AccountId: 011433970860
ContactId: 0bc162b4-9477-4275-9462-7e33cd22b0d0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1364660 ms
Total Talk Time (AGENT): 383748 ms
Total Talk Time (CUSTOMER): 443261 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/27/0bc162b4-9477-4275-9462-7e33cd22b0d0_20250327T20:15_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEGATIVE] Hi, [PII]. I put in a claim for my wellness and with the mammogram, and it was denied.
[AGENT][NEUTRAL] OK, well, I can look into the claim with you. Um, may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure, [PII].
[CUSTOMER][NEUTRAL] And it's [PII].
[AGENT][NEUTRAL] Thank you, Ms. [PII]. May I have your policy number?
[CUSTOMER][NEUTRAL] Um, not sure, 02224557.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[AGENT][NEUTRAL] And I have you here. I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] Sure. Date of birth [PII] [PII]. And what was the last thing?
[AGENT][NEUTRAL] Your email address?
[CUSTOMER][NEUTRAL] Oh, [PII], no, no, no, uh, I don't know. [PII].
[CUSTOMER][NEUTRAL] Or [PII].
[AGENT][NEUTRAL] Thank you and um all the information provided is a verification of benefits, not a guarantee of payment. So let me take a look at the claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] It says it was denied because benefits for the plan year are exhausted. Hold on one moment.
[AGENT][NEUTRAL] Let me take a look at the claim. Do you mind if I put, I'm just looking at the dates. Do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] So, is there another mammogram that was given?
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] This to me,
[AGENT][NEUTRAL] Oh, so it's [PII], but you already did. OK, I got it.
[AGENT][NEUTRAL] Hello, Ms. [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] All right, thank you so much for holding. I apologize for the wait. So I had to take a look at the policy because it's on a plan year versus a calendar year. So from August, um, each year, it um, is your plan year is when it starts over, but you had a mammogram um or wellness claim [PII] was the date of service.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it's only one per per plan year, so it's still, it has, it's not August yet, so it's still the same plan year, but that benefit was already used for the March data service.
[CUSTOMER][NEUTRAL] OK, OK, and that is for the accident or critical illness?
[AGENT][NEUTRAL] This is critical illness.
[CUSTOMER][NEUTRAL] Yeah, and does the accident plan have a wellness?
[AGENT][NEUTRAL] Let me see, hold on one second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, so I'm in the policy now. I'm just waiting for the benefits to populate. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, I think it must because it looks like I got paid one in [PII].
[AGENT][NEUTRAL] No
[AGENT][NEUTRAL] Hold on one moment. Let me pull up the big policy because from right here, I don't see a wellness benefit. Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, and while you're thinking, I know I know you're you're in the middle of something too, but when we signed up for this, we got it through our employer R&B and back then the APL representative we were supposed to get two wellnesses per year like in other words, one was a mammogram right so alright let me rephrase that.
[CUSTOMER][POSITIVE] So we got a mammogram benefit every year and then a wellness benefit every year.
[CUSTOMER][NEUTRAL] So we actually got 2, and I don't remember if it was on the accident or the critical illness, but we were supposed to get 2.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I don't know, see if you see that anywhere back then and and the guy's name was [PII]. He did it together. He did it for us.
[AGENT][NEUTRAL] OK, so for the wellness benefit on the accident policy, the, the accident policy does not have a wellness benefit.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then,
[CUSTOMER][NEUTRAL] All right. And the critical illness?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But it goes August to August.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Alright, that makes sense. I know what that means.
[CUSTOMER][NEUTRAL] Alright, so I got one paid.
[CUSTOMER][NEUTRAL] I got one paid for now this is, that says, this says group accident for 1 of $2450. I'm looking in my, my, my claim.
[AGENT][NEUTRAL] Hold on
[AGENT][NEUTRAL] OK, hold on one moment. And what was the date of service?
[CUSTOMER][NEUTRAL] And that was
[CUSTOMER][NEUTRAL] It well it says date received. I don't know the date of service is it on here?
[AGENT][NEUTRAL] Um, hold on one moment.
[CUSTOMER][NEUTRAL] Oh, service date. OK. So here, OK, so I'm just looking back 38328.
[CUSTOMER][NEUTRAL] Of 24
[AGENT][NEUTRAL] Is the data service?
[CUSTOMER][NEUTRAL] And that was on the group accident.
[CUSTOMER][NEUTRAL] It's yeah, service from date, is that the date of service?
[CUSTOMER][NEUTRAL] It says service from date.
[AGENT][NEUTRAL] Is it claim number 3442381?
[CUSTOMER][NEUTRAL] I'm at 24, no.
[AGENT][NEUTRAL] OK, so then no, that's not the data service. OK, hold on one moment.
[CUSTOMER][NEUTRAL] No, that's not what I'm looking at.
[CUSTOMER][NEUTRAL] Alright, so I'm looking at a, uh, it's called my claims upload document.
[CUSTOMER][NEUTRAL] My coverage.
[AGENT][NEUTRAL] What, OK, so what are the claim, so do you see the claim numbers?
[CUSTOMER][NEUTRAL] I see a confirmation number and a claim number. OK, yes. OK, maybe I was wrong. So this claim number.
[CUSTOMER][NEUTRAL] It's 344-2381.
[AGENT][NEUTRAL] OK, so yes, hold on one second.
[AGENT][NEUTRAL] Let me see what this is.
[AGENT][NEUTRAL] So it's a screening.
[AGENT][NEUTRAL] So accident screening, um, let me see what's considered accident screening. That's $2 per person at $50 but that's different than wellness. So let me see what all is covered in there. Hold on one second.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so yeah, that's the, the, it is a screening benefit, but it's different, it's not the same as wellness, but you can use it for screening.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and that's on the accident plan, right?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Alright, so it's called a screening and not a wellness. What does, what page is that on the policy? I think I just found the policy.
[AGENT][NEUTRAL] Um, page 18.
[CUSTOMER][NEUTRAL] All right, hold tight. Let me get there.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Because I don't wanna call back next year.
[CUSTOMER][NEUTRAL] OK. Uh, oh, wait, wait, 5 is, OK.
[CUSTOMER][NEUTRAL] Alright, so what is considered a screening?
[AGENT][NEUTRAL] So, on page 2.
[CUSTOMER][NEUTRAL] It says render the opposition.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] So on page 23.
[AGENT][NEUTRAL] Section 10, it has definitions.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then it'll show you what's considered um an accident screening there.
[AGENT][NEUTRAL] So like your routine physicals, um, if there was anything for like a weight reduction program, bone density screening, stress tests, um, your hemoglobin and A1C testing, sleeping disorders.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So it really has nothing to do with an accident. It's just the screening that it will pay.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK. OK. OK.
[AGENT][POSITIVE] Yeah, that's an additional benefit that y'all added on there.
[CUSTOMER][NEUTRAL] OK, got you, got you, got you, got you, got you, got you. Alright, let me, uh, print. Alright, let me save. Hold on, let me just, alright, I'm gonna go back here and then my and then my critical illness policy.
[AGENT][POSITIVE] Mhm. Take your time.
[CUSTOMER][NEUTRAL] I'm downloading that for just a second.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] There we go.
[CUSTOMER][NEUTRAL] OK, this one is called a wellness benefit, a wellness test.
[CUSTOMER][NEUTRAL] For each day, a covered person receives one or more of the following tests as an outpatient basis. routine physical and a generally medicated septic screening test cover condition, mammogram.
[CUSTOMER][NEUTRAL] This is payable every 2 years.
[CUSTOMER][NEUTRAL] Never heard of that?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And you also cover for a vaccine?
[AGENT][NEUTRAL] Are you looking under um critical illness?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK. Hold on, let me go there. I was in an accident.
[CUSTOMER][NEUTRAL] On page 8 where it says wellness benefits.
[AGENT][NEUTRAL] Right, right, we were in an accident. Hold on, let me go to that policy.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah.
[AGENT][NEUTRAL] OK. And you're looking at the um wellness screening?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, hold on.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Oh, I'm saving it.
[AGENT][POSITIVE] Yes, you have a vaccine benefit as well on here.
[CUSTOMER][NEUTRAL] Uh, what
[CUSTOMER][NEUTRAL] OK. Um,
[CUSTOMER][NEGATIVE] What do you call this thing? Policy? I'm like having a total brain fart. OK. Um.
[AGENT][NEUTRAL] It's OK.
[CUSTOMER][NEUTRAL] OK. All right. So if I have a mammogram and a vaccine, they're both gonna pay?
[AGENT][NEUTRAL] Right, because there are two separate benefits.
[CUSTOMER][NEUTRAL] Or is it
[AGENT][NEUTRAL] So the mammogram
[CUSTOMER][NEUTRAL] OK, so there's a health thing. You go ahead.
[AGENT][NEUTRAL] Thank you. So the health screening benefit will pay $50 mammograms will pay $50 and then the vaccines will pay $25. So those are all separate benefits. So if you submit for each, it'll pay.
[CUSTOMER][NEUTRAL] Well, aren't in that some. I didn't know that. OK then.
[CUSTOMER][POSITIVE] All righty.
[CUSTOMER][POSITIVE] OK, well thank you very much. Now wait before we hang up, if we can go back.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] If we go back to.
[CUSTOMER][NEUTRAL] Hold on, if it says my right so my group critical illness.
[CUSTOMER][NEUTRAL] If my policy goes August to August, my last claim.
[CUSTOMER][NEUTRAL] Right, was on 42 of 24, correct?
[AGENT][NEUTRAL] Um, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So the last claim.
[AGENT][NEUTRAL] The last time we received for the critical illness was [PII] and it was for
[AGENT][NEUTRAL] Data service [PII].
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] But if you look, if, if you go older the the next one, the next oldest one was 42 of 24, you see that? That's two lines down, OK? So if that was in January, Feb, March, April, then my policy renewed in August.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Then the 3:13 should pay.
[CUSTOMER][NEUTRAL] Because if it, it was April and then we go May, June, July, August, August it renews, so I should get it again.
[AGENT][NEUTRAL] I'm sorry. Wait a minute. This is all, this is March and [PII].
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so let's go back. So [PII] January, February, March, April, see the third line down.
[CUSTOMER][NEUTRAL] It says critical illness.
[CUSTOMER][NEUTRAL] Policy number receive date [PII].
[CUSTOMER][NEUTRAL] OK, that was for data service [PII].
[CUSTOMER][NEUTRAL] And I was paid $50 so then in [PII] my policy renews.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It rolls over to another year, so then [PII] is a different year.
[CUSTOMER][NEUTRAL] I know it's hard, it's hard to keep in your head, but.
[AGENT][NEUTRAL] OK, hold on one second.
[AGENT][NEUTRAL] Just hold on one second.
[CUSTOMER][NEGATIVE] I know, I know, pain in the butt. I know.
[AGENT][NEUTRAL] So it's [PII]. So you're saying the [PII] is after [PII].
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So for this one, I can do two things. If you'd like, I can send this over to claims to be reprocessed or to be looked at again. Um, or if you wanted to talk to a claims representative, I can um see if I can get one on the line for you to go over the claim with you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, which, which one is easier? I mean, what's
[AGENT][NEUTRAL] Well, it's up to you. Um, if you want me to give someone a call now, I can, or if you want me to send a request over to them to uh look at the claim and see if it needs to be reprocessed and reach out, whichever you prefer.
[CUSTOMER][NEUTRAL] Um, just send it back over.
[AGENT][NEUTRAL] Are you sure?
[CUSTOMER][NEUTRAL] Well, what do you think I should do?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, I don't, I don't, I don't know, I don't mind, whichever. I just want to do whichever one you want.
[CUSTOMER][NEUTRAL] All right, you can send me over to someone that's fine.
[AGENT][NEUTRAL] You should. That's what you want.
[CUSTOMER][POSITIVE] That's, that's hilarious, yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and before I transfer you over, was there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, you were very sweet though. Thank you.
[AGENT][POSITIVE] You're very welcome and thanks for calling APL. Hold on one moment, OK?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Deferring
[CUSTOMER][POSITIVE] Good afternoon. Thanks for calling APO. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], this is [PII] on the care team. How are you?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][NEUTRAL] I'm doing good. Um, I have a um insured on the other line who asked to speak to someone. She, um, well, you want me to give you the policy number first?
[CUSTOMER][POSITIVE] Yeah, give me one second. OK, I'm ready.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, it's 222-455-557.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And um it's claim number 3576873.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It was denied because the plan year um benefits were exhausted, but she's stating that it's uh
[AGENT][NEUTRAL] Different plan year since it's after [PII] and I went over it with her, but now she's asking to speak to someone else um for clarity on it.
[CUSTOMER][NEUTRAL] OK give me 1 2nd.
[CUSTOMER][NEUTRAL] Data is.
[CUSTOMER][NEUTRAL] 2025.
[CUSTOMER][NEUTRAL] I get to say it's gone.
[CUSTOMER][NEUTRAL] See it's a different plan here.
[CUSTOMER][NEUTRAL] Alright, just send to run over.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hello, Ms. [PII].
[CUSTOMER][POSITIVE] Good afternoon.
[AGENT][POSITIVE] Thank you so much for holding. Um, I have clients on the line and [PII] will be assisting you further, OK?
[CUSTOMER][POSITIVE] Thank you, darling.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Good afternoon thanks