AccountId: 011433970860
ContactId: d1e83a9a-d205-409a-9f05-7b8f20afce87
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 826570 ms
Total Talk Time (AGENT): 444662 ms
Total Talk Time (CUSTOMER): 268498 ms
Interruptions: 3
Overall Sentiment: AGENT=0.5, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/31/d1e83a9a-d205-409a-9f05-7b8f20afce87_20250131T16:44_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII] in [PII]. How are you doing?
[AGENT][POSITIVE] I'm good. How are you?
[CUSTOMER][POSITIVE] Doing great doing great I'm a broker and I'm just calling to check on a claim for one of our customers.
[AGENT][NEUTRAL] OK, [PII], can I get a good callback number?
[CUSTOMER][NEUTRAL] Yes ma'am, it's [PII].
[AGENT][NEUTRAL] OK, thank you, [PII]. Do you have the policy number?
[CUSTOMER][NEUTRAL] Yes ma'am, policy number is 2579483.
[AGENT][NEUTRAL] OK, thank you [PII], can you confirm the insured's name and date of birth for me?
[CUSTOMER][NEUTRAL] Yes, it is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Um, let's see here. I think I recognize his name.
[AGENT][NEUTRAL] You said you're calling to check on claim status rep.
[CUSTOMER][NEUTRAL] Yes ma'am it says processed online. I'm just double checking it.
[AGENT][NEUTRAL] Mm, OK. Let's see what's going on.
[AGENT][NEUTRAL] I do recognize this name. What's the data service and build amount or you have a claim number?
[CUSTOMER][NEUTRAL] Claim number 3557389.
[AGENT][POSITIVE] Yeah, I actually processed this claim yesterday actually. That's why I recognize it.
[AGENT][NEUTRAL] OK, so we received it the [PII] and we processed it yesterday so it would have been released last night at [PII]. They do not have direct deposit set up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it's gonna go in the form of a paper check, um, so we were able to pay it in the amount of $2800. Um, we paid the hospital admission benefit $1500 the room and board $300 and the surgery benefit, um, $1000 and those were 123, 123.
[AGENT][NEUTRAL] We did see that they had an office visit on [PII], but we did have to deny that they had a copay on there of $25 but we don't have any charge I mean we don't have um like any charges diagnosis codes. It looks like it was just a receipt for that office visit.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But we need itemized billing.
[AGENT][NEUTRAL] For that office visit.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] Quick question for you, so we did the $1000 for the surgery, the $1500 for being admitted, and the, the, now is it $100 a day or is it $200 a day if they're in ICU?
[AGENT][NEUTRAL] Um, it doesn't look like he was an actual ICU. Um, it's $100 for room and board and then there is $100 for ICU benefits.
[AGENT][NEUTRAL] Let me pull up this claim. Give me just.
[CUSTOMER][NEUTRAL] Check, check the second attachment that I sent. It was on the [PII]. It's a um UB 04, and at the very first charges.
[AGENT][NEUTRAL] Yeah, that's what I'm pulling up now.
[AGENT][NEUTRAL] Give me just a second while this is loading.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Now if it's intermediate ICU that does not um stand for actual ICU charges.
[CUSTOMER][NEUTRAL] So where it says intensive care intermediate 3 units. So what does that mean?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Intermediate is a step down. Yes, intermediate ICU is a step down from actual ICU benefits.
[CUSTOMER][NEUTRAL] So he's saying he was in a regular.
[AGENT][NEUTRAL] I see um intermediate, yes, it's a 206 revenue code so intermediate is not, so if you're an ICU that's actual ICU but intermediate is just a room and board, it's just a regular room, it's not actual ICU, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, um, I had to learn that the hard way actually, yes.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, it's confusing because they put it on there and instead of just put normal, normal room, you know what I mean? um.
[AGENT][NEUTRAL] Let's see here, let me pull up.
[AGENT][NEUTRAL] Let me pull up something for you. I'll go over that with you real quick. Give me just a second. Let me get on my.
[AGENT][NEUTRAL] Attachments closed here um here we go, here it is if you're ever looking at these UBS.
[CUSTOMER][POSITIVE] It's fine. It's no problem.
[AGENT][NEUTRAL] And you see those, you see that revenue code 206?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let me see, I'm sorry, I'm gonna jump right back on it. Let's see.
[CUSTOMER][NEUTRAL] Alright, so revenue code, let me look where revenue code is on here.
[CUSTOMER][NEUTRAL] So where show me where oh on the left side I see it OK.
[AGENT][NEUTRAL] On the left hand side where it says 206 and beside it it says as intensive care, then it says intermediate.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So if you see anywhere between 200 to 204.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's gonna be actual ICU.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That's gonna be, you know, general ICU, surgical, medical, pediatric, psychiatric, anything like that. But when it gets above 204, that's where we're gonna stand and um just intermediate ICU to a regular room and board.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[CUSTOMER][POSITIVE] Got it OK.
[AGENT][NEUTRAL] Just kind of little notes for you.
[CUSTOMER][NEUTRAL] So 200 to 204 ICU 205 to.
[AGENT][NEUTRAL] Um, some of them can go above 206 for regular ICU for any burn unit victims, anything like that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Um, we have burn care, ICU trauma, um, other intensive care is like 209. The actual 206, unfortunately is intermediate and won't stand for regular, um, actual ICU benefits, unfortunately.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK, got it. OK, um, let me double check one more thing while I have you here if you don't mind, um, let me just see if it even pops up on here let's see.
[AGENT][NEUTRAL] OK, yeah, that's fine.
[CUSTOMER][NEUTRAL] And this one might not be processed yet. I just told him I double check while I'm doing this.
[CUSTOMER][NEUTRAL] How's everything going over there?
[AGENT][POSITIVE] It's going um it's Friday thank goodness.
[CUSTOMER][NEUTRAL] You've been staying busy?
[AGENT][NEGATIVE] We have, um, it's January and we're actually slammed and.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEGATIVE] I feel like I'm drowning this week.
[CUSTOMER][NEUTRAL] Supposed to slow down in January, right?
[AGENT][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] I go on vacation next week and I'm excited.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Awesome, great. OK, I found the guy, um, it's a separate person just let me know um when you're ready.
[AGENT][NEUTRAL] OK, give me just a second here, let me put in my notes for this one and then we will jump on to the next one. What is that policy number if you don't mind?
[CUSTOMER][NEUTRAL] Policy number is 2271221.
[AGENT][NEUTRAL] OK, let's see here.
[CUSTOMER][NEUTRAL] And it's actually on his son [PII].
[CUSTOMER][NEUTRAL] With a date of birth of [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well I'm sorry, not [PII].
[AGENT][NEUTRAL] [PII]. Let's see, is it a claim you're looking at?
[CUSTOMER][NEUTRAL] Yes, I know we processed the original payment which I believe was like $1000 or $2000 somewhere around there, um, but he had to have surgery on the fracture.
[AGENT][NEUTRAL] OK, do you have a claim number or date of service?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Let's see, it looks like the initial claim that we paid was received on [PII]. That was the one that ended in 614.
[AGENT][NEUTRAL] OK, let's see, let me go back to the original screen. OK, so I do see 614 and then I see a new claim came in on 125.
[CUSTOMER][NEUTRAL] And that was, that was basically a continuation of the other claim because he had to have surgery.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] So we additionally paid $975.
[CUSTOMER][NEUTRAL] OK, so the 900 that the, the um stuff that just came in, the 900 paid on that, it was that for the surgery benefit basically on the uh fracture?
[AGENT][NEUTRAL] Um, let's see, we paid $125 for a DME item.
[AGENT][NEUTRAL] And then we did pay $750 on a surgical repair.
[CUSTOMER][POSITIVE] OK, OK, so he got an extra 900 with that information that was sent you perfect and on the initial check.
[AGENT][NEUTRAL] And then we paid, go go ahead I'm sorry.
[CUSTOMER][NEUTRAL] I'm sorry, go ahead. No, no, no, that's OK, um, keep going.
[AGENT][NEUTRAL] And then we did pay $100 on um physical therapy it looks like on a data service of $117.
[CUSTOMER][POSITIVE] OK, great, great.
[CUSTOMER][NEUTRAL] Um, in that initial check we sent out was it like 2000 and some change?
[AGENT][NEUTRAL] Uh, let's see here. Um, it looks like.
[AGENT][NEUTRAL] 650 on that one and then.
[AGENT][NEUTRAL] No, that was just 650 on the initial check.
[CUSTOMER][NEUTRAL] OK, I thought he got more than that, um, because I thought we paid for the fracture the first time around.
[AGENT][NEUTRAL] No, it looks like um $100 on physical therapy, $300 on X-ray, and um
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Let's see 250.
[AGENT][NEUTRAL] On an imaging benefit.
[CUSTOMER][NEUTRAL] OK, so no fracture was paid on the first one.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] But we did pay, but on the 2nd 1 we paid a fracture benefit.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And that was you said the 6:50.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I be
[CUSTOMER][NEUTRAL] I'm sorry, let me check it.
[CUSTOMER][POSITIVE] Cause I know the surgery benefit, it was a, there's one fracture benefit and then if you have to have surgery on the bone, it's a higher benefit.
[CUSTOMER][NEUTRAL] Let's just double check it just while I have you and now I can put it to bed for him. I'm sorry, um.
[AGENT][NEUTRAL] No, no, no, you're fine. Let's see, 29881. Let me see what the CPT code is.
[AGENT][POSITIVE] Yes, it was a surgical benefit that we paid.
[CUSTOMER][NEUTRAL] OK, what was the fracture? I'm, I'm, I'm, I'm going down the list real quick with the bones. Does it say what what fracture we paid?
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I do not see an actual fracture, but I see the surgical repair.
[CUSTOMER][NEUTRAL] Surgical repair of, does it say of what?
[AGENT][NEUTRAL] Uh just the knee.
[CUSTOMER][NEUTRAL] OK, so maybe.
[AGENT][NEUTRAL] Let me actually go into this claim and get the diagnosis code here.
[CUSTOMER][NEUTRAL] Yeah, let's see.
[AGENT][NEUTRAL] Let me see what we're looking at.
[CUSTOMER][NEUTRAL] I'm wondering
[CUSTOMER][NEUTRAL] Let me go back to his email sorry.
[AGENT][NEUTRAL] No, no, no, you're, you're fine.
[CUSTOMER][NEUTRAL] I thought this would be
[CUSTOMER][NEUTRAL] I realized that I was missing something on there, OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so they did not put a fracture diagnosis code on this claim.
[AGENT][NEUTRAL] They put a other tear lateral meniscus.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Other term medial meniscus.
[CUSTOMER][NEUTRAL] Oh, OK, maybe this wasn't a fracture then.
[AGENT][NEUTRAL] Yeah, they did. No, no, no, you're fine. Let me go to this other claim as well and let me pull up this diagnosis code as well. Sorry, we have to just go into a few different screens here to get them. OK, yes, so the only, um, they did not get a fracture benefit because the diagnosis code state that it's the other ear lateral meniscus and the other tear medial meniscus.
[CUSTOMER][NEGATIVE] Man, I'm doing so many claims, so it was an actual fracture.
[CUSTOMER][POSITIVE] No, that's perfectly fine.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] OK, so he's got some follow ups. It looks like he sent me, OK, I'll work on that. OK, so that's why I, I was, the numbers weren't what I thought is because it was actually not a fracture, it was like a tear.
[AGENT][NEUTRAL] Right, they, it's just lateral medial meniscus tear on both, um, on both of these claims. That's the diagnosis that we received. Mhm.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] You got it. So, so the surgery benefit he got was for the tear, so it was the repair of the tear.
[AGENT][NEUTRAL] Yes, sir. Yes, sir.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] Um, and on that first claim that we did go over for all over, um, just remember that office visit for 18, we do need that itemized billing with the diagno it looks like it's probably gonna be the same diagnosis code, but we do need that information and just some itemized billing or some medical notes. Um, we did receive a bunch of receipts and it looks like he was prepaying for his surgical and his hospital stay.
[CUSTOMER][NEUTRAL] That'll work.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We don't need that information because it honestly it just looks like a few receipts that he sent us but um that 18 if he can get us that information or you can get us that information, that would be great and we can just pay that office visit.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] But just kind of throwing that out there if he does want his benefits if they're payable we can definitely move forward with that.
[CUSTOMER][POSITIVE] Got it, got it.
[CUSTOMER][POSITIVE] Perfect I'll work on that and I appreciate all your help today.
[AGENT][POSITIVE] Oh, you're welcome. Is there anything else I can take a look at for you?
[CUSTOMER][POSITIVE] That's it. I hope you have a great day and a great weekend. Enjoy your vacation.
[AGENT][POSITIVE] Oh yes thanks thanks [PII] and thank you for calling APL. I hope you have a great day.
[CUSTOMER][POSITIVE] You too. Thank you.
[AGENT][NEUTRAL] All right, bye bye.
[CUSTOMER][POSITIVE] Thanks bye bye.