AccountId: 011433970860
ContactId: 03fa65f5-3a57-44e3-bfbd-e8dea614b847
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 650000 ms
Total Talk Time (AGENT): 216261 ms
Total Talk Time (CUSTOMER): 166359 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/10/03fa65f5-3a57-44e3-bfbd-e8dea614b847_20250210T20:26_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Um, hi [PII], my name is [PII], and I'm with the broker's office. Um, I had called in a few minutes ago to check about, um, a claim that I had faxed in for an employee, um, and when I was talking to the.
[AGENT][NEUTRAL] [PII], I can barely hear you. You sound far away.
[CUSTOMER][NEUTRAL] OK, I don't, I don't know why that would be.
[CUSTOMER][POSITIVE] My mic has turned up all the way.
[AGENT][NEUTRAL] OK. Go ahead. Go ahead, yes, go ahead.
[CUSTOMER][NEUTRAL] Is that any better?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, when I was talking to the other rep, she was telling me that um multiple claims had been received recently for this person and uh when I talked to her, the employee, she said she didn't know what other claims should have been um submitted so she wanted me to see if I could find out.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, what's the group number, [PII]?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You want her the policy number?
[AGENT][NEUTRAL] Yeah, I'll take that too, but you said you're calling on behalf of the group.
[CUSTOMER][NEUTRAL] Um, well, I'm from the broker's office, so.
[AGENT][NEUTRAL] OK, from the broker's office, OK.
[CUSTOMER][NEUTRAL] Yeah, um, the policy number is 02129475.
[AGENT][NEUTRAL] OK, what's a good callback number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] What's your email address, [PII]?
[CUSTOMER][NEUTRAL] Uh [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And what's the name of the broker agency?
[CUSTOMER][NEUTRAL] H&H Insurance solutions.
[AGENT][NEUTRAL] It's H and H, OK.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] And what is the employee's name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK, so what other claims is the employee referring to?
[CUSTOMER][NEUTRAL] Um, I don't know. Like I said, I called in checking about one I had sent in for her recently for [PII].
[AGENT][NEUTRAL] Uh, uh-huh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And the person that I spoke to said oh well we've had multiple claims.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Come in.
[AGENT][NEUTRAL] Hm
[CUSTOMER][NEGATIVE] Which she proceeded to tell me that the provider had also filed a claim for this same data service so but I don't know if that's what she meant by the multiple claims because she said something about a service in May and that was what really um confused [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm still looking.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII], what's your last name? Is it [PII]?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, I see the previous call I'm just trying to confirm.
[AGENT][NEUTRAL] Let's see
[AGENT][NEUTRAL] So you called on the [PII].
[AGENT][NEUTRAL] There is an [PII].
[AGENT][NEUTRAL] Well, that's actually submitted by the provider.
[AGENT][NEUTRAL] The only claim that I see.
[AGENT][NEUTRAL] Submitted by um insured slash broker's office is the [PII]. The others are have been submitted by his healthcare providers.
[CUSTOMER][MIXED] OK, but she was confused by.
[AGENT][NEUTRAL] And let me
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Was there one in May? because she said the only thing she had done in May was her annual.
[AGENT][NEUTRAL] I do not see any claims for May.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Yeah, no, the policy number that you gave me, I'm sorry, there is one in May, [PII].
[AGENT][NEUTRAL] And it looks like it was a wellness, some type of wellness screening?
[CUSTOMER][NEUTRAL] Yeah she said she had our annual.
[AGENT][NEGATIVE] And that one, yeah, that was denied because well this is not covered under the meddling policy.
[AGENT][NEUTRAL] Um, but
[CUSTOMER][NEGATIVE] Yeah, they really shouldn't OK, yeah.
[AGENT][NEUTRAL] Yeah, let me see.
[CUSTOMER][NEGATIVE] I, I knew it wouldn't be, but there really shouldn't even have been a balance that day anyway because that was covered by our insurance.
[AGENT][NEUTRAL] Right, right, yeah, she sent it. Someone sent it in to us. It shows the no, it shows that the either the insured or your office, someone sent it in. It was not the provider though.
[CUSTOMER][NEUTRAL] Must have been the provider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So maybe, so maybe they did not know, um, give me one sec oh I know the um when she sent this information in it also included um the [PII] date of service for the hospital, so she may not have realized that it was attached to it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And just send in the hospital bill.
[CUSTOMER][NEUTRAL] Oh yeah, that, uh, I sent, I sent the EOB, but that's because it, I mean it was on the EOB with the hospital bill, but I wasn't filing that as a claim.
[AGENT][NEUTRAL] That's OK, that's what it is.
[AGENT][NEUTRAL] Yeah, any, any, any, uh, dates of service that we receive, uh, [PII], we have to process it even if, you know, the insured is not seeking reimbursement, we have to acknowledge every date of, yeah, that's what that is.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, yeah, that was on the AOB with the hospital stuff.
[AGENT][NEUTRAL] OK, yeah, so they wanna inform yeah, him and that any time we receive a claim or EOB or whatever we have to acknowledge every date of service that's listed on the document, OK.
[CUSTOMER][NEUTRAL] I do see that.
[CUSTOMER][NEUTRAL] OK, got you.
[CUSTOMER][NEUTRAL] Well that explains that so my next question is how much is their um outpatient benefit?
[AGENT][NEUTRAL] Benefit I'll check that for you so I'm showing.
[AGENT][NEUTRAL] So I'm showing a maximum outpatient benefit of up to $3400 per calendar year. However, the outpatient and the inpatient benefit is combined.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] For instance, the maximum inpatient, which is admission to the hospital, that benefit is up to $6750 per calendar year. So let's say hypothetically that he exhausts the $3400 outpatient benefit, we would subtract that from the $6750.
[AGENT][NEUTRAL] Uh, you know, the inpatient benefit since they're combined.
[AGENT][NEUTRAL] That makes sense?
[CUSTOMER][NEUTRAL] Oh, so they don't have two separate?
[AGENT][NEUTRAL] It's not separate. It says that it's, it's, it's combined.
[AGENT][NEUTRAL] Combined inpatient outpatient benefit.
[CUSTOMER][NEUTRAL] We don't
[CUSTOMER][NEUTRAL] Hm, I might need to look into that because we don't usually do policies like that.
[AGENT][NEUTRAL] Mhm. Yeah, they're combined.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And
[CUSTOMER][POSITIVE] All right, good to know alright well thank you very much for that information that clears up what I was curious about.
[AGENT][NEUTRAL] OK. All right, [PII]. You're welcome. Anything else?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] No ma'am, that's it thank you.
[AGENT][POSITIVE] OK, thank you for thank you for calling APL have a good day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye-bye.