AccountId: 011433970860
ContactId: ebdfb7c5-f3b7-4a39-aa40-ff7aaef67883
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 504279 ms
Total Talk Time (AGENT): 193766 ms
Total Talk Time (CUSTOMER): 164582 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/13/ebdfb7c5-f3b7-4a39-aa40-ff7aaef67883_20250613T16:01_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], um, my name is [PII], and I was calling, um, I have an employee who wants to do file an appeal on her claim. What type of, uh, where can I find that form or is that something you could email me?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So it's actually for the appeal there's no form uh we just require that it's a letter basically in writing stating the reason for the appeal.
[AGENT][NEUTRAL] And they have 180 days from the decision date to appeal it.
[AGENT][NEUTRAL] And then I can give you the mailing address where it needs to be sent to.
[CUSTOMER][NEUTRAL] OK, where does it need to be sent to?
[AGENT][NEUTRAL] So it would be APL and it's attention appeal department.
[AGENT][NEUTRAL] At [PII].
[AGENT][NEUTRAL] And that is in [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] OK, can you give me that [PII] number again? I, I have [PII], but I think you had a 4 in there.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, it's 2, it's uh [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, yeah, I don't know why I wrote 0. I'm like, I know I heard a 4.
[CUSTOMER][NEUTRAL] OK, so it's [PII].
[AGENT][NEUTRAL] Yes, ma'am, and then just let the insured know that once the appeal is submitted and received, it can take up to 30 days to render any sort of decision.
[CUSTOMER][NEUTRAL] OK, and um so basically this just needs to be a letter from them or from the doctor? Like, OK, from them, do they need any like.
[AGENT][NEUTRAL] Mm mhm.
[AGENT][NEUTRAL] Yeah, it's from the insured.
[CUSTOMER][NEUTRAL] Do they need any
[CUSTOMER][NEUTRAL] Um, documents from the doctor in there or anything with the letter.
[AGENT][NEUTRAL] Believe so. I'll double check here and just see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEGATIVE] To be honest, if I tell her she just has to write a letter, one, it's probably not gonna be very nice because she's not in a good mood right now. And, and two, she's, she's probably just gonna um
[AGENT][NEGATIVE] I gotcha.
[CUSTOMER][NEUTRAL] Probably say what she just told me that the diagnosis was a heart attack and nobody told her anything different.
[AGENT][NEUTRAL] Right. OK. Let's see.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Do you have the claim number that was denied? Maybe I can look at it and see.
[CUSTOMER][NEUTRAL] Yeah, let's see I think it's an I just got an email yesterday from.
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] Claim number 3597425.
[CUSTOMER][NEUTRAL] Um, so I did get an email, you know, explaining the reason for the denial, and I had informed, um, her name is [PII], Miss [PII] of that, and that's kind of when she got a little mad because the, basically the email says, um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Her, when she was admitted, she was diagnosed.
[CUSTOMER][NEUTRAL] Um, non-ST elevated myocardial infarction. However, when she was discharged, there was a different diagnosis on there.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And that's where she was like, uh, you know, even her cardiologist is telling her and treating her for a heart attack. So I'm, I'm just going off of what she's saying.
[AGENT][NEUTRAL] OK, so let me.
[AGENT][NEUTRAL] I can
[AGENT][NEUTRAL] OK. And then do you by chance have [PII]'s date of birth?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, yeah, let me pull that up.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] So on the denial, I'm seeing that it's stating that it needs an itemized medical bill, but I'm trying to look and see what.
[AGENT][NEUTRAL] Was submitted here.
[CUSTOMER][NEUTRAL] Yeah, there was a few.
[CUSTOMER][NEUTRAL] Yeah, she had received that and we uploaded.
[CUSTOMER][NEUTRAL] Uh, let me pull what we uploaded, um.
[CUSTOMER][NEUTRAL] And then that's the last claim number that I have before the new system went into play.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then we can't uh we couldn't see anything so then I was just going off of what we had saved.
[CUSTOMER][NEUTRAL] In our notes and uploaded.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] But I believe there was something submitted after that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, so yeah, then there's some denial stating.
[AGENT][NEUTRAL] Not covered condition.
[AGENT][NEGATIVE] I'm guessing because the one ending in 7425 was the one asking for additional info and then there were some uploads after that and now it's saying not a covered condition.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] So, on the individual appeal, it doesn't state um that we specifically need anything from a physician or doctor.
[AGENT][NEUTRAL] Um, if it's an issue like you were saying where, I guess initially they were saying it was one thing, but at the end of it, she was diagnosed with this and treated for this, like the heart attack or, um, then maybe she could get a letter from that physician just reconfirming that that she could send with. Um, yeah, it's, it's not required, but it might.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Um, eliminate some frustration and just help her out, you know what I mean? Um, so it wouldn't necessarily, yeah, it wouldn't necessarily be a bad idea, um, cause they can always request more information from the physician as well. But if she already gets something from them stating that, that would definitely be work in her favor.
[CUSTOMER][NEUTRAL] Right, yeah.
[CUSTOMER][NEUTRAL] OK, yeah, she, she goes to the doctor on the [PII], so I'll tell her to get the um.
[AGENT][NEUTRAL] Yeah, just like a letter and just like explain to the provider that um why you know it was denied and why she's needing the letter and yeah they should be able to to help her out with that.
[CUSTOMER][NEUTRAL] A letter.
[CUSTOMER][POSITIVE] OK perfect thank you so much for your help.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] You're welcome. Have a good day.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] You too thank you.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Bye.