AccountId: 011433970860
ContactId: d011d825-fb0b-4b4a-a70b-e5f329140f78
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 509380 ms
Total Talk Time (AGENT): 165513 ms
Total Talk Time (CUSTOMER): 281192 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/26/d011d825-fb0b-4b4a-a70b-e5f329140f78_20250626T12:41_UTC.wav
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[CUSTOMER][NEUTRAL] Take this with you.
[AGENT][NEUTRAL] This is. How may I help you?
[CUSTOMER][NEUTRAL] Hi, good morning, um, I'm calling because I'm having a little bit of issues, um, accessing my claims online. I see that a claim got denied or didn't get paid, and I'm trying to see what information is missing.
[AGENT][NEUTRAL] May I have a policy number?
[CUSTOMER][NEUTRAL] Yeah, one second, um.
[CUSTOMER][NEUTRAL] Would the policy number be like the payer ID or?
[AGENT][NEUTRAL] No, ma'am. It should say certificate number, inpatient or outpatient cert number.
[AGENT][NEUTRAL] I can take a claim number.
[CUSTOMER][NEUTRAL] Um, I think inpatient benefit cert number, is that it?
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK, 023.
[CUSTOMER][NEUTRAL] 392[PII]35 M as in Maria L as in Lucas 7.
[AGENT][NEUTRAL] May I have your name and a good call back number?
[CUSTOMER][NEUTRAL] Yeah, this is [PII] and a call back is [PII].
[AGENT][NEUTRAL] Can you verify your date of birth, your mailing address, and your email, please?
[CUSTOMER][NEUTRAL] Yes, [PII], um, [PII] zip code is [PII], and, um, email is [PII].
[AGENT][NEUTRAL] Thank you for verifying that information. Please be advised that verification of coverage does not guarantee the payment of a claim. So we do have a different email on file.
[AGENT][NEUTRAL] When you were accessing it.
[CUSTOMER][NEUTRAL] Oh, it's probably my husband.
[CUSTOMER][NEUTRAL] Yeah, and it might be my husband's MDSM 44.
[CUSTOMER][NEUTRAL] Um, [PII], does that sound right?
[AGENT][NEUTRAL] Correct. When you were trying to access it, did it ask you for an email?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, yeah, I mean, I access it through my there's like a new online portal now, um, and it's just the new portal is a little bit wonky like it won't let me see.
[CUSTOMER][NEUTRAL] You know how you guys usually like produce some sort of statement for the claim um it won't let me access the statement so I don't know like what happened um with this uh with this claim that I'm trying to get approved so you know I thought I could just do it over over the phone.
[AGENT][NEUTRAL] OK, do you have the claim number or who is the claim for?
[CUSTOMER][NEUTRAL] Um, I don't have the claim number, but, um, the claim is for it. I can tell you when it was made. Um, I think it's, it's the last claim. I think I put it in like [PII] or something like that. It's for [PII] for our daughter.
[CUSTOMER][NEUTRAL] Um, and it was an ER visit.
[AGENT][NEUTRAL] OK. Looks like the ER visit on [PII].
[AGENT][NEUTRAL] Under claim number, so this one processed under 3614409 and looks like they denied it as a due. Let me go find the original.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] They denied what, sorry?
[AGENT][NEUTRAL] As a duplicate?
[AGENT][NEUTRAL] Let me see if I can
[CUSTOMER][NEUTRAL] Well, yeah, because I had submitted, I had submitted that claim before, um, but the issue was like I never, we never received an EOB, um, from the insurance because it, it, it took a, it was a massive process, it took a while, so they kept denying it because they needed like an actual statement that showed like, OK, this is an ER visit, so I resubmitted it last week because I finally had that.
[CUSTOMER][NEUTRAL] So, uh, I, I mean, I don't know if there's something that we can do about it, um.
[AGENT][NEUTRAL] OK, so it looks like they denied it originally. It's not a sickness, not an injury. So it looks like the diagnosis was not a sickness or injury.
[CUSTOMER][NEUTRAL] Yeah, that's why it was right because it was wrong because I didn't like what the only thing I had for that claim originally was a referral from the pediatrician to take my daughter to the ER, but the referral was made in like a, it was made in like a regular appointment if you know what I'm saying. So like we took her to a follow up appointment after she was born, and we were rushed to the ER during that appointment. After that, I didn't get like I didn't get documentation from the ER um.
[CUSTOMER][NEUTRAL] Until June, which is like when I submitted um the explanation of benefits where you can clearly see it's an emergency room visit.
[CUSTOMER][NEGATIVE] So obviously, the baby was sick.
[AGENT][NEUTRAL] OK. So that's what they're looking for, the actual diagnosis. Let me see if there's anything in here.
[CUSTOMER][NEUTRAL] I mean, I think um I think I have submitted in the past like the.
[CUSTOMER][NEUTRAL] The diagnosis stuff, like the referral to be rushed to the ER but there, that, what happened was her temperature dropped a lot. Like there wasn't
[CUSTOMER][NEUTRAL] You know what I'm saying, there wasn't like a diagnosis made. It's just like the doctor told me you need to bring your daughter to the ER, um, so that's what we did.
[AGENT][NEUTRAL] OK. So I'm going through and it looks like on one of the pages.
[AGENT][NEUTRAL] And counter diagnosis it says worried well, discharge diagnosis on [PII].
[AGENT][NEUTRAL] person feared health complaint in which no diagnosis is made with the final diagnosis.
[AGENT][NEUTRAL] So what I'll do with this one.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Because it says reason for visit is [PII]. So what I'll do is I'll send this over.
[CUSTOMER][NEUTRAL] Yeah, sorry, go ahead.
[AGENT][NEUTRAL] And let a supervisor review this.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] Yeah, does it say sorry, let me, sorry to interrupt you there because this was so long ago. Does it say like reason for visit temperature? Is that what it says?
[AGENT][NEUTRAL] Yes, it says, reason for visit temp concern.
[CUSTOMER][NEUTRAL] Right, cause, yeah, cause her temperature was too low. That's why they sent us to the ER um.
[CUSTOMER][NEUTRAL] But you know I think they were missing like some sort of like explanation of benefits which is what I just uploaded so I'm not sure if we can like merge everything.
[CUSTOMER][NEUTRAL] Um, and call it a day or like how they want me to submit this, but I really want to get this paid.
[AGENT][NEUTRAL] OK. So what I'll do is I'll write this up and I'll send it over for review and once they return this um findings on the review, I'll call you back and give you an update on this.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK perfect and then can I ask you for a favor while I have you? We actually moved, um, so we need to change our address to be able to receive the claims and stuff. Can you help me out with that?
[AGENT][NEUTRAL] Yes, ma'am. What is your new address?
[CUSTOMER][NEUTRAL] So the new address is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then um it's [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then the zip code is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, I have [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. So I'll put this in as the request so that they can get that updated. I'll go ahead and send over the write up for this for a supervisor to review and once they determine their findings, I'll give you a call back at [PII].
[CUSTOMER][POSITIVE] Perfect. That would be great. Um, and then obviously, you know, if I need to get any other documentation, um, I, I can do that, but I think we should be.
[CUSTOMER][POSITIVE] We should be all set. Um, it might just be a matter of like merging this, so let me know. I'll be, I'll be, um, I'll have my phone on, so we'll, we'll be expecting your call. Thank you so much.
[AGENT][POSITIVE] You're so welcome and thank you for calling American Public Life, [PII]. Have a great day. Bye-bye.
[CUSTOMER][POSITIVE] Have a good one you too.