AccountId: 011433970860
ContactId: f1f12889-ba01-4c38-9c39-d86f85c1729b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 497209 ms
Total Talk Time (AGENT): 223809 ms
Total Talk Time (CUSTOMER): 162500 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/23/f1f12889-ba01-4c38-9c39-d86f85c1729b_20250623T19:14_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, [PII], it's [PII]. How are you today?
[AGENT][NEUTRAL] I'm fine thanks how are you?
[CUSTOMER][NEUTRAL] I'm all right. Can you please look at a claim because I, I do not understand this claim remark.
[CUSTOMER][NEUTRAL] For this particular.
[CUSTOMER][NEUTRAL] Claim.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The policy number is 183-4900.
[CUSTOMER][NEUTRAL] And [PII], it's on claim number 360.
[CUSTOMER][NEUTRAL] 5434
[CUSTOMER][NEUTRAL] The patient is [PII].
[CUSTOMER][NEUTRAL] So I get the office visits are not covered. The other code is for a venna puncture.
[CUSTOMER][NEGATIVE] And that denial paragraph.
[CUSTOMER][NEUTRAL] Says that we sent.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] We've sent a release of authorization.
[AGENT][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] For medical providers?
[AGENT][NEUTRAL] Yeah, so it looks like we sent out documentation to them to complete. It looks like we sent out an authorization form for them to sign and date along with information regarding the name, um, address, and, and to help a number of the medical providers. And so once the insured sends back that information completed to us, then we'll, they'll be able to um continue processing the claim.
[CUSTOMER][NEGATIVE] But we received the claim form, OK, but we've received the claim from the provider that's what I'm not understanding.
[CUSTOMER][NEGATIVE] And we denied part of it as office visits are not covered and then we're requesting that other for a venna puncture.
[AGENT][NEUTRAL] Yes, it looks like we're needing to get mhm so in order for us to get additional information for the claim, the insured has to authorize that and if we don't have an authorization on file then the provider will not respond to us if we have like if we're asking for additional information.
[CUSTOMER][NEUTRAL] And the provider filed the claim.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I've just never seen this.
[CUSTOMER][NEUTRAL] had used
[CUSTOMER][NEUTRAL] On a meddling policy when the provider filed the claim.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, it just, it's just for us for us to be able to correspond back with the provider. It's just because of the HIPAA.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] If it's any additional information regarding the claim then unless we have an authorization on file from the insured, then they will not respond to us.
[CUSTOMER][NEUTRAL] OK, so I just read that remark, that full paragraph to this lady on the line.
[AGENT][NEUTRAL] Um, let's see, yes, yeah, it's always starting on the second line, um.
[AGENT][NEUTRAL] Yeah, so she should have received and let's see what date this claim was processed.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Oh, has she not received any of those documents?
[AGENT][NEUTRAL] Uh, what was this?
[CUSTOMER][NEUTRAL] The doctor's office?
[AGENT][NEUTRAL] The, are you talking to the insured or the doctors?
[CUSTOMER][NEUTRAL] I'm talking to the doctor's office. No, I'm talking to the provider that filed the claim.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] OK. I know, I thought you were talking to the insured.
[CUSTOMER][NEUTRAL] Yeah, no, no, no. The doctor's office.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Uh yes. Um, give me just a second. Let me just take a look here.
[CUSTOMER][NEUTRAL] Yeah, that's why I was, I mean, I was just confused if the doctor's office filed the claim.
[CUSTOMER][NEUTRAL] I've, I've just not seen this remark on a med link claim.
[CUSTOMER][NEUTRAL] When a provider file the claim.
[AGENT][NEUTRAL] That's crazy. Do you mind if I put you on hold for just a second while I just take a look and see what we sent?
[CUSTOMER][POSITIVE] Yeah, sure. Yeah, no, no, yeah, that would be great. I, I, yeah, cause I was trying to avoid a hub ticket, but I also just
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Didn't know if that remark was correct.
[AGENT][NEUTRAL] OK, sure, give me just a second.
[CUSTOMER][NEUTRAL] Kind of.
[CUSTOMER][NEUTRAL] OK. You are on hold.
[AGENT][POSITIVE] Hey, sorry about that. Uh, can you take a quick look at something with me real quick?
[AGENT][NEUTRAL] OK, so I have [PII] on the other line and she's having like a question regarding this claim number. I guess we sent this code that she's saying that she's never seen before that she wants to make sure that we use the right code to send this to a health provider, but we're, I, I guess we're asking for additional information.
[AGENT][NEUTRAL] OK, so we sent it, right, so then that's what I thought like we send an authorization to the insured that we can request additional information from the provider, right?
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] OK, I don't know why she's giving me such such pushback on that talking about we didn't do the right code and why are we, why would we do this for a physician's claim.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] I guess she's not understanding why we would do that on a phys on a physician claim.
[AGENT][NEUTRAL] And I said probably because we need additional information to process it, but not for us to process it, we need additional information from the insured.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I'll just let her know.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Bye.
[AGENT][NEUTRAL] OK, sorry about that, [PII] are you still there?
[CUSTOMER][NEUTRAL] Oh, that's OK. Yeah, I am. Uh-huh.
[AGENT][NEUTRAL] Yeah, so I checked with the um adjuster and yes, the code is correct that we normally use this code for a provider claim even though it's a provider claim, but because we need additional information from them and that in order to get it we need an authorization on file for the physician to respond back to us.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. All right.
[CUSTOMER][NEUTRAL] OK, because the claim and also just an FYI the claim whatever claim document was received is not up under that claim number, I mean like.
[CUSTOMER][NEUTRAL] When we did the shortcut from ELBI clicking on the claim number to have the documents opening on base, you know.
[CUSTOMER][NEUTRAL] The claim is not under that claim number.
[CUSTOMER][NEUTRAL] It's only a provider EOB and a dental EOB. I mean, I mean.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The AB to the insured, but there's not a claim.
[CUSTOMER][NEUTRAL] The claims information is not in.
[AGENT][NEUTRAL] Oh OK. Yeah, sometimes you have to open it up like in like the policy under the policy number sometimes. That's what I'll do and then I'll, and usually all the documents should be under the policy number if it's not under the claim number.
[CUSTOMER][NEUTRAL] Yeah, well,
[CUSTOMER][NEUTRAL] Yeah, but we don't know which is which when we're on a call when you do it like that, there's a lot of claim it won't.
[AGENT][NEUTRAL] Oh yeah. You can go by the reported date.
[CUSTOMER][NEUTRAL] You know what I mean? They're all just.
[AGENT][NEUTRAL] That that's how I just match it up by the reported date and um for that claim number and sometimes they'll have the claim number listed too when you look at under the policy um I don't know why it does that sometimes but yeah that's just how I sometimes go around it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Gotcha. All right. Well, thank you for checking for me on that. I appreciate you.
[AGENT][POSITIVE] Sure, you're welcome.
[CUSTOMER][POSITIVE] OK, [PII]. Have a good afternoon.
[AGENT][POSITIVE] Uh thanks you too.
[CUSTOMER][POSITIVE] Thanks. Thanks. Bye-bye.
[AGENT][NEUTRAL] Bye bye.