AccountId: 011433970860
ContactId: d6145642-41c1-4b07-b646-c7ec0f9e0a70
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 822580 ms
Total Talk Time (AGENT): 344151 ms
Total Talk Time (CUSTOMER): 437204 ms
Interruptions: 5
Overall Sentiment: AGENT=0.5, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/20/d6145642-41c1-4b07-b646-c7ec0f9e0a70_20250320T21:06_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hey [PII], my name's [PII]. I'm calling over from Aetna Insurance. This call can be monitored or recorded for quality and training purposes. I have a mutual member here on the line with us as well, [PII]. um, we're just calling to get some clarification. Uh, he's trying to process some claims with you guys and, uh, the previous representative there, um, told him.
[CUSTOMER][NEUTRAL] That he's needing diagnosis codes um for like all these claims dating back like 3 years um so we're just calling to see if that's correct or are you guys satisfied with just the explanation of benefits from Aetna?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK Miss [PII], um, do you have like a policy number that I can pull?
[CUSTOMER][NEUTRAL] Yeah, yeah, I have that. How are you? OK, yes ma'am, yeah, it's 0246.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] 5032 M as in Mike L as in Lima 7.
[AGENT][POSITIVE] Thank you. And let me have a callback number just in case we get disconnected.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And um for security, I need to verify your date of birth, mailing address and email address on file.
[CUSTOMER][NEUTRAL] [PII] [PII] and you should have [PII].
[CUSTOMER][NEUTRAL] For [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We have your work email, Mr. [PII].
[CUSTOMER][NEUTRAL] Oh, you guys have the work one, yeah, it's [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] All right, and.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Yes, we're gonna need the diagnosis code. Uh, we need diagnosis codes to process claims.
[CUSTOMER][NEUTRAL] So, um, I mean only on our explanation of benefits only the procedure code is listed uh the member would need to contact like every provider to get an itemized bill to get those diagnosis codes um we're also wondering do you guys take diagnosis codes verbally? Could I like verbally give that to you right now to plug in or do you guys need the paper copy?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] We need a paper copy. We don't take information over the phone.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, um, is this like a new policy, uh.
[CUSTOMER][NEUTRAL] Because he said he's been doing this for years with just the EOB and had no issue. Yeah, like previously I would do is kind of just upload the EOB and and that was enough, but when I spoke to [PII] from you guys earlier, maybe 1015 minutes ago.
[CUSTOMER][NEUTRAL] She was like, yeah, it's something new and we kind of need the uh diagnostic code now, which I, I cannot just get it on my own, you know what I mean? I cannot go to [PII] and, and, and, and get it on my own. I will have to go back and, and call every single doctor.
[AGENT][NEGATIVE] Oh no.
[CUSTOMER][NEUTRAL] And some of those doctors are like for my wife and my daughter, so I would have to have them call cause of HIPAA. They might not even be, you know, be willing to give me the diagnostic code, so.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Wow, OK.
[AGENT][NEUTRAL] Um, correct, yes. Um, Aetna doesn't usually have any, uh, diagnosis codes on the EOBs, so we don't ask for the member to call the primary insurance. Um, we ask for the member to get the information from the provider of service, um, but yeah, before, like in the past, we used to take diagnosis calls over the phone. We're not doing that no more due to regulations.
[AGENT][NEUTRAL] Um, so we need now, um, the information in a paper form, um, so it needs to be sent in as an itemized bill with the diagnosis codes.
[CUSTOMER][NEUTRAL] So I will need the itemized bill for 28 different visits basically going back 3.5 years.
[AGENT][NEUTRAL] And these are office visit or what type of service is this?
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah, they're all office visits.
[AGENT][NEUTRAL] Your office visits, OK, let me.
[CUSTOMER][NEUTRAL] 12 22 23 24, that's 8 each.
[CUSTOMER][NEUTRAL] And then this year I have 4 because of this, this line that's a maximum of 1 person is 4.
[CUSTOMER][NEUTRAL] And then I gotta, I gotta figure out from January on what my wife and my daughters have gone to the doctor as well. I gotta figure those out.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mhm. OK. Yeah, um, yeah, unfortunately, Aetna is not gonna have that information. Um, so, um, it's not gonna be under EOB. They probably have it, but not where they can just put it in the EOB and send it to us. Um, so.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So, yeah, I mean, they, they, they can go in and kind of read it out to me, but it's, it's, I'm, I'm, I'm putting the work on them and I just kind of rather do it myself. I don't want to be abusive like that, you know. I, I, I can have them now, you know, tell them the dates and they can give me the, the diagnostic code, but again, it will be verbal.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] So I, I would still have to call my doctor and, right, I was still, I, I can write them down in a piece of paper and send them to you guys, but you know, I don't know if that's, I don't know if that's enough or
[AGENT][NEUTRAL] Yeah, that would be better.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] You know, like if I make like, like a checklist of hey this is on this day, this is the, the, this is the diagnostic code, I don't know if that will be enough, or do you guys actually want the whole billing.
[AGENT][NEUTRAL] And you say you spoke to me.
[CUSTOMER][POSITIVE] It it's worth of bidding for one visit where.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, yeah, uh, let me get with the claims department, um, and check and see since they're old claims, um, and see if there's any way you can just write them down, sign your name, and send them in, um.
[AGENT][NEUTRAL] Let me see if that's a possibility.
[CUSTOMER][NEUTRAL] I like I can write them down on the
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I can write them down on the EOB and resend the EOBs, you know what I mean?
[AGENT][NEUTRAL] Yeah, um, and, and again, that, that's, that was something back in the days that we will do, but right now it's just something that came new that we cannot do that any longer due to regulations. And um so I'll have to consult with the claims department because they're the ones that's gonna be processing the claim and um they're the ones that can say go ahead or not. So uh if you don't mind holding for me, let me try to get somebody in that department, OK?
[CUSTOMER][NEUTRAL] I, I, I say I can do that.
[CUSTOMER][NEUTRAL] Yeah, no, I get you. I, I, I.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right, right, right.
[CUSTOMER][NEUTRAL] Right, no, I get you, I get you.
[CUSTOMER][POSITIVE] Appreciate you thank you so much. Thank you.
[AGENT][POSITIVE] You're welcome. Thank you, one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Sing
[CUSTOMER][POSITIVE] Thank you for contacting ATL. My name is [PII]. How may I help you?
[AGENT][NEUTRAL] Hi [PII], how are you? This is [PII].
[CUSTOMER][NEUTRAL] Yes, hi, how are you?
[AGENT][POSITIVE] Hey, I'm good and you?
[CUSTOMER][NEUTRAL] Oh, I'm still here.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Um, I have a, um, OK, I have a kind of like a weird situation, but I need your help.
[AGENT][NEUTRAL] Um, I have a policy number 1659449.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, I have Mr. [PII] on the line. He is with the representative of Aetna on the line as well. Um, and they are, um, calling because he spoke to [PII] this morning and it looks like um he has a lot of claims that he needs to send in diagnosis cos.
[AGENT][NEUTRAL] Uh, they are, yeah, they are all claims, and he said that um it's about 20 claims that he will have to go to each provider and get that, and he don't think he's gonna be able to get all that. And that says that they don't have that information on the EOBs, but they do have the information verbally that they can give it to him and he can send it to us. I told him that, you know, right now we don't take those over the phone. We don't take it right in either. It has to be like an itemized with the diagnosis code in order for us to process.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And but he said that since they're all claims that it's gonna be almost impossible for him to get all of them. So I don't know if you can do anything for him. I said, well, let me just, you know, call because uh claims department and see what we can do and you know.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah, of course.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So here's the, so, um, these were, these were processed. I'm just going by them one by one, OK, so these were processed by by [PII], uh, um.
[AGENT][NEUTRAL] Mhm mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And um you know I guess he can make an appeal uh to, you know, he can send in an appeal and ask to have this reviewed if he wants to, but she's the one who did every single one of these and um since she is not only, you know, she's an auditor and she and my guess now they're.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Uh, I just got through having one. Just, I just got off the phone with her about 3 seconds ago, uh, where we had some going back to 22, 23, where she, uh, talked to, um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I wouldn't tell this guy that, but where she talked to, uh, [PII] and and tried to see if you know going back to 22, 23 if something like this could be. So what I would suggest to him is that, um, and, and she actually uh I'm, I'm going to have to go back in and reprocess some that I pinned for the uh DM 400, uh, because she got these approved on on this one guy. So what I would do, um, is that I would have this guy, uh, reference these uh these claims.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] And that we can give him the claim numbers we can give him a couple of them just whatever and I'd have him send in an appeal and he can do that. His, his policy is active and he should be able to do that online. In fact, I think he's sending his stuff online. It's now you said he's, uh, he's with a provider or talking to us.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, he, he's, he's with the primary insurance. He's with Aetna, which, um, yeah, like I told him that you usually he, he don't get that information from Aetna. He gets that information from the provider of service, but, um, yeah, I don't know if, if you can just, since I told him I was gonna transfer him, if you can just kind of tell him what to do.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yes, of course.
[AGENT][NEUTRAL] And what to send, um, and, um, yeah, so he has like an idea of what to do because, um, and then for future, I just go ahead, um, so you think for future that will be something that we can say that they can just go ahead and send in a meal or no, no, no, no, no, OK.
[CUSTOMER][NEUTRAL] Uh, no, no, no, I really don't. I, the only thing, the only reason that um that uh I'm even suggesting this is the only reason that [PII] called me about them is because the claims were like from [PII], um, and so they were old enough, uh, that we, you know, and so, um.
[AGENT][NEUTRAL] Mm, mhm.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I think that's so what I'm gonna do is I'm gonna ask, I'm not gonna tell him any of that stuff because it's just gonna be confusing. So what I can, I will just ask that uh um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] That he's sending an appeal on the claims and I think at this point somebody needs to actually look at them and, and we need to get a directive because we don't want to have to ask this guy back for the money because that's I don't want this stuff going through audit and you know that they changed the audit process so that now it's just like it's, I don't know, like a maze to get through, you know, so we're all very scared audit.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] Uh, yes, I will gladly talk to him now. What is his name? I'm sorry, I didn't catch his name.
[AGENT][NEUTRAL] I know.
[AGENT][NEUTRAL] OK. His name is [PII].
[CUSTOMER][NEUTRAL] OK, so you're talking to the to the guy. OK, you're talking to Mr. [PII], OK, that's.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, I got Mr. [PII] and I got Ms. [PII] from Aetna. They're both in the line.
[CUSTOMER][NEGATIVE] OK, and I'm sorry, I, I hate to ask it, um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I don't speak Spanish at all. I, I, I quit the. Oh, thank you. Thank you, thank you, thank you. I, I took it in high school and that was so many years ago. I'm not even saying, you know.
[AGENT][NEUTRAL] Oh, he speaks English. It's all English.
[AGENT][NEUTRAL] Yes
[AGENT][NEUTRAL] trust me, if he was in Spanish, I would have been like, OK, tell me what to tell him.
[CUSTOMER][POSITIVE] Yeah, I think [PII] was in, in, in office when I, when I went was taking Spanish, so yes, thank you very much. I will go to help him.
[AGENT][NEUTRAL] Oh yeah, you're welcome. All right. Well, here he comes and um the callback number, I'm just gonna go ahead and put it in the system, OK?
[CUSTOMER][POSITIVE] Yes, yeah, I see it ending in [PII]. That's great. Perfect.
[AGENT][NEUTRAL] [PII] yeah.
[AGENT][POSITIVE] Yeah, OK. All right. Here he comes. Thank you, [PII]. Have a good afternoon. You're welcome. Thank you for holding and being patient for Mr. [PII]. and Ms. [PII], I got Miss [PII] on the line. Uh, she's in the claims department and she's gonna assist you from here.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Sure thank you appreciate it thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Good afternoon. Thank you for contacting us. Um, I, I have, uh, spoken with, uh, with, with one of my supervisors regarding this, and what we, we just, uh, changed our directive, um, where we were asking for, um, supporting documentation to evidence.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] However, some of your claims date back.