AccountId: 011433970860
ContactId: f114345b-f622-4996-b518-fbc342665073
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 678960 ms
Total Talk Time (AGENT): 164338 ms
Total Talk Time (CUSTOMER): 240683 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/12/f114345b-f622-4996-b518-fbc342665073_20250612T20:52_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thanks for calling APO. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] with the care team. I have a broker on the line. She was, uh, getting a call back from claims, and she missed the call, um, and I had spoke with her earlier I had actually put in the ticket to get her a call back, um.
[AGENT][NEUTRAL] The policy number.
[CUSTOMER][NEUTRAL] The policy number is 17193999.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's in regards to part 4,
[CUSTOMER][NEUTRAL] I read her the claim remarks on the documents that were needed, but she's saying that she thought they were submitted and she needs help understanding um what's wrong with the documents that were submitted and what's missing because she she said that um everything that was submitted should have sufficed.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, just one moment.
[CUSTOMER][NEUTRAL] And do you need her callback number?
[AGENT][NEUTRAL] Are, are you gonna put it in notes?
[CUSTOMER][NEUTRAL] Uh, yeah, and they should be in the notes from earlier because she called about 0 20 minutes ago.
[AGENT][NEUTRAL] Is it [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Alright, got it.
[CUSTOMER][NEUTRAL] All right.
[AGENT][POSITIVE] Alright thank you.
[CUSTOMER][POSITIVE] Uh, I will introduce you and I'll bring her right over.
[AGENT][NEUTRAL] OK
[CUSTOMER][POSITIVE] Hi [PII], I have [PII] from uh claim support. She'll be able to talk you through those documents, OK? Thank you so much. I appreciate all your help.
[CUSTOMER][POSITIVE] Alright thank you have a great day.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII] and how can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I'm calling on claim number 36,123,000.
[AGENT][NEUTRAL] OK. Yes, ma'am.
[CUSTOMER][NEUTRAL] No, just 20s. I apologize.
[AGENT][NEUTRAL] Got you, OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] I was advised that the EOB is missing. It's fine, we can get that, but then also in the voicemail they expressed something about needing diagnosis codes. I do see that a few codes are included, so what are we looking for?
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK. So the codes that are included in the information that was sent over, those are procedure codes and the procedure code just tell us what uh what type of treatment they had. So the diagnosis code actually tells us why they went in for medical treatment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And so we just need something from the hospital, the, the discharge uh papers or the ER physician's notes that tells us why this person came into the emergency room.
[CUSTOMER][NEUTRAL] OK, and then.
[CUSTOMER][POSITIVE] I also I'm looking at a claim submitted and paid out for another employee because I help this group a lot and.
[CUSTOMER][NEUTRAL] They only have a billing code or a procedure code.
[CUSTOMER][NEUTRAL] And it was approved, so what's the difference between the two?
[AGENT][NEUTRAL] Can I get the policy number so I can look to see what information was sent in on that one?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, give me one second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Oh, I guess you need.
[CUSTOMER][NEUTRAL] Hold on, can I give you their social?
[AGENT][NEUTRAL] Uh, let me go to another screen. Hold on one second.
[AGENT][POSITIVE] OK, I'm ready.
[CUSTOMER][NEUTRAL] OK, it's 593641543.
[AGENT][NEUTRAL] OK, and the patient's name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And do you have a data service on the claim that we paid on?
[CUSTOMER][NEUTRAL] Yeah, um, let's see.
[CUSTOMER][NEUTRAL] Looks like 1 10 2025, 2 12 2025, 2 14 2025.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 21
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And 25.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 214.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So the charges.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So it looks like the first time I'm looking at the [PII] data service.
[AGENT][NEUTRAL] So it looks like the first time that that claim was submitted, it was submitted with the diagnosis code.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And we needed the explanation of benefits and then once the explanation of benefits was sent in, we already had the diagnosis code so we were able to make a payment on that claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] Can I give you another example just because this lady is gonna drive me crazy if I don't.
[AGENT][NEUTRAL] Another uh patient saying.
[CUSTOMER][NEUTRAL] It, yeah, another claim.
[CUSTOMER][NEUTRAL] I have a Social Security.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] And I apologize. This is just for the owner, so he is.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] OK, I'm ready.
[CUSTOMER][NEUTRAL] So it's [PII].
[AGENT][NEUTRAL] OK, and the patient's name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] OK, and do you have a data service for her that we paid on?
[CUSTOMER][NEUTRAL] Yes, it was, oh that's state today hold on.
[CUSTOMER][NEUTRAL] Date of service is [PII].
[AGENT][NEUTRAL] OK, on that one we did not make a payment but I can still look at it.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, on this one, as I stated, we did not make a payment on this one,
[AGENT][NEUTRAL] It was submitted with the uh billing along with the explanation of benefits.
[CUSTOMER][NEUTRAL] So this claim 524 for [PII] was not paid.
[AGENT][NEUTRAL] No, ma'am, um, because our policy does not cover DME.
[CUSTOMER][NEUTRAL] It doesn't
[CUSTOMER][NEUTRAL] Cover I'm sorry, what?
[AGENT][NEGATIVE] It does not cover durable medical equipment.
[CUSTOMER][NEUTRAL] Uh, medical equipment, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So for [PII], you already had documentation that includes the diagnostic codes.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] And then she it was AOB and then she resubmitted and then [PII] was not paid because that's for medical equipment, OK.
[AGENT][POSITIVE] Mhm. That's correct.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] Well, I, I sure no I appreciate you. It's just.
[CUSTOMER][NEUTRAL] If you were on my side of things, you'd get it.
[AGENT][NEUTRAL] Yeah, I understand, yes, ma'am.
[AGENT][NEUTRAL] Yeah, but once we get the explanation of benefits and the um the diagnosis code, as I stated, uh, being that they went to the emergency room, they can just ask for the discharge summary from the emergency room which that's usually gonna tell why they went in for the emergency room visit.
[AGENT][NEUTRAL] And we should be able to use that in the explanation of benefits.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][POSITIVE] All right. Well, I appreciate your help.
[AGENT][POSITIVE] You are so very welcome. Is there anything else I can help you with on this evening?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] No, that's it. So just to confirm, it's not the, I'm sorry, I do have one more question.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's diagnostic codes, right, is what we're looking for diagnosis.
[AGENT][NEUTRAL] Diagnosis.
[AGENT][NEUTRAL] Diagnosis.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, well that is it. Thank you so much.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Alrighty thanks for calling APO have a great rest of your day.
[CUSTOMER][NEUTRAL] You too. Bye now.
[AGENT][NEUTRAL] All right bye bye.