AccountId: 011433970860
ContactId: d42689ca-fccc-4f74-a70e-35ba08e021bc
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 416779 ms
Total Talk Time (AGENT): 223435 ms
Total Talk Time (CUSTOMER): 192654 ms
Interruptions: 0
Overall Sentiment: AGENT=1.6, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/d42689ca-fccc-4f74-a70e-35ba08e021bc_20250429T12:24_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] Hi, I'm calling because um I submitted a claim for um my dependent and um the claim was for an urgent care visit, which um should have been covered by APL. But for some reason, when my insurance company processed it and on the explanation of benefits, they put the name of like the actual provider that saw her and not the name of like the facility where she went.
[CUSTOMER][NEUTRAL] So the claim was denied saying that, um, you know, we don't have coverage for office visits, which is correct, we don't. But this was not like a regular office visit, it was an urgent care visit. So I have now received like a more itemized bill from the urgent care facility that has both things on there, has the name of the provider and the name of the facility, and I just uploaded it to the portal, but I just wanted to make sure that that was enough or if there's something that I need to get from my provider, for my insurance.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so you have uploaded some additional information for a claim for your dependent. Is that correct, related to her urgent, his or her urgent care?
[CUSTOMER][NEUTRAL] Correct, but I didn't know how to like add it to like the existing claim, so I think I just created a new one. I don't know if that was right or wrong. um I didn't see where I could, OK.
[AGENT][NEUTRAL] OK, so yes,
[AGENT][NEUTRAL] I can help you. I can take a look at it and verify that it was uploaded and everything. So who am I speaking with first off, please?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] My first name is [PII] and last name [PII].
[AGENT][POSITIVE] OK, thank you. And Miss [PII], what is a good callback number for you, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And then your policy number, please?
[CUSTOMER][NEUTRAL] The policy number is 245-03772.
[AGENT][NEUTRAL] OK thank you give me a moment please to get all of your information pulled up.
[CUSTOMER][NEUTRAL] Sure, sure.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, Ms. [PII], I will need to verify several things with you first for security and also any information provided would be a verification of benefits and not a guarantee of payment. So if you will first please verify the primary subscriber's name and date of birth and then your date of birth and your child's name and date of birth.
[CUSTOMER][NEUTRAL] OK, so the subscriber is Nelson [PII], [PII]. I am [PII], [PII], and this is for [PII], which is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And then also your home mailing address, please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm thank you. The phone number that we have on file is actually your number. I'm assuming it's the same as the one you gave me. OK. And the last thing to verify is the email address on file.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] And it does appear to be.
[CUSTOMER][NEUTRAL] Um, I'm assuming it's mine, [PII]. Yes.
[AGENT][NEUTRAL] OK, all right, thank you. OK, so as far as how you uploaded the information, you did do that correctly. There is not a way to tie to an existing claim number, but the system will be able to recognize, you know, with the dates of service, what that's for. So you've uploaded new a new itemized bill and a explanation of benefits.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] From your primary as well?
[CUSTOMER][NEUTRAL] I yeah, so I uploaded like the screenshot from the portal with the explanation of benefits because it has the diagnosis code which the actual explanation benefits do not. So I reuploaded that. I had, I had sent it before, but what the what the new thing is the itemized bill from the urgent care.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] OK. So, and your, the itemized bill and the explanation of benefits from your primary insurance match as far as
[AGENT][NEUTRAL] All of that information. Is that correct?
[CUSTOMER][NEUTRAL] I mean they match the thing that's weird is I have never had the explanation of benefits for urgent care give me the name of the provider and not the facility. So the explanation of benefits has like the actual guy that saw her, but then the itemized bill shows you that it's like CMD whatever it's called urgent care and then his name so I don't know.
[AGENT][NEUTRAL] Right. OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so you've uploaded as much, right, so what we'll have to do is I can't tell you at this point if that's sufficient or not, but I can see that it's been received. It is now in line for review, so it will be just like the initial claim that you update, excuse me, uploaded.
[CUSTOMER][NEUTRAL] What else to get?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] Once it has been reviewed, I believe that let me go back and check.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, I see that you all are opting in for the text notification alerts once it's been processed. So when you receive that notification if you're not instantly able to log in and see the status, that's because you'll probably you'll receive the text before it goes through like our overnight process which makes it viewable to you in your portal but if you get that text you could call us and we could verbally tell you what the status is over the phone.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] OK, I'm just, so you're not able to, I guess I have to wait for it to get processed for to find out if the new information is enough. OK, it's just, it doesn't even make sense because my office visits like are $80 they're not $100 like it's.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes. Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] It was very obviously an urgent care. I just don't know why Amed processed it with the provider, the actual PA that saw her and not.
[CUSTOMER][NEUTRAL] Not the name of the facility, but.
[AGENT][NEUTRAL] Right, and I can't, you know, I can't say that, obviously, as far as their billing and how that was reviewed by the primary, but we will review the information that, you know, you have uploaded, um, and then again, once it has been reviewed, you'll receive that or should receive that notification and if there's any.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You know, saying additional at that point, same thing you could provide it if we came back and said, OK, well we were in need of this or.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Whatever the circumstance may be.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Got it. Um, OK, excellent. Thank you so much for your help.
[AGENT][POSITIVE] OK. Well, yes, ma'am, you're certainly welcome. And is there anything else, Miss [PII] that I can help you with this morning?
[CUSTOMER][POSITIVE] No we're all set thank you so much.
[AGENT][POSITIVE] OK, well, you're welcome and thank you for calling APL. I hope you have a wonderful day.
[CUSTOMER][NEUTRAL] You do the same bye bye.
[AGENT][POSITIVE] Thank you, bye bye.