AccountId: 011433970860
ContactId: fbdde4e0-1bcf-4687-a14e-d7e5ecb994e5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 519239 ms
Total Talk Time (AGENT): 155272 ms
Total Talk Time (CUSTOMER): 154847 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/09/fbdde4e0-1bcf-4687-a14e-d7e5ecb994e5_20250609T15:38_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] [PII], this is [PII].
[CUSTOMER][NEUTRAL] I'm calling in reference to 730.
[CUSTOMER][NEUTRAL] 492.
[AGENT][NEUTRAL] OK, let me pull that up here. 1 2nd.
[AGENT][NEUTRAL] All right, and then for security, if I could just verify, please, Mr. [PII], your date of birth and address.
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][POSITIVE] Thank you. How can I help today, sir?
[CUSTOMER][NEUTRAL] I filed a claim.
[CUSTOMER][NEUTRAL] On
[CUSTOMER][NEUTRAL] Well, I filed a claim.
[CUSTOMER][NEUTRAL] And I'll fax to you.
[CUSTOMER][NEUTRAL] On [PII], a
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Biopsy for cancer, which was positive, that was done on [PII]. In that claim, I had a copy of a bill.
[CUSTOMER][NEUTRAL] Which had codes on it, and I had also a copy of the pathology report which confirmed the cancer.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] So I get a denial that says this policy does not provide benefits for office visits.
[CUSTOMER][NEUTRAL] In order to give consideration to your claim, we need a fully itemized surgery bill. This is a biopsy, it's not a surgery.
[CUSTOMER][NEUTRAL] In order to continue the processing your claim, please provide the following information, itemized bill for the surgery performed. That was with it.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I provided you the pathology report. So what is the issue with having this claim?
[CUSTOMER][NEUTRAL] Paid
[AGENT][NEUTRAL] OK, let me look at what we had received here. I gotta pull that up. Give me just a moment.
[CUSTOMER][NEUTRAL] And all I'm seeing is that that you're going to pay.
[CUSTOMER][NEUTRAL] Is
[CUSTOMER][NEUTRAL] I'm not really sure what you're going to pay, but I think it's a surgical benefit. It does talk about a
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You're just gonna pay a benefit, you're not gonna really pay based upon the bill or anything.
[AGENT][NEUTRAL] OK, let me see here.
[AGENT][NEUTRAL] Surgical pathology. OK.
[AGENT][NEUTRAL] OK, yeah, I see that it shows.
[AGENT][NEUTRAL] write out a diagnosis.
[AGENT][NEUTRAL] On the pathology and associates, it looks like it's what you submitted to us.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so it's stating itemized billing for the surgery performed, listing the charge and the procedure code for the surgery. So, there are no procedure codes or any of that listed on there.
[CUSTOMER][NEUTRAL] If you look at the insurance claim form.
[CUSTOMER][NEUTRAL] There is a form from Health Choice, uh duplicate which came from.
[CUSTOMER][NEUTRAL] Uh, neurological specialist.
[CUSTOMER][NEUTRAL] It shows a code.
[CUSTOMER][NEUTRAL] Uh, 51798 $70 another one for 810. What is, I mean, that's what other companies are requesting. What's different for you?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Looks like, yeah, that's not what they needed. OK.
[AGENT][NEUTRAL] Um, let me, the only other thing I can do on this, [PII], is I can have an examiner call you back and tell you exactly what they need to process it or I can get somebody on the line right now if you don't want to wait for a call back it's up to you.
[CUSTOMER][NEUTRAL] I want to talk to somebody that tells me, and let's just say, this thing's approved, what is it going to pay?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So let me get somebody on the line that's an examiner that can go over this with you and tell you exactly why they need what they need to process this out. Do you have a good callback number in case something happens on the transfer?
[CUSTOMER][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Alright, hold the line for me just one moment please.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Like you should know what your benefits are.
[CUSTOMER][NEUTRAL] Transferring.
[AGENT][NEGATIVE] I didn't even do right again.
[CUSTOMER][POSITIVE] Good morning. Thanks for calling APO. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey [PII], this is [PII] over in customer care. How are you today?
[CUSTOMER][POSITIVE] I'm doing good how are you?
[AGENT][NEUTRAL] Hey, I'm good. Um, I have an insured on the line that would like to speak to somebody in regards to a claim. Can you help with that?
[CUSTOMER][NEUTRAL] Uh, policy number.
[AGENT][NEUTRAL] 730492.
[AGENT][NEUTRAL] For [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the claim number is 36095002.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, we went over the denials and I was telling him that, you know, we needed an itemized surgery bill. Um, I did pull up what he submitted. He's giving a little pushback because he doesn't understand why the um health insurance information on the claim isn't being accepted when that has procedure codes on it.
[AGENT][NEUTRAL] And so he was just asking to speak to somebody else.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, send him on over.
[AGENT][NEUTRAL] OK, I'm just gonna let him know I'm gonna transfer him one second.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for your patience Mr. [PII]. I have somebody on the claims department on the line. I'm gonna go and transfer you through.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] [PII], did she give you any of the information I gave her?
[CUSTOMER][NEUTRAL] Yes sir, she gave me your policy number, the claim number and um.