AccountId: 011433970860
ContactId: ec6bfffa-a24c-4345-9eb8-4bc7f0b1f3cc
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 719559 ms
Total Talk Time (AGENT): 329480 ms
Total Talk Time (CUSTOMER): 310838 ms
Interruptions: 8
Overall Sentiment: AGENT=0.7, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/04/ec6bfffa-a24c-4345-9eb8-4bc7f0b1f3cc_20250304T19:47_UTC.wav
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[AGENT][NEUTRAL] Good afternoon, thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi. Hi, [PII]. Good afternoon. I have a question regarding a claim that I submitted.
[AGENT][NEUTRAL] OK. Are you calling on behalf of yourself or behalf of a provider?
[CUSTOMER][NEUTRAL] behalf of myself.
[AGENT][POSITIVE] Yes, ma'am, I can help you with that. And who am I speaking with, please?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] OK, Ms. [PII], thank you. And what is a good callback number for you in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, and your policy number, please?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, OK, um, just a minute. I gotta pull it up but it's not on the phone.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, um, group number or?
[AGENT][NEUTRAL] No, ma'am. Your policy certificate number or there should be another number on your ID card and besides just your group number?
[CUSTOMER][NEUTRAL] There's a payer ID number, a group number, plan.
[CUSTOMER][NEUTRAL] And there's benefit certificate number in hospital outpatient.
[AGENT][NEUTRAL] The benefits, uh-huh. Yes, ma'am. I need that number. The in-hospital. Mhm. Is this for an outpatient claim that you filed? What type of claim did you file? For an inpatient admission?
[CUSTOMER][NEUTRAL] OK. Which one?
[CUSTOMER][NEUTRAL] In hospital?
[CUSTOMER][NEUTRAL] Yes, yes, it is.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] For the outpatient because I had surgery on my hip and I wanted to um put through a claim regarding the deductible.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and you, you have filed that claim, is that correct?
[CUSTOMER][NEUTRAL] I have already, yes.
[AGENT][NEUTRAL] OK, yes, and give me the outpatient number then.
[CUSTOMER][NEUTRAL] OK. It's 02476599 M as in Mary, L as in Larry, 8.
[AGENT][NEUTRAL] OK, thank you. So give me a moment, Ms. [PII], to get your information pulled up. Once I do, I will have to verify several things with you. Um, first for security and also any information that I provide will be a verification of benefits and not a guarantee of payment. So just one moment please.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so first off, Ms. [PII], if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] OK, my date of birth is [PII].
[AGENT][POSITIVE] Thank you. And also your home mailing address, please?
[CUSTOMER][NEUTRAL] Home mailing address is [PII].
[AGENT][NEUTRAL] OK, thank you. Also your the phone number rather that we have on file for you is the same as the one you gave me, so that is your best contact number, is that correct?
[CUSTOMER][POSITIVE] Correct. Mhm.
[AGENT][NEUTRAL] OK, and the last piece of information to verify will be your email address please.
[CUSTOMER][NEUTRAL] Uh, my email address is [PII].
[AGENT][POSITIVE] OK, thank you so much. So Miss [PII], have you created your profile in our portal in the online service center?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Have you done that?
[CUSTOMER][NEUTRAL] Yes, I have.
[AGENT][POSITIVE] OK, good. OK.
[AGENT][NEUTRAL] All right, so you can also, I see that you did the reason I was asking is you did not opt in for text notification alerts but you can um sign into your portal and you can opt in for that if you want so that when a claim has been processed, you would receive a text notification alert. Now, on the most recent claim that we have processed for you was on 226. What date was your surgery?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], maybe.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Is this for the Cleveland Clinic in [PII]?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK. So I do see that that claim was reviewed and at this point, it was denied.
[AGENT][NEUTRAL] I can give you the claim number and you can also see that in your portal as well as these remarks that I'm going to read to you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] But the denial on here states in order to provide further consideration of this claim, please submit the following items.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Number one, the explanation of benefits from the primary insurance carrier for this service.
[AGENT][NEUTRAL] And 2, the that.
[CUSTOMER][NEUTRAL] Um, according to the, OK, OK, uh, OK, that's I, I read that. I read that. I have that printed out, um.
[AGENT][NEUTRAL] And the second
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I did go to the portal and I want to get to more elaboration regarding what's needed because I submitted along with my claim, um, the reason that it was actually from the hospital itself, the receipt, and it says.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Uh, hospital charges, CPT 27,130, um, orthopedic, all that, is that not sufficient enough?
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] No, ma'am, because that's not the diagnosis.
[AGENT][NEUTRAL] Those are the procedure codes, not the diagnosis code.
[CUSTOMER][NEUTRAL] OK. So, OK. So what do you, what do you mean diagnosis, uh, reasoning, uh, I mean, I can, I have a whole, you know, uh, email, uh, I would, uh, you know, I can go and pull it up from Cleveland Clinic, all these diagnosis regarding my hip. Is that what you need? Do you need me to attach that?
[AGENT][NEUTRAL] Yes, ma'am. We need to know the reason for why you were there and had your surgery. So we need the diagnosis code and then your explanation of benefits from your primary insurance. And you can just upload those documents directly into your portal like you did this other information.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] X
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm, OK, uh, what do you mean explanation of benefit? I need to know that so.
[AGENT][NEUTRAL] Your primary insurance mhm. Your primary insurance carrier would have an explanation of benefits from where they file the claim with your primary insurance for this surgery.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] What do you mean? My prime, what do you need? Do you need it from my insurance company? Or do you need it from my, from my insurance company?
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] No, ma'am.
[AGENT][NEUTRAL] Explanation of benefits from the primary insurance carrier for this service.
[CUSTOMER][NEUTRAL] No, OK.
[CUSTOMER][NEUTRAL] Which is my, um, my insurance company, my insurance.
[AGENT][NEUTRAL] Your
[AGENT][NEUTRAL] Yes, ma'am, your primary insurance company. Uh-huh.
[CUSTOMER][NEUTRAL] OK, do you need it from them then?
[AGENT][NEUTRAL] Well, you need to, they're not going to send that to us. You would send that to us.
[CUSTOMER][POSITIVE] The explanation benefits from my.
[CUSTOMER][NEUTRAL] My insurance
[CUSTOMER][NEUTRAL] No, no, no, no, no, you, yeah, the document itself, it's from the, the explanation of benefits from like uh insurance company.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] From your primary insurance company, right. Mhm.
[CUSTOMER][NEUTRAL] Explan
[CUSTOMER][NEUTRAL] Yeah, uh, explaining the, the benefits.
[CUSTOMER][NEUTRAL] Pertaining to this claim or pertaining to this, this um surgery?
[AGENT][NEUTRAL] Yes, ma'am, because the hospital would have filed your claim with your primary insurance company first.
[CUSTOMER][NEUTRAL] Uh, uh-huh, right.
[AGENT][NEUTRAL] So we need a copy of that explanation of benefits showing your deduct any amounts that were applied to the deductible co-pay or co-insurance.
[AGENT][NEUTRAL] Because that's what this policy with APL helps you with, so we have to have that.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK. Uh, uh, um, OK. So this is coming from the insurance company. I'll just ask them to provide that and then you, yeah, the diagnosis is this from my um physician, the primary care physician. OK. OK, great. OK, um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Put that together because I just want to make sure where I'm getting the documents from.
[AGENT][NEUTRAL] Oh, sure.
[CUSTOMER][POSITIVE] OK, thank you very much.
[AGENT][POSITIVE] Well, you are certainly very welcome. And is there anything else that I could help you with this afternoon, Ms. [PII]?
[CUSTOMER][NEUTRAL] Um, all I need to do is just upload this information and then, um, and then, and check on the status. How long do you think the status, uh, would be after I upload them?
[AGENT][NEUTRAL] It's typically 7 to 10 business days once they have been uploaded for review.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you will not be it now um you may already be aware of this but I can say that this is the only claim that we currently have on file for you so when you upload the other documents that we're in need of, you will not be able to add them to the claim number that you currently see so you're just gonna click upload files just like you did initially and then our system will know that this was information that we were in need of for another claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, OK. So, OK, uh, I, I was wondering if I, if I could redo, I could redo another claim. So I just attach, I just, yeah, I attach these two and I don't have to redo any claim. OK. Oh, thank you for letting.
[AGENT][NEUTRAL] No. Yeah, no, you're just.
[AGENT][NEUTRAL] Well, yeah, you're not gonna attach, yeah, you won't be able to attach them, so it's gonna look like you're filing a new claim. Just click upload files just like you did before. Mhm. And then.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] Mhm mhm OK.
[AGENT][NEUTRAL] Our the system will know that that's part of this claim.
[CUSTOMER][NEUTRAL] Yes, OK, I'll just.
[CUSTOMER][POSITIVE] OK, OK, very good, thank you very much.
[AGENT][POSITIVE] OK. Well, you are certainly very welcome. So again, if that's everything I can help you with at the moment, thank you for calling APO and I hope you have a great afternoon.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK. OK. OK, great. So that's all I need and um I, I don't think there's after I do have those documents in hand and I don't think it it there's a possibility it's not gonna be declined just once I upload those documents that's required, right?
[AGENT][NEUTRAL] I'm sorry. Is it possible? I didn't understand everything you asked.
[CUSTOMER][NEUTRAL] I, I, I, I, I'm asking, uh, I don't, you don't see at first see any, um, issues regarding what, uh, regarding, uh, OK.
[AGENT][NEUTRAL] I, yes, ma'am, I would not be right. I can't, because we can't process claims over the phone. We will just have to wait till we can receive the information for review.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Makes sense. Thank you.
[AGENT][POSITIVE] Well, you're welcome.
[CUSTOMER][NEUTRAL] Right, OK.
[AGENT][POSITIVE] Well, have a nice day. Yes, ma'am, you too, and thank you again for calling. Bye-bye.
[CUSTOMER][POSITIVE] Have a good day.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Not a problem. OK, bye bye.