AccountId: 011433970860
ContactId: fcb356a3-8267-4af7-b24f-d22ab31d3cff
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1061420 ms
Total Talk Time (AGENT): 370839 ms
Total Talk Time (CUSTOMER): 407913 ms
Interruptions: 11
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/14/fcb356a3-8267-4af7-b24f-d22ab31d3cff_20250214T18:10_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi this is [PII]. I'm just calling to get an update on my case.
[AGENT][NEUTRAL] OK, and spell your name for me, [PII].
[CUSTOMER][NEUTRAL] [PII], it's [PII] yes, [PII].
[AGENT][NEUTRAL] Oh, [PII].
[AGENT][NEUTRAL] OK. OK. What's your policy number?
[CUSTOMER][NEUTRAL] 02283755
[AGENT][NEUTRAL] And I get phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And [PII], what's your date of birth and your mailing address?
[CUSTOMER][NEUTRAL] [PII] at [PII].
[AGENT][NEUTRAL] And your email address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you for that and you're just following up on your claim. It looks like it was reviewed today.
[AGENT][NEUTRAL] Let me see what it's saying here.
[AGENT][NEUTRAL] OK. It's saying that based on the information received, it does not appear that an accident, that an accidental bodily injury occurred.
[AGENT][NEUTRAL] Um, therefore, no benefits are payable. And so, what type of accident is it?
[CUSTOMER][NEUTRAL] It's uh, it happened at work. I'm, I mean, I'm going to physical therapy. Today is my first day. I don't understand what you mean.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEGATIVE] I'm going to physical therapy today and I'm going, I have an upcoming uh orthopedic appointment coming up. I don't understand what you mean by that.
[CUSTOMER][NEGATIVE] It's an injury. I'm hurt.
[AGENT][NEUTRAL] Yeah, but what part of your body injury? What's the injury?
[CUSTOMER][NEUTRAL] If I'm going to physical therapy.
[CUSTOMER][NEGATIVE] It's my, it's my lower back that's hurt.
[AGENT][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] It it it says it on the it says it on the itemized bill.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] Yeah, I'm just reading to you what the remark code says. Give me just a second.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Still looking.
[AGENT][NEUTRAL] I'm gonna place you on a brief hold, OK, [PII]? Give me one second.
[CUSTOMER][NEUTRAL] Of
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hey
[CUSTOMER][NEUTRAL] Referring.
[CUSTOMER][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How may I help you?
[AGENT][NEUTRAL] Hi, [PII], this is [PII]. How are you?
[CUSTOMER][NEUTRAL] Fine, how are you?
[AGENT][POSITIVE] Good. Happy [PII].
[CUSTOMER][POSITIVE] Thank you to you too.
[AGENT][NEUTRAL] I have an insured on the phone. Let me give you the policy number.
[AGENT][NEUTRAL] It's 228-3755 [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I read the remark code to him and specifically, what does that mean? He said he injured his back. It's the 356-3690.
[CUSTOMER][NEUTRAL] Which kind is it?
[CUSTOMER][NEUTRAL] OK, let me see what we got here.
[AGENT][NEUTRAL] And he just said he injured his back at work.
[AGENT][NEUTRAL] And that's a lot of words in that that remark.
[CUSTOMER][NEUTRAL] So the, this particular coverage only covers if it's due to.
[CUSTOMER][NEUTRAL] Um, bodily injury. So let me see what he's sending cause the diagnosis code is not saying it was any body, bodily injury. So let me see what we got.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Let's see here if it comes up.
[AGENT][NEUTRAL] Like, should that be like an S code?
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] Not necessarily? OK.
[CUSTOMER][NEUTRAL] Yeah, for example, not necessarily, but for example, yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Is it OK.
[CUSTOMER][NEUTRAL] Well, that document is not close. Let me try another way.
[CUSTOMER][NEUTRAL] So wait a minute, have this claim, I'm showing this claim is in audit. It is, so this hasn't been issued yet.
[CUSTOMER][NEUTRAL] We haven't even reviewed it yet.
[AGENT][NEUTRAL] But look at, look in lion.
[CUSTOMER][NEUTRAL] It's an audit. This was just processed today. It's an audit review by the examiner.
[AGENT][NEUTRAL] OK. So if I went to see LPAY, would I see that?
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] No, cause it's a denial, so we haven't even released this yet. Uh, yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me see what else we got because it's under review.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh let me see what all we got though.
[CUSTOMER][NEUTRAL] Did you already tell him that denial? Oh.
[AGENT][NEUTRAL] I did, I did.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I'm just gonna back that up and say it's being reviewed.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Yeah, it is because it has not been released from audit yet, but yeah, looking.
[AGENT][NEUTRAL] How do, how do we know that?
[CUSTOMER][NEUTRAL] Well, only because I would advise if you see that same process date as today's date.
[AGENT][NEUTRAL] Like a RN.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I would just tell, I usually advise you to tell them that it's it's in review.
[CUSTOMER][NEUTRAL] Cause especially if it's an audit, but you don't know that it's an audit on your end, but if you see that today's date, I would just let, I usually let them know it's in final review.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Do we not use that internal pin that 072 code that IA 072 anymore?
[CUSTOMER][NEUTRAL] Cause we don't know if we can
[CUSTOMER][NEUTRAL] Um, that's only if you're waiting on something to process the claim.
[AGENT][NEUTRAL] Seem like there was a pin code if it was being uh reviewed by.
[AGENT][NEUTRAL] I know it's an internal code, but I don't remember what it was.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] No, we don't, the claim isn't pending w[PII] it's an audit.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] All right, because it, we don't have a, we wouldn't know that it's an audit, I guess. That's what I'm saying.
[CUSTOMER][NEUTRAL] Mm mm, no. So I'm saying that if you ever see a claim with this it's processed the same status date, I would advise you to tell them that it's in, it's in final processing. I wouldn't give no benefits amounts, I wouldn't give anything regarding the denial either.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, so the process date is today.
[CUSTOMER][NEUTRAL] Until that EOB is actually printed.
[AGENT][NEUTRAL] OK. OK. So if I looked at the stat date and it's today, am I automatically assume that it's an audit?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, not necessarily, but I still was testing find a review because even if it's not an audit, if it's them to go back and feel like they should have added something differently, they can by the end of the day cause you'll be had printed.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] They can still make changes to that entire claim today.
[AGENT][NEUTRAL] Now how would we know that, Ms. [PII]?
[CUSTOMER][NEGATIVE] Well, EOBs don't print. The actual EOB don't print till tonight. Any claim. Yeah, and even, even on dollar amounts, even when you don't see that that dollar amount has not been released. I mean even when you see that dollar amount it's still showing like a 11 $1900. I still wouldn't tell them that this is a benefit amount you're gonna get because that EOB haven't even printed and somebody can still go back in there and make changes to that dollar amount by the end of the day.
[AGENT][NEUTRAL] Uh, the evening, yeah. Yeah.
[AGENT][NEUTRAL] Ah
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So, yeah.
[CUSTOMER][NEUTRAL] But it looks like, OK, we got the claim form. Let me see what else we got here.
[CUSTOMER][NEUTRAL] To see what else he's sending because so far I'm just seeing the claim form.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, that diagnosis code is only saying he has back pain.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, um, I, since you have already told him that remark code, I would just advise him based off the information, it's just only indicating that, you know, you have back pain.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But the policy only covers if there's any um bodily injury and that information provided does not indicate that that bodily injury occurred.
[AGENT][NEUTRAL] Mhm. Oh, Lord. He is, he's on 200, OK.
[CUSTOMER][NEUTRAL] Is it, OK, well, tell them that it's, you can tell them that it's still in it's currently in review though cause it is, cause it hasn't been released from audit.
[AGENT][NEUTRAL] I'll do that. I, I'll do.
[AGENT][NEUTRAL] Yeah, he is on 200.
[CUSTOMER][NEUTRAL] Yeah, it hadn't been released.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I'll do that. All right, bye-bye.
[CUSTOMER][NEUTRAL] All right. OK. Bye.
[AGENT][NEUTRAL] Hey [PII], thank you so much for holding um I was checking with the area that's reviewing the claim and they wanted to let you know that they're reviewing it.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Um, and like I said, it was processed today, so they're actually still reviewing it.
[CUSTOMER][NEGATIVE] OK, I was about to say because I was off work due to that injury for a whole week. Workers' comp paid me for, paid me for a week because of that injury. So there's no way, there's no way you guys are claiming that it wasn't an injury if I was off work for a whole week.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Well, the, the code that's on the claim that you sent, it just says back pain. That doesn't indicate that there was an injury. That just says back pain. The documents that you sent us.
[CUSTOMER][NEUTRAL] Well, that's from the ER. The ER didn't evaluate me. I went to the doc to urgent care clinic the next day who, you know, where I went, you know, for the past 2 or 3 weeks because I couldn't get a hold of your agent.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] What did they say?
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] It's a back injury. It's, it's a back injury. They, they, they referred me.
[AGENT][NEUTRAL] OK. So did you send in notes from the.
[AGENT][NEUTRAL] Did you send in notes from the urgent care?
[CUSTOMER][NEGATIVE] No, that all I was told, all I was all I was told from you guys was that you guys needed my itemized bill.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So I so I gave you guys that.
[AGENT][NEUTRAL] Right. And on the itemized bill, it just says low back pain. It doesn't say there was any bodily injury.
[CUSTOMER][NEUTRAL] Yeah, well, if I need to get uh if I need to get a, a paper for my urgent care, I can, so.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] OK. OK. What did the urgent care say, [PII]?
[CUSTOMER][NEUTRAL] That I have a back injury. They referred me to go to a, to do physical therapy, which I start today. And then they told me that they also want me to go see an orthopedic.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, um.
[AGENT][NEUTRAL] It is currently in review. Do you know how soon you can get the, the, the documentation from the urgent care facility? Like, like the.
[CUSTOMER][NEUTRAL] I can probably ask them if they can email me.
[AGENT][NEUTRAL] You know, like the either their itemized bill or like your um office notes for that day or any uh records that they may have.
[CUSTOMER][NEUTRAL] Yeah, I'll, I'll ask for all that stuff right now and have them emailed to me and I'll upload it into the into the page that you guys have, yeah, the portal as soon as I get home today because I'm at work.
[AGENT][NEUTRAL] In the portal, OK.
[AGENT][POSITIVE] OK, OK, that'll be good.
[AGENT][POSITIVE] OK. OK, that'll be good.
[AGENT][NEUTRAL] Because what we have now, it says low back pain. It doesn't specifically say that, that you injured anything. There was not a bodily injury.
[CUSTOMER][NEGATIVE] You know, and I was, I was off work for a whole week because I couldn't, I couldn't stand on my own feet, so.
[AGENT][NEUTRAL] Yeah, I get it. I'm not saying that you, you weren't. I'm just saying we need the documentation to, to match what you're saying. So I'm not saying it didn't happen or you didn't have a bodily injury, but we need the documentation that states just what you're saying. And if the urgent cares information says that, I would get that and send it in to us, upload it online.
[CUSTOMER][NEUTRAL] Right, OK, I'm, I'm gonna call them right now then.
[AGENT][NEUTRAL] OK, alrighty and um if you can ask them for uh I'm gonna give you a form name, OK? It's an acronym request this form from them.
[AGENT][NEUTRAL] Because it's very detailed. It's C as in Charlie, Elm, Mary, S Sam.
[CUSTOMER][NEUTRAL] What is it?
[AGENT][NEUTRAL] And number 1,500 1500.
[AGENT][NEUTRAL] And that is their itemized bill.
[CUSTOMER][NEUTRAL] S S S
[AGENT][NEUTRAL] CMS.
[CUSTOMER][NEUTRAL] SMS what CMS OK.
[AGENT][NEUTRAL] CMS.
[CUSTOMER][NEUTRAL] And you're asking me, you're asking me to tell them to get you to give me a what?
[AGENT][NEUTRAL] This is their itemized bill.
[CUSTOMER][NEUTRAL] What exactly do I need to tell him?
[AGENT][NEUTRAL] This is their itemized bill and it's called a CMS 1500 form.
[CUSTOMER][NEUTRAL] OK, so I just need him to uh to tell him to email me their CMS 1500.
[AGENT][NEUTRAL] Form
[CUSTOMER][NEUTRAL] Form with my information.
[AGENT][NEUTRAL] And because it has
[AGENT][NEUTRAL] Yes, and because it has private information, a lot of times the providers won't email it to you.
[CUSTOMER][NEUTRAL] OK, so where would you like for me to email that to you or how would I get that to you?
[AGENT][NEUTRAL] You can, you can have if they would fax it, they can fax it or if they have to give it to you, which they usually do because of the the PHI, and then you fax it over to us would be fine or you upload it or you upload it online would be fine. It's 877.
[CUSTOMER][NEUTRAL] What's the fax number you guys have?
[CUSTOMER][NEUTRAL] 877
[AGENT][NEUTRAL] 365.
[CUSTOMER][NEUTRAL] 365.
[AGENT][NEUTRAL] 942 3.
[CUSTOMER][NEUTRAL] 942 3.
[AGENT][NEUTRAL] Whichever you would think would be the quickest, you getting it and you uploading it, um, or if you know 100% sure that they can fax it to us today.
[CUSTOMER][NEUTRAL] Let me call him and see if if uh I can get him to do that.
[AGENT][NEUTRAL] OK. All right, [PII].
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Alrighty, anything else I can help out with today?
[CUSTOMER][NEUTRAL] Uh, when they ask me who they're faxing this to, what do I tell them your, your exact name, the American.
[AGENT][NEUTRAL] American, American public life.
[CUSTOMER][NEUTRAL] Life insurance.
[AGENT][NEUTRAL] Yes. And then the policy number that you gave me, you can just have them and I think it requires it on that form, but just give them your policy number and then they could notate your policy number on that, um, on that document.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, OK, all right.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK.