AccountId: 011433970860
ContactId: d918c236-8d0d-48ed-8660-11e8b721a2ef
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 689250 ms
Total Talk Time (AGENT): 320837 ms
Total Talk Time (CUSTOMER): 195558 ms
Interruptions: 2
Overall Sentiment: AGENT=2, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/d918c236-8d0d-48ed-8660-11e8b721a2ef_20250109T20:58_UTC.wav
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[AGENT][POSITIVE] Hi, thank you so much for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, this is [PII]. How are you today?
[AGENT][POSITIVE] Oh, I'm doing wonderful, Miss [PII]. How are you?
[CUSTOMER][NEGATIVE] Good, listen, I'm hoping you can help me, um, so I submitted a claim. I had to fax it because I have my coverage. I have hospitalization cancer all that through you guys last year and my company benefits changed vendors starting on one so I can't, I can go into my account online, but I can't see anything. It's like it's not updating anyway.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, yes.
[CUSTOMER][NEUTRAL] Yeah, so I got an email that said go to your account to see your claim submission information like mhm it's not out there. So I'm calling to see what you guys if you needed something else if you've got everything you needed or if they had questions.
[AGENT][POSITIVE] Yeah, I'd love to help you with the status update on your last claim, Ms. [PII], and do you mind if I get your policy number so I can take a look into it?
[CUSTOMER][NEUTRAL] Yes, and it's gonna show probably closed or canceled, but it's 02290566.
[AGENT][POSITIVE] Wonderful and while I'm pulling that up, do you mind if I also go ahead and get a good call back number in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure, [PII].
[AGENT][POSITIVE] Perfect thank you so much. I appreciate that.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And.
[AGENT][NEUTRAL] Would you be able to verify for me your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Perfect and I do just need to verify your mailing address if you can.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Wonderful and then lastly just the email address on file.
[CUSTOMER][NEUTRAL] It should be [PII].
[AGENT][NEUTRAL] Oh it looks like it might have been your professional one.
[CUSTOMER][NEUTRAL] OK, [PII].
[AGENT][POSITIVE] Perfect, thank you so much. And then that phone number on file looks like the same one we just did, so that's good.
[AGENT][NEUTRAL] All right, so I actually do see that your claim is here, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] It looks like.
[AGENT][NEUTRAL] Let me just pull this up. I wanna make sure I'm looking at the right thing.
[AGENT][NEUTRAL] It looks like it was accidentally like processed like it was done in error because I have like just an error code on it, um, and so I'm wondering if it is not quite done, but if you don't mind, I'm going to.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm just gonna put you on a brief hold and I'm going to reach out to somebody and double check that and it was for your the.
[AGENT][NEUTRAL] For the claim you submitted at the end of December, right?
[CUSTOMER][NEUTRAL] Yeah, so I did one like a wellness, you know, for just the wellness annual wellness stuff, and then the one for the hospitalization.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, I wonder if maybe they're under your other policy and that's why I'm seeing an error. Hang tight, let me look.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Absolutely.
[AGENT][POSITIVE] Alright, I appreciate your patience. I'm still looking into it a little.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] All right, so, um, that claim, it looks like the first part of it, the mammo procedure, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That, that procedure code, I do have the denial remark. Um, I'm so sorry, I actually just left the remark, um, stating that the diagnostic and prevention benefit has been exhausted for this calendar year. It looks like um we had previously paid out in the [PII] calendar year, your dihaus diagnostic benefit, and it looks like it was for, it also says Mamo on it but from [PII].
[AGENT][NEUTRAL] Um, at Health Imaging Partners. So that benefit had already been used. On the other one though, it does say um that it looks like on the claim there was the biopsy for cancer and it was maybe positive. Is that what I'm reading correctly?
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, um, it was, uh, high, uh, cervical dysplasia, so I don't know.
[AGENT][NEUTRAL] OK, so on that one they're requesting some more information, um, and it's asking for the uh pathology report and if you can send that, we can um do some further consideration on the claim.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, um, and then that was more for hospitalization because I was hospitalized.
[CUSTOMER][NEUTRAL] So are they looking at that as well?
[AGENT][NEUTRAL] OK, so it looks like they actually ended up processing this under the cancer policy and not the hospitalization policy. And it looks like for that hospitalization policy, um, you're going to want to include um
[AGENT][NEUTRAL] Your
[AGENT][NEUTRAL] Um, explanation of benefits from your primary insurance can, can talk, explanation of benefits from your primary insurance carrier, and then, um, your like itemized bill that has your procedure codes and your diagnosis codes, and then you'll want to submit that with one of our hospital indemnity uh claim forms. And if you need to, I can email you a cop[PII] of that claim form so you have it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh yeah, I thought that's what I submitted yeah I thought that's what I did.
[AGENT][POSITIVE] And you don't have to go.
[AGENT][NEUTRAL] It looks like the form we had was your wellness claim form ended up being submitted.
[AGENT][NEUTRAL] Um, and so I think that's why they processed it under the.
[AGENT][NEUTRAL] The other one
[CUSTOMER][NEUTRAL] Mm because I sent two different ones.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Does that mean that's a possibility you didn't get the other one, so I did submit.
[AGENT][NEUTRAL] I'm not sure yet because I'm just seeing the one and it's 6 pages but it's all I mean I guess it's only 5 if you take off the cover letter.
[AGENT][NEUTRAL] Um, but it's just the wellness claim.
[CUSTOMER][NEUTRAL] Yeah, it's, uh, yeah.
[CUSTOMER][NEUTRAL] So I did submit the hospitalization indemnity.
[CUSTOMER][NEUTRAL] Claim form?
[CUSTOMER][NEGATIVE] But it sounds like you might not have gotten that.
[AGENT][NEUTRAL] I don't believe we've received that, no, but if you wanna resubmit it with the itemized bill with procedure codes, diagnosis codes, and your explanation of benefits from your primary insurance carrier, I know they'll give consideration to that as well.
[CUSTOMER][NEUTRAL] OK, um, so the itemized bill was done what I submitted was notes from the hospital, so I'm assuming that's not what you need.
[AGENT][NEUTRAL] No, so let me pull up that claim form. I don't wanna give you any of the wrong information.
[CUSTOMER][NEUTRAL] That 6 page stuff.
[CUSTOMER][NEUTRAL] Yeah, because I've got it pulled up, it just says an itemized bill with diagnosis from the provider and the complete section E is not required.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Just sections A through F, so it just wants an EOB submitted with it.
[AGENT][NEUTRAL] You know what? I think I was thinking of a different one, so no just your itemized bill you don't even need.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] You don't, I don't think you need the EOB just the itemized bill with your diagnosis codes.
[CUSTOMER][NEUTRAL] Because that would have been on the 6th page of the from the hospital.
[CUSTOMER][NEUTRAL] But um
[CUSTOMER][POSITIVE] Yeah, I can use it with an EOB that would give everything as well.
[AGENT][NEUTRAL] Yeah if you could I mean even just the the form I'm looking at I do have like.
[AGENT][NEUTRAL] I don't have any itemized billing on here it's telling me like what you had done and when you had it done but not individual charges of any kind, just like the test perform and the date of service on the test.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Um, so yeah, I would, if you wanna resubmit that I, I'm, I'm so sorry maybe it got lost along the way somewhere, but if you do want to resubmit that we don't have any time like it's not like you're gonna run out of time on our side, um, we'll absolutely consider it once we get it.
[CUSTOMER][NEUTRAL] OK, then I will just resubmit it since I filled it out and signed it and everything. I'll just resubmit it and then send an EOB. I know I had problems sending everything in one group together, so I had to do it in multiple text and it may have been, um, just my system error, but I will resend that hospitalization claim form.
[AGENT][POSITIVE] OK perfect thank you so much and then if there's anything else we can do to help you just let us know and we'll do our best to take care of you OK?
[CUSTOMER][NEUTRAL] And the ERB
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Will do thank you.
[AGENT][POSITIVE] Hey, it's my pleasure. Thank you so much for calling us here at APL and I hope you have a fabulous day.
[CUSTOMER][POSITIVE] Thank you. You too.
[AGENT][POSITIVE] Thanks. Bye bye.
[CUSTOMER][NEUTRAL] Mm bye bye.