AccountId: 011433970860
ContactId: d15227cb-42bb-489f-83fe-7ea0309506bd
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1332430 ms
Total Talk Time (AGENT): 264280 ms
Total Talk Time (CUSTOMER): 490159 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/10/d15227cb-42bb-489f-83fe-7ea0309506bd_20250610T19:48_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah, hi. Um, my name is [PII] and I received, um, uh, a letter from you guys stating that you needed an a itemized statement for the claim I have.
[AGENT][NEUTRAL] OK. Do you have your policy number, [PII]?
[CUSTOMER][NEUTRAL] Uh, policy number is 02578091.
[AGENT][NEUTRAL] OK, thank you. And can you verify your date of birth for me?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And then just need your address and your email address.
[CUSTOMER][NEUTRAL] Yeah, [PII]. Email address is [PII].
[AGENT][NEUTRAL] OK, and then lastly just a good callback number in case we're disconnected.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and what's that claim for yourself?
[CUSTOMER][NEUTRAL] Yeah, it was for me.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I have a claim number as well.
[AGENT][NEUTRAL] OK, yeah, it looks like it's 3608645. Is that right?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, yeah, it looks like we are needing the, we've got your claim form, and then let me see what I've got attached.
[CUSTOMER][NEUTRAL] The item
[CUSTOMER][NEUTRAL] As I said, the itemized bill was attached to the same email that the claim form was.
[AGENT][NEUTRAL] OK. Um, let's see.
[CUSTOMER][NEUTRAL] I mean if anything it's missing some diagnosis codes which I can also pull.
[AGENT][NEUTRAL] Yes, that's what's missing is the diagnosis. We've got the itemized bill, it's just missing the diagnosis. We've got all the, it breaks down all the charges, um, and lists the procedures, but doesn't have a diagnosis anywhere.
[CUSTOMER][NEUTRAL] So with it, so I also had noticed that
[CUSTOMER][NEUTRAL] I, I, that, because, so it said that Riddle Hospital was not part of, was not in network. However, two other hospitals that are part of the same health system.
[CUSTOMER][NEGATIVE] As riddle are in network. So I'm very confused about why that was not covered at all.
[AGENT][NEUTRAL] Well, it, we're not covering it because we need the diagnosis codes.
[AGENT][NEUTRAL] We, we can't process the claim.
[CUSTOMER][NEUTRAL] OK, so the insurance told me.
[CUSTOMER][NEGATIVE] OK, so the insurance, when I talked to somebody else, they said that uh it's not being covered because it's not in network.
[AGENT][NEUTRAL] And and you were talking to
[AGENT][NEUTRAL] You know who you were.
[CUSTOMER][NEGATIVE] Oh, I, I don't even know at this point. I can't find my notes. I have a lot of different people. I've talked to [PII] multiple times, and he's apparently a broker who's absolutely useless.
[CUSTOMER][NEUTRAL] Um, I, I don't know, but they were like, it's because it's not in network and I was really kind of just.
[CUSTOMER][NEUTRAL] I don't even know who [PII] is the person I talked to, and that's who gave me your contact information.
[AGENT][NEUTRAL] OK. Uh.
[CUSTOMER][NEUTRAL] Um, diagnosis codes, diagnosis codes. I don't see that on the itemized bill.
[AGENT][NEUTRAL] Yeah, they
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Do you have access to like your portal with the hospital? Sometimes the notes can contain it.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh yeah I can do that hold on um.
[AGENT][NEUTRAL] OK, yeah, sometimes they're there um we can use that information.
[CUSTOMER][NEUTRAL] And all right.
[CUSTOMER][NEUTRAL] So there's two dates, so there's the [PII] date.
[CUSTOMER][NEUTRAL] And diagnosis code, diagnosis code. So diagnosis is kidney infection and that's for [PII].
[AGENT][NEUTRAL] OK, yeah, we, we'll just need some type of documentation pulled from the hospital or your portal or something as the actual code.
[CUSTOMER][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] What, what about, uh, the actual code uh.
[AGENT][NEUTRAL] Like the diagnosis code.
[CUSTOMER][NEUTRAL] Cause I have the
[CUSTOMER][NEUTRAL] So I have the ED after visit summary, um, notes from care team. Let's see here.
[CUSTOMER][NEUTRAL] ED provider notes.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] discharge patient evaluated. Uh, it says, so I mean, I have a clinical note. It doesn't have the actual like ICD 10, but it says clinical impression kidney infection.
[CUSTOMER][NEUTRAL] For [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Yeah, we need some
[CUSTOMER][NEUTRAL] It's the whole workout.
[AGENT][NEUTRAL] OK. And there's no notes anywhere that indicate the ICD 10?
[CUSTOMER][NEUTRAL] I mean, if you wanna give me a second, I can look up ICD 10 if that's that important, um.
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEGATIVE] Uh, it's ridiculous. I see 10.
[CUSTOMER][NEUTRAL] Kidney infection.
[CUSTOMER][NEUTRAL] Uh, alright, so the ICD 10 for kidney infection is N as in Nancy 10.
[AGENT][NEUTRAL] OK, yeah, it, it just, it has to be on documentation from the hospital. We can't do anything by phone.
[CUSTOMER][NEUTRAL] Like I said,
[CUSTOMER][NEUTRAL] So no, I, I, OK, so here's the deal though. I'm looking at all the documentation from the hospital. It doesn't, because it's a patient portal, it doesn't typically have diagnosis codes on it because most patients don't understand the diagnosis codes and get very confused. So typically on a patient for, I work in healthcare, so I deal with this stuff all day every day. So it says on there, clinical impression, kidney infection, it is written in there on the clinical note. However, it does not have an ICD 10, which the ICD 10 is.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And 10.
[AGENT][NEUTRAL] Let me, let, if you can hold on one moment, I'll double check and see if that's OK. Hold on one moment.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Wrap it up.
[AGENT][NEUTRAL] OK. I don't know.
[AGENT][NEUTRAL] OK, sorry about that. Yes, if it clearly states the diagnosis is kidney infection, then that will suffice.
[CUSTOMER][NEUTRAL] OK, good. Because then the other one from November clearly states kidney stones.
[AGENT][NEUTRAL] Are you're saying the one that you submitted?
[CUSTOMER][NEUTRAL] No, no. So, all right. So there are two dates of service that I'm fighting to have covered. It is [PII] and then [PII]. So there are two different diagnosis codes, but they're still related to the kidneys.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, I've got that
[CUSTOMER][NEUTRAL] And it's clearly dated on each of the clinical summaries that I have that, you know, what date goes with which diagnosis.
[AGENT][NEUTRAL] OK, that's, yeah, that's fine. You can submit that.
[CUSTOMER][NEUTRAL] OK, how do I submit that?
[AGENT][NEUTRAL] Uh, do you have an account with us on our online portal? Have you created an account?
[CUSTOMER][NEUTRAL] So I
[CUSTOMER][NEUTRAL] I don't think so, but I tried to create one and it wouldn't let me, so I'm very confused. So it's [PII].
[AGENT][NEUTRAL] secured. [PII].
[CUSTOMER][NEUTRAL] OK, so I'm going to, I'm trying to sign up again, so my last name.
[CUSTOMER][NEUTRAL] Uh, let's see here. Let's try the member I policy number, not policy number, so I have no idea what that number is, uh, 19.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] OK, so you're on the, you're on the create a new account?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] I and you picked insured.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. And then it'll be your social security number.
[CUSTOMER][NEUTRAL] Is it that M number?
[AGENT][NEUTRAL] No, it'll be last name then social with no dashes.
[CUSTOMER][NEUTRAL] All right, uh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then your residential zip code?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEGATIVE] It says error no user was found and that was just trying to sign up.
[AGENT][NEUTRAL] OK, so you're putting in your last name, [PII].
[AGENT][NEUTRAL] What uh do you know what browser you're using?
[CUSTOMER][POSITIVE] Yes, correct.
[CUSTOMER][NEUTRAL] What what? What browser so it's Google Chrome.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and then you entered your social security number with no dashes, correct?
[CUSTOMER][POSITIVE] That's correct.
[AGENT][NEUTRAL] I have a zip code [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] That is correct.
[AGENT][NEUTRAL] Then [PII]
[AGENT][NEUTRAL] [PII] [PII]
[CUSTOMER][NEUTRAL] [PII] [PII]
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And my date of birth is [PII].
[AGENT][NEUTRAL] OK, and it didn't take you to complete your account set up?
[AGENT][NEUTRAL] And then verification is necessary.
[CUSTOMER][NEUTRAL] No, every time
[CUSTOMER][NEGATIVE] It said uh when I tried to sign up it says sign up error with an X and error bolded says no user was found with the information that was entered. Please try again and that's under the sign up option.
[AGENT][NEUTRAL] OK, and you're at [PII]?
[CUSTOMER][NEUTRAL] That is correct, yeah, it says slash sign up because that's the option I hit.
[AGENT][NEUTRAL] OK, cause I'm getting through with the information I've entered, so can you clear out your cash or your history?
[AGENT][POSITIVE] Because it's working for me.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] OK, let's see here.
[AGENT][NEUTRAL] So it's [PII] and it's create your OSC account.
[AGENT][NEUTRAL] There's not a sign up, that's create your OSD account.
[CUSTOMER][NEUTRAL] Do that.
[CUSTOMER][NEUTRAL] OK, let's see here.
[CUSTOMER][NEUTRAL] Alright, that is deleted.
[CUSTOMER][NEUTRAL] I'll just do this again. So it's create your OSC had just cleared my cache insured.
[CUSTOMER][NEUTRAL] And 358.
[CUSTOMER][NEUTRAL] 19014 [PII] at
[CUSTOMER][NEUTRAL] [PII] [PII] next.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] It's still saying no user was found with the information.
[AGENT][NEUTRAL] I've got your social [PII].
[CUSTOMER][NEUTRAL] Yeah, that's not my social.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It, what is your social?
[CUSTOMER][NEUTRAL] My social is [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I wonder if you have me under my husband's social. Is the last four of that social that you have on there is that [PII]?
[AGENT][NEUTRAL] No, it's [PII].
[CUSTOMER][NEGATIVE] No, that is definitely not my social at all.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] That is correct.
[AGENT][NEUTRAL] OK, um, let me see if that updated.
[AGENT][NEUTRAL] OK, no, it didn't update. Let me see. Mm.
[AGENT][NEUTRAL] OK, um,
[AGENT][NEUTRAL] No, I did not.
[AGENT][NEUTRAL] OK, I've got let's see, I've got to update it in our system now let me.
[AGENT][NEUTRAL] OK, one.
[AGENT][NEUTRAL] 6
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, now try it with your corrected social.
[CUSTOMER][NEUTRAL] Insured.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII] [PII] on that.
[CUSTOMER][NEUTRAL] Um [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Here we go, complete your account set up.
[AGENT][NEUTRAL] OK, we'll ask for a verification code. Once you create your password, it's gonna ask you to log back in and it's gonna ask for another verification code. So just to keep that in mind, it'll ask for two verification codes, just takes a moment.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] No, no worries.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] Uh [PII] verify and password.
[CUSTOMER][NEUTRAL] Go to dashboard.
[CUSTOMER][NEUTRAL] Log in.
[CUSTOMER][NEUTRAL] Send verification code. Oh gosh.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] They're fine.
[CUSTOMER][POSITIVE] OK, so I'm in officially you have a clean started.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] no
[CUSTOMER][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] And um.
[CUSTOMER][NEUTRAL] OK. So where am I putting this stuff at?
[AGENT][NEUTRAL] Um, so if you go to your dashboard.
[AGENT][NEUTRAL] It'll say, do you need to file wellness or traditional claim?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And you'll just start your claim and then upload the information that we discussed.
[AGENT][NEUTRAL] And then we'll get it um review.
[CUSTOMER][NEUTRAL] Um, and
[CUSTOMER][NEUTRAL] Alright, so it's a traditional claim, right? Next step.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK, next up pop was policy information.
[CUSTOMER][NEUTRAL] Upload them in a later step. Skip select to claim reel.
[CUSTOMER][POSITIVE] Mm, sounds about right.
[CUSTOMER][NEUTRAL] Upload claim documents click here.
[CUSTOMER][NEGATIVE] Eating not open.
[CUSTOMER][NEUTRAL] Um, do not open so.
[CUSTOMER][NEUTRAL] OK, submit.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Alright, it's thinking.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What was your name again?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] All right, so it says claims submitted uh successfully.
[AGENT][NEUTRAL] OK, um, once we get that, um, it, it takes about 24 hours to appear on our system. So once we get that in the system, it will take about 7 working days to review and then we can, as long as we've got that diagnosis, then it should be fine and we'll be able to process the claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, alright, so 24 hours to appear in your system and then 7 business days.
[CUSTOMER][NEUTRAL] Uh, for the claim to be resubmitted, is that what I'm understanding?
[AGENT][NEUTRAL] For it to be reprocessed, yes.
[CUSTOMER][NEUTRAL] Some days for.
[CUSTOMER][NEUTRAL] claim to be.
[CUSTOMER][NEUTRAL] Reprocessed.
[CUSTOMER][NEUTRAL] OK, is there anything else?
[AGENT][NEUTRAL] Uh, no, that, that should be it that we need to process that claim. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Nope, that's it.
[AGENT][POSITIVE] OK. Well, thank you for calling APL. I hope you have a good afternoon.
[CUSTOMER][POSITIVE] Yep you too bye bye.
[AGENT][NEUTRAL] Bye.