AccountId: 011433970860
ContactId: ce3c052f-7584-4520-aa7c-3b37793b5803
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 342920 ms
Total Talk Time (AGENT): 147663 ms
Total Talk Time (CUSTOMER): 158078 ms
Interruptions: 1
Overall Sentiment: AGENT=1, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/22/ce3c052f-7584-4520-aa7c-3b37793b5803_20250522T17:19_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], it's [PII]. How are you?
[AGENT][POSITIVE] I'm good. How are you?
[CUSTOMER][NEUTRAL] I'm alright, thank you. So I have an insured's mother on the line. She was calling regarding a denied claim for the child.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] What's the policy number?
[CUSTOMER][NEUTRAL] And I, it is 214-1813.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The claim number is going to be 359802 I mean the claim is for part three.
[AGENT][NEUTRAL] What's that part number?
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] The day the claim number is 3598064.
[AGENT][NEUTRAL] 35,980 OK.
[CUSTOMER][NEUTRAL] Mhm and I've gone over the remark with her I've explained the um appeal process, but she's wanting more clarification on what that remark code means.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, I can help her with that.
[CUSTOMER][NEUTRAL] And she's fully verified, and this is [PII] on the line.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And her call back number [PII], let me see, hold on, my phone's not up. It's the phone number that's up on the screen that you should see.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yes, ma'am. That's it.
[AGENT][POSITIVE] OK, alrighty.
[CUSTOMER][POSITIVE] OK. All right, thank you. Thank you so much. OK.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Bye-bye.
[AGENT][NEUTRAL] Bye bye.
[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, hi, um, I'm, I was speaking to somebody, uh, due to a claim that was that was denied, um, and they transferred me to you, uh, to see if I can get more clarification on the reason.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And that's a claim for [PII], is that correct?
[CUSTOMER][POSITIVE] That's correct.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, uh, so on this claim that I'm looking at.
[AGENT][NEUTRAL] The claim denied because the policy does not provide benefits for treatments of the conditions other than a sickness or injury. So any claims uh that are submitted to us have to be due to a sickness or injury. Uh, the claim when it was billed to us.
[AGENT][NEUTRAL] Uh, it has the diagnosis code, uh,
[AGENT][NEUTRAL] A feared health, a feared health complaint whom no diagnosis is made. So that basically means that you, you know, you went in because you feared that something was wrong or there was something wrong, but there was no diagnosis made.
[AGENT][NEUTRAL] On that claim. So, if the baby or the child had gone in due to a fever, due to a cough, uh, due to something like that, we would have to have a diagnosis code letting us know that's what they came in due to, uh, other than just a fear complaint.
[CUSTOMER][NEGATIVE] Oh my God. So this is ridiculous. Of course, I took him in for a sickness. Like I, like I'm just gonna go to the ER like, 00 my God.
[AGENT][NEUTRAL] Uh, I mean, we can, we can only go about the diagnosis code that the doctor puts on the information or the hospital puts on the information.
[CUSTOMER][NEGATIVE] I, I cannot believe this.
[CUSTOMER][NEGATIVE] No, I, I understand that, and that's, that's where this type of miscommunication now is costing me something that should be covered, you know, because I, I, he was taken because he was sick. It is a sickness, you know what I mean? So the fact that they didn't put a diagnosis code is like a proper one, is ridiculous. Like, that, that affects me and, and our finances, and it's just ridiculous. And, and I know it's not your fault, but wow. Is there any way that I can like
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Is there any way to dispute this?
[AGENT][NEUTRAL] Um, yes, I mean you can always send us an appeal. You can just send us an appeal, um.
[AGENT][NEUTRAL] Um, you know, letting us know, you know, why you think the claim should be paid, um.
[AGENT][NEUTRAL] And just then send that in to us and we can review it to see.
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Question, if I have like the, you know, they gave me like the paperwork, the discharge papers.
[AGENT][NEUTRAL] You think OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] If I submit that with the appeal, would that probably help?
[AGENT][POSITIVE] Yes ma'am, as much information that you can submit to us, yes ma'am, that would help.
[CUSTOMER][NEUTRAL] Because I usually sleep all of that.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] Alright, I'm also gonna call um the insurance Aetna to see to make sure that that's there's no other diagnosis code on there because.
[CUSTOMER][NEGATIVE] This is just ridiculous.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So how can I, how can I file the appeal? Can I do that um electronically or it has to be by mail?
[AGENT][NEUTRAL] Uh, no, ma'am, you can just write a letter, write a letter in in reference to claim number 3598064.
[AGENT][NEUTRAL] Since that's the claim number that we actually denied the claim under.
[AGENT][NEUTRAL] And just tell us why you think the claim should have been covered and attach any documentation that you want us to review.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I send that where?
[AGENT][NEUTRAL] Um, if you're gonna upload it, you just upload it the way you did your other claims, or you can fax it over to us.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Do you want the fax nu[PII]?
[CUSTOMER][NEUTRAL] OK, I
[CUSTOMER][NEUTRAL] No, it's OK. I'll just upload it that's fine.
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][POSITIVE] All right, thank you for your help. I really appreciate it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You're welcome. Did you have any other questions for me?
[CUSTOMER][NEUTRAL] No, that was all.
[AGENT][POSITIVE] OK, well thank you for calling the APL you have a great rest of your day.
[CUSTOMER][POSITIVE] Thanks, you too.
[AGENT][NEUTRAL] All right bye bye.