AccountId: 011433970860
ContactId: d3a78251-fde4-4f65-9033-ddfc0302de0d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 916890 ms
Total Talk Time (AGENT): 211198 ms
Total Talk Time (CUSTOMER): 270979 ms
Interruptions: 0
Overall Sentiment: AGENT=1.3, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/06/d3a78251-fde4-4f65-9033-ddfc0302de0d_20250606T15:33_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi this is [PII] with Broker Resources. How are you doing?
[AGENT][POSITIVE] I'm good. How are you?
[CUSTOMER][NEUTRAL] I'm good thank you um I have a broker on the line who is curious about a claim number. His name is [PII] and he's calling in regards to uh group number 21471.
[AGENT][NEUTRAL] OK. And what's the policy number for the claim?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] He wasn't able to give that to me. He's having issues with the OSC and so he has the claim number. Um, it was 3596 and then he started cutting out on the, the last few. He is on a broker on the um account. His email is listed on there um so you are able to speak with him about it.
[AGENT][POSITIVE] OK. Yes, ma'am. I can help him.
[CUSTOMER][POSITIVE] OK perfect I'm gonna um introduce you OK?
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Of course.
[CUSTOMER][NEUTRAL] [PII], are you still there?
[CUSTOMER][NEUTRAL] Yeah, I'm here.
[CUSTOMER][NEUTRAL] OK perfect I have someone online um from our claims department that will be able to give you a status update on that claim, OK?
[CUSTOMER][NEUTRAL] OK, I'll hold.
[CUSTOMER][NEUTRAL] Oh no she's on the line right now.
[AGENT][NEUTRAL] Yeah, I'm here, [PII].
[CUSTOMER][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] How are you?
[AGENT][NEUTRAL] Hi, [PII]. This is [PII]. I'm in the claims department. How are you?
[CUSTOMER][POSITIVE] I'm doing well.
[AGENT][NEUTRAL] OK. Yes, sir. I can further assist you with the claim. Do you have the claim number?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yes, uh, 359-064-2.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][POSITIVE] OK, thank you now.
[CUSTOMER][NEUTRAL] I called earlier this week and they told me they were working on it, so they told me to call on Friday to find out what the status is so that's why I'm calling.
[AGENT][NEUTRAL] OK. Yes, sir. I'll be happy to assist you with the status. Could you please verify the member's name and date of birth?
[CUSTOMER][NEUTRAL] OK, uh, [PII].
[CUSTOMER][NEUTRAL] His date of birth, uh, that'll take a little looking up because I don't have access to your portal right now because I was locked out for whatever reason, so I'm trying to get that redone again.
[AGENT][POSITIVE] OK, no problem.
[CUSTOMER][NEUTRAL] Yeah, when I had access to your portal, I uploaded everything, so I'm just trying to find out what the status is.
[AGENT][NEUTRAL] OK. Are you still trying to find the date of birth?
[CUSTOMER][NEUTRAL] OK, I can find it though. Give me one second. Let me, I just gonna log into employee now. Give me 1 2nd.
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] Sure, I don't mind waiting.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] OK, no problem.
[CUSTOMER][NEUTRAL] log into the portal.
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] navigator log in.
[CUSTOMER][NEUTRAL] I can look it up in 2 seconds.
[CUSTOMER][NEUTRAL] code.
[CUSTOMER][NEUTRAL] And this one is this one.
[CUSTOMER][NEUTRAL] OK, it's not this one.
[CUSTOMER][NEUTRAL] a different point.
[CUSTOMER][NEUTRAL] it
[CUSTOMER][NEUTRAL] restaurant.
[CUSTOMER][NEUTRAL] Let me look up, got it.
[CUSTOMER][NEUTRAL] OK uh.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, profile.
[CUSTOMER][NEUTRAL] His date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and the claim number, please.
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] Uh, could you please repeat the claim number?
[CUSTOMER][NEUTRAL] 359-064-2
[AGENT][NEUTRAL] OK. Yes, sir. That claim is denying because we need the explanation of benefits from the primary insurance company.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I uploaded it already.
[CUSTOMER][NEUTRAL] It was uploaded and put into the system and I had access to your portal.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Look in the portal you should see it there because I know I uploaded it last week before I just changed your uh portal and then it got locked out so I gotta get it reinstated again.
[AGENT][NEUTRAL] Yeah, I do see where something was resubmitted on the [PII]. I'm opening the image now to take a look. One moment.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] No problem.
[AGENT][NEUTRAL] OK. Yes, sir. Thank you for your patience. I'm showing that what we received was a statement and um what we need is the explanation of benefits from the primary insurance company and we also need the diagnosis code.
[AGENT][NEUTRAL] And that's why the claim is denied.
[CUSTOMER][NEUTRAL] I'm sorry, one more
[CUSTOMER][NEUTRAL] What else do you need?
[AGENT][NEUTRAL] We need the explanation of benefits from the primary insurance company for this service, and we also need the diagnosis code, um, and the diagnosis code is not pre-printed on the explanation of benefits. So we would need that to come from the provider, from the hospital or um the physician.
[CUSTOMER][NEGATIVE] Everything, everything has been submitted. I submitted everything multiple times. I mean this is getting ridiculous now. I don't know how many times you can ask me for the same things. I sent all the stuff from the hospital. I sent the EOB that they asked on the [PII]. I sent the bill. I mean, I don't know what else you guys want.
[CUSTOMER][NEGATIVE] It's getting ridiculous.
[AGENT][NEUTRAL] Yes, sir, and I apologize, but um,
[CUSTOMER][NEUTRAL] If I had if I if I had if I had access to your your system, then I would be able to show you all the things I've uploaded. Everything's been uploaded multiple times.
[AGENT][NEUTRAL] Yeah, well, actually our system um was upgraded and um what you would need to do is go in and.
[AGENT][NEUTRAL] Reenter your reenter your um
[AGENT][NEUTRAL] Information you would need to reset up your information in the system because the system was upgraded. I apologize if you didn't receive notification of that.
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEGATIVE] Yeah, we never got that, yeah exactly, and then I couldn't log in and my coworker and Core Gables couldn't log in either, and it's like nobody told us anything and you guys just change everything without notifying anybody, which is a little upsetting, but this is getting ridiculous now with this claim. This has been going on for months now with this guy.
[CUSTOMER][NEUTRAL] And I don't know what else you guys need because I mean I submitted everything.
[AGENT][NEUTRAL] Yes, sir. I apologize. All we have in our system is the statement that we received from the hospital.
[AGENT][NEUTRAL] It was for date of service [PII] for a um hospital admission. All we have is the statement.
[CUSTOMER][NEUTRAL] OK, I got, I, I submitted this is, this is going back so far. I mean this is this is all the way back from uh.
[CUSTOMER][NEUTRAL] 35, this is not now.
[CUSTOMER][NEUTRAL] I, I, I all the discharge information from Florida Ventura Hospital, all the information from the hospital. I submitted the bill. I submitted the EOB.
[CUSTOMER][NEGATIVE] I mean, can someone send me an email, tell me exactly what else, what else you guys need because it's getting ridiculous now because just to the point now where the client's getting pissed off, the employees getting pissed off, and I'm the one to hold, you know, the brunt of it because, you know, they don't look at you guys, you look at me, so that's why I'm trying to figure this out.
[AGENT][NEUTRAL] Right. Well, um, I apologize. You should have received an explanation of benefits um showing what, what else we need, but um I can fax it to you. I can fax you the explanation of benefits and they will let you know that we need the EOB from the primary insurance company and we'll need the diagnosis code. So I can fax you the explanation of benefits with that information where we're requesting that.
[CUSTOMER][NEUTRAL] So the thing you say the thing you got on the [PII] wasn't it that I thought that was the EOB.
[AGENT][NEUTRAL] No, sir. All we have is a statement from the hospital. That's it.
[CUSTOMER][NEUTRAL] Hold on a second.
[CUSTOMER][NEUTRAL] Uh let me see what I sent.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, a statement from the hospital for 226-25 to 3225.
[CUSTOMER][NEUTRAL] OK, hold on, let me see something here.
[CUSTOMER][NEUTRAL] Uh, right now my computer is slowing down here. Give me one second. I don't know if that's going on.
[CUSTOMER][NEGATIVE] And then he's freezing up here. Give me one second.
[CUSTOMER][NEUTRAL] Come on, open up.
[CUSTOMER][NEUTRAL] Let me see if I can find another way.
[CUSTOMER][NEUTRAL] I mean this came from UHC explanation of benefits.
[CUSTOMER][NEUTRAL] Let's see
[AGENT][NEUTRAL] OK. Yes, sir. That's what we need and we also need documentation from the hospital or one of the providers, one of the doctors um with the diagnosis code. If you can fax that that to us, if that's easier, I can give you our fax number.
[AGENT][NEUTRAL] And I can also give you the claim number.
[CUSTOMER][NEUTRAL] Wait a second, uh.
[CUSTOMER][NEUTRAL] OK, wait a second, so.
[CUSTOMER][NEUTRAL] So the uh so the uh.
[CUSTOMER][NEGATIVE] So the discharge information that explains everything that was done for his uh acute loss anemia, that's not enough. You need something else from the damn hospital now?
[AGENT][NEUTRAL] No, um, we don't need anything else from the hospital. We need the um primary carrier's explanation of benefits and we need documentation um with a diagnosis code on it. And I said that it could come from the hospital. If you can't get it from the hospital, you can get it from one of the providers. We just need documentation from a provider with a diagnosis code.
[AGENT][NEUTRAL] The diagnosis code is the code for the illness, the reason for the hospital admission.
[CUSTOMER][POSITIVE] Got you, got you. I wish you guys would do something because you're making me do everything. OK, let me see if I can figure this out. Thank you.
[AGENT][NEUTRAL] Is there anything else I can assist you with?
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Hello. Is there anything else I can assist you with?
[AGENT][POSITIVE] Uh thank you for calling APL. Have a great weekend.