AccountId: 011433970860
ContactId: d03f950b-d06c-4cc8-a03b-0054bdaa30ae
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1033618 ms
Total Talk Time (AGENT): 533841 ms
Total Talk Time (CUSTOMER): 248370 ms
Interruptions: 3
Overall Sentiment: AGENT=0.8, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/28/d03f950b-d06c-4cc8-a03b-0054bdaa30ae_20250228T13:25_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Good morning [PII]. I'm just calling to find out um why my claim was denied.
[AGENT][NEUTRAL] OK, so you're the insured and we process the claim for you and you're wanting to find out about why it was denied, is that correct?
[CUSTOMER][POSITIVE] Correct, yes.
[AGENT][POSITIVE] Yes, ma'am. I can help you with that. And who am I speaking with, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you. And Miss [PII], what is a good callback number for you in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, and your policy number, please?
[CUSTOMER][NEUTRAL] 2184473
[AGENT][NEUTRAL] OK, thank you. So if you'll give me just a moment, Miss [PII], to get your information pulled up, then I will need to verify several things with you first for security.
[AGENT][NEUTRAL] And also any information that I provide for you today would be a verification of benefits and not a guarantee of payments, so just one moment please.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and again, Miss [PII], any information that I do provide for you today would be a verification of benefits and not a guarantee of payment. So first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you. Also your home mailing address, please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. The phone number we have for you is the same as the one you gave me, so that is your best contact number, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you and lastly your email address?
[CUSTOMER][NEUTRAL] Oh, excuse me, [PII].
[AGENT][NEUTRAL] OK, thank you so much. So I do see that we would process the claim just yesterday. Is that the one that you're calling about?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, alright, so give me just one moment. I can see to Miss [PII] that you're set up in the online service center so you will have access to this explanation of benefits with the remarks on it, OK? Uh, because it just went through our nightly processing last night that's probably not available for you to see yet but it will be.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so give me one moment to pull up the information on it.
[AGENT][NEUTRAL] This is for Doctor [PII].
[CUSTOMER][NEUTRAL] Yeah, it's for um 2 procedures I had. I was admitted for.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, so give me one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. So the remark on here for the denial states, the medical test for this state of service is not a covered diagnostic test. Therefore, no benefit is payable for this claim.
[AGENT][NEUTRAL] Cover test include MRI, CAT scan.
[AGENT][NEUTRAL] An RAIU, which is a thyroid uptake test, a CT PET scan.
[AGENT][NEUTRAL] Angiogram.
[AGENT][NEUTRAL] Barium, excuse me, barium enema lower GI series.
[AGENT][NEUTRAL] Myelogram, nuclear stress test, arteriogram.
[AGENT][NEUTRAL] Barium swallow, upper GI series, sleep study, and a transesophageal echocardiogram, which is a TEE. Those are the approved diagnostic tests under this limited benefit plan.
[CUSTOMER][NEUTRAL] But it's
[CUSTOMER][NEGATIVE] And it clearly says on here, upper GI endoscopy, so I don't understand how that's not covered.
[CUSTOMER][NEUTRAL] And the other one was, well, colonoscopy, which I don't know if since it doesn't say low or whatever.
[AGENT][NEGATIVE] That is not.
[CUSTOMER][NEGATIVE] But it's a colonoscopy and then an upper, let me see what is it, and then not just that, I was admitted into the hospital under anesthesia, so why wouldn't it pay the benefit for a hospital admit? Like I sent the discharge papers and everything, so I'm, I'm just not understanding.
[AGENT][NEUTRAL] Yes sir.
[AGENT][NEUTRAL] OK, so first off, um, you do have the right to file an appeal, Ms. [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you have, you may do that within 180 days from the date of this decision on this claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you can provide any additional information for our consideration.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now on this particular claim, I only show that this is for the testing, this is not for an admission.
[AGENT][NEUTRAL] Let me look at this
[AGENT][NEUTRAL] Give me just a moment.
[CUSTOMER][NEUTRAL] So I'm OK.
[AGENT][NEUTRAL] I'm sorry, no, go ahead. If you had a question. I'm just trying to look at.
[CUSTOMER][NEUTRAL] So I'm just wondering like if I provided discharge instructions, like what do I need to provide to show that I was admitted? Like I can't be discharged if I wasn't admitted.
[CUSTOMER][NEUTRAL] And I provided the discharge paperwork.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Give me just a moment.
[AGENT][NEUTRAL] And how long were you in the hospital for?
[CUSTOMER][NEUTRAL] It was a day.
[AGENT][NEUTRAL] OK, let me look at the information on your policy as more as far as.
[AGENT][NEUTRAL] What is considered an inpatient admission. So just a moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so your hospital confinement.
[AGENT][NEUTRAL] On here states the covered person must be confined to a hospital as an inpatient on the advice of a physician for at least 18 consecutive hours.
[AGENT][NEUTRAL] To be considered one day of hospital confinement.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So just for clarity, for this, this, I'm reading the paperwork for the upper GI endoscopy, that's not a covered um test or whatever?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Let me
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Go take a shower.
[CUSTOMER][NEUTRAL] It uh
[CUSTOMER][NEUTRAL] That people look at the thing.
[CUSTOMER][POSITIVE] It really does.
[CUSTOMER][NEUTRAL] That's
[AGENT][NEUTRAL] Again, Ms. [PII], just bear with me while I'm looking at a few things, OK?
[AGENT][NEUTRAL] OK, so Miss [PII] I can transfer you over to one of the
[AGENT][NEUTRAL] Uh, claims examiners who can verify how this was coded. I can only see that it's, you know, diagnostic with what your, uh, diagnosis code was, but they could tell you exactly what the procedure code was that we received to be able to answer that better for you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And if you do decide to file an appeal on this, again, you do have 180 days.
[AGENT][NEUTRAL] From the date of the decision and the claim would just be um excuse me, the appeal would be submitted just like you did your claims to but to attention appeals department.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] So what do I do for it? I'm sorry, to file an appeal, what do I need to do?
[AGENT][NEUTRAL] Yeah, ma'am, you're fine.
[AGENT][NEUTRAL] You would
[AGENT][NEUTRAL] Send any additional information you can also include a letter you can send anything that you would like to have reconsidered as to why you're, you know.
[AGENT][NEUTRAL] Appealing the decision on the claim for it to be further reviewed.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And how do I submit it?
[AGENT][NEUTRAL] You can, yes ma'am, I can give you the mailing address that you can send it to because it will need to go to our appeals department.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So it's not anything that can be like uploaded or faxed over, it has to be mailed in?
[AGENT][NEUTRAL] You can, um,
[AGENT][NEUTRAL] Yes, you could upload it into your portal, but it will need to be clearly.
[AGENT][NEUTRAL] Marked as attention appeals so that it is not reviewed it's just a duplicate of a previously, you know, submitted.
[AGENT][NEUTRAL] Claim
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And when I transfer you over, as I said, I will let them know the reason for your call.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Since you're saying that, you know, and that you should not have to re-verify any of your information.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. All right, Ms. [PII]. Well, is there anything else that I can help you with?
[CUSTOMER][NEUTRAL] No, ma'am, that, that's it.
[AGENT][POSITIVE] OK, well thank you so much for calling APL and I hope you have a very nice and safe weekend.
[CUSTOMER][POSITIVE] Thank you, you as well.
[AGENT][POSITIVE] Uh, hi, yes, ma'am. Thank you too. So just one moment, please.
[CUSTOMER][NEUTRAL] Referring.
[CUSTOMER][NEUTRAL] For calling APL, this is [PII]. How can I help you?
[AGENT][POSITIVE] Well, hello, [PII]. It's [PII]. Good morning. Happy Friday.
[CUSTOMER][POSITIVE] Good morning.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Well, I have an insured on the line and I've gone over her claim. I've told her about the appeals process, but
[AGENT][NEUTRAL] OK, first off, the policy number, [PII], I get ahead of myself. It's 021-84473.
[AGENT][NEUTRAL] For [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it's on the most recent claim that was processed on yesterday, 356-927-4.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Went over the remarks. She says that what she has was an upper GI series. Now, all I can see is, you know, it was diagnostic. I read her the full description.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] On the remark
[CUSTOMER][NEUTRAL] OK, let me see this.
[AGENT][NEUTRAL] But I can't see what that is. I did tell, OK, and I did tell her about the appeals process, and I just want to clarify one thing, [PII], since I have you on the line. Appeals can be faxed and uploaded as well, as long as they're clearly marked to attention appeals department.
[CUSTOMER][NEUTRAL] What we got here.
[CUSTOMER][NEUTRAL] Yeah, they can, yeah.
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] So I've given her that information but I could see her diagnosis, OK, but as far as the procedure, so she's just wanting.
[CUSTOMER][NEUTRAL] So it looks like she had a colonoscopy. Let's see if it's the same.
[AGENT][NEUTRAL] That was, she said that. Mhm. She said she did have that as well, but she said she had 2, what she said.
[CUSTOMER][NEUTRAL] Colonoscopy.
[CUSTOMER][NEUTRAL] Let me see what else we got here.
[CUSTOMER][NEUTRAL] It's a little blurred, but let me see where.
[AGENT][NEUTRAL] Yeah
[AGENT][NEGATIVE] My eyesight's so bad. If it was blurred, I wouldn't be able to read it. I can barely read it when it's super crisp.
[CUSTOMER][NEUTRAL] And on this other page cause this other ones just talking about, OK, she has.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, she let's see here. OK, I do see the upper GL let me.
[CUSTOMER][NEUTRAL] Take a look here.
[AGENT][POSITIVE] Thank you, ma'am.
[AGENT][NEUTRAL] And she is fully verified too, so.
[CUSTOMER][NEUTRAL] So the, under the diagnostic, it does cover for uh upper GI so we'll have to send a request to have this. I wonder where, let me see where she got these CPT codes from, let me take a look.
[CUSTOMER][NEUTRAL] To make sure where where this was listed on the document.
[CUSTOMER][NEUTRAL] Cause right now I'm not seeing them.
[CUSTOMER][NEGATIVE] Oh wait, hold on, I'm looking at something else wrong screen.
[CUSTOMER][NEUTRAL] I clicked off, clicked on the wrong screen. Can you give me that? Oh, that my, I got the policy number I clicked on clicked on my other screen.
[AGENT][NEUTRAL] All right, OK.
[CUSTOMER][NEUTRAL] Here we go.
[CUSTOMER][NEUTRAL] Yeah, there is a, a benefit for an upper GI so we'll just have to send a request on this claim to get it reprocessed, but I do see that she did also have an upper GI.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] She had a colonoscopy in the upper GI was performed.
[AGENT][NEUTRAL] Right. And uh she understands that the colonoscopy, like I said, I read through all that. So, are you gonna send that then? I mean, I can just tell her that. Are you gonna send the request or do you want to speak to her and let her know?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I can get with the examiner to reprocess the claim.
[AGENT][NEUTRAL] It doesn't
[AGENT][NEUTRAL] OK, well I'll just let her know that that's what we're gonna do.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] OK. All right. Well, you are the best. Thank you so much. I will be happy to relay that information instead of transferring it to you, OK?
[CUSTOMER][NEUTRAL] I can do that. Mhm.
[CUSTOMER][POSITIVE] Alright, that works.
[AGENT][POSITIVE] OK, thanks, [PII].
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK, bye bye.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Hi, Ms. [PII]. This is still [PII]. OK, so on, um, I had someone to look at the information that I told you I couldn't see, and we are going to have this information reprocessed for the upper GI series as I explained to you, you do know the colonoscopy is not covered, but we are gonna send it back for reprocessing on the upper GI.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that
[CUSTOMER][NEUTRAL] So, so I don't need to file an appeal. They're gonna re-review it.
[AGENT][NEUTRAL] You don't need to do, no, ma'am. You don't need to do anything at this point on that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Yes, because she was able to look at some information and is going to send it back to have it reprocessed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] All right. Well, can I help you with anything else then this morning?
[CUSTOMER][NEUTRAL] Uh, no, ma'am, that is it.
[AGENT][POSITIVE] OK, Ms. [PII]. Well, again, it was my pleasure in speaking to you today and I hope you have a wonderful weekend.
[CUSTOMER][POSITIVE] Thank you. You as well.
[AGENT][POSITIVE] Yes ma'am, thank you.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] Bye bye. OK, bye-bye.
[CUSTOMER][POSITIVE] Exactly.