them for a um an itemized bill with your procedure code and ICD 10 code.
[AGENT][NEUTRAL] And then once you receive your explanation of benefits, you can submit that the documentation uh to us, but if you, uh, you know, let them know the ICD 10 code, that is the medical terminology for the diagnosis code, and they would know exactly what you're requesting.
[CUSTOMER][NEUTRAL] OK, so I guess the bill, I mean the bill they gave me had codes on it, but are those not the right codes?
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEGATIVE] Must not be.
[AGENT][NEUTRAL] So I'm looking at, um, I just looked at.
[AGENT][NEUTRAL] I saw the explanation of benefits and the, your explanation of benefits does have the procedure code on there, but the ICD 10 code is not there. And most times a provider will not put the ICD pin code, you would have to request that uh just due to privacy. They normally would not put that information on your bill, so you would have to request that information.
[CUSTOMER][POSITIVE] I see, OK, that's all new to me, so thanks for explaining it.
[AGENT][POSITIVE] No problem, but if you have any other questions or issues, just give us a call, but I will go ahead and take care of this charge for you.
[CUSTOMER][NEUTRAL] Well, there, yeah, yeah, there was another claim related to this diagnosis that was also denied, um.
[CUSTOMER][NEUTRAL] that they're not coming after me yet, but I expect they will try to get I submitted it.
[CUSTOMER][NEUTRAL] And it got rejected, but I didn't have a bill and it was, it was a procedure at the urologist's office after the CT scan. It was um cystocystography cys.
[CUSTOMER][NEUTRAL] he went, he
[AGENT][NEUTRAL] What is the service date? Do you know the service date for it?
[CUSTOMER][NEUTRAL] Uh, yeah, I'm gonna look that up. Let's see, uh, it was not too long, it was, it was in October.
[AGENT][NEUTRAL] Is it the [PII] charge?
[CUSTOMER][POSITIVE] Yes, exactly, yes.
[AGENT][NEUTRAL] OK, let me look here.
[CUSTOMER][NEUTRAL] It's totally, it's the same diagnosis uh for that procedure too.
[AGENT][NEUTRAL] OK, OK, because I do show we did request the
[AGENT][NEUTRAL] Explanation of benefits on that one and it is also on the same explanation. I'm sorry, we did request the ICD 10 code, the diagnosis code. It is on the same explanation of benefits, so I will take care of both charges.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Perfect perfect and uh and I'm glad the stone is gone so I'm not I'm, I'm gonna drink a lot of water, you know, this has been quite a learning experience I can tell you we did have a hot summer here in [PII] and I probably shouldn't have gone to Disney because I got a little dehydrated, so, um.
[AGENT][POSITIVE] Well, that's good.
[AGENT][NEUTRAL] Mm, OK. OK. Well, I will.
[CUSTOMER][NEUTRAL] And, and I take a, I take a blood pressure med and it, it totally dehydrates you, you know? It's a water pill, you know, so, um.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That's true. That's true.
[CUSTOMER][NEUTRAL] Yeah, and then, and, you know, I tell people and then all these stories come out, these kidney stone stories of all these people, and I'm like, wow, you do, you know, but this is my first time. Um, I'm not sure I would go through all this stuff the second time, you know, I would probably just let it pass and not do all these tests, but I just did what the doctor told me to do, you know.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah. OK. Well, we will, uh, like I said, I'll get that taken care of. Um,
[AGENT][NEUTRAL] And uh there shouldn't be any issues with these two charges, uh, with this diagnosis.
[CUSTOMER][POSITIVE] That's, that's great to hear. I mean, it's hard enough to be sick and not feel well, and then it's, you know, it's an added problem when it just becomes a financial problem too. So I thought it was supposed to be covered and I'm hoping it would be, and I'm glad to hear you could help [PII]e so much today. I thank you.
[AGENT][POSITIVE] OK. No problem. You guys have a wonderful day. Is there anything else you need from me, [PII]?
[CUSTOMER][NEUTRAL] You too.
[CUSTOMER][NEUTRAL] Uh, this is [PII], it's that's, it's OK. I need it. I told, that's OK. I told [PII], well you put us on hold. I said, we do have it, [PII]. I said, no, it's all good, but no.
[AGENT][NEUTRAL] Oh, [PII], I'm sorry.
[AGENT][POSITIVE] I'm so sorry.
[AGENT][POSITIVE] Oh I'm sorry. You both have that sweet voice. I'm sorry.
[CUSTOMER][POSITIVE] Oh well that's good to know. So I'm good. Is there anything else, [PII], that I can help you with before we go today?
[CUSTOMER][NEUTRAL] No [PII], thank you. Well, you are so welcome and if there is any other questions you just give us a call but otherwise I hope you have a very nice afternoon and [PII]. Can I, can I ask you another question? I don't end this phone call. So, so I don't know if you noticed the policy lapse because my employer.