AccountId: 011433970860
ContactId: 0e9406f9-b36d-40a8-a2a2-f52c38c1e2db
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 676419 ms
Total Talk Time (AGENT): 415073 ms
Total Talk Time (CUSTOMER): 158464 ms
Interruptions: 2
Overall Sentiment: AGENT=0.5, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/28/0e9406f9-b36d-40a8-a2a2-f52c38c1e2db_20250528T15:00_UTC.wav
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[AGENT][NEUTRAL] And thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII] in [PII] again how you doing?
[AGENT][NEUTRAL] Hey [PII]. I'm still fine. How about you?
[CUSTOMER][POSITIVE] Doing good, doing good. It's uh, the phone's never stopped, so, uh, calling back. I'm sorry.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] I know that's right. That's all right. That's all right. Uh, let's see, your callback number is [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][POSITIVE] OK, thank you. And how can I help you, [PII]?
[CUSTOMER][NEUTRAL] Um, can I give you a policy number, please?
[AGENT][NEUTRAL] So are you needing to check claim status or?
[CUSTOMER][POSITIVE] Yes ma'am, yes ma'am.
[AGENT][NEUTRAL] OK. All right. And what is the policy number?
[CUSTOMER][NEUTRAL] Policy number is 237-03992.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] All right. Thank you. One moment.
[AGENT][NEUTRAL] And go ahead and just verbally give me your email address please?
[CUSTOMER][NEUTRAL] It is um [PII].
[AGENT][NEUTRAL] Thank you. And any information, [PII], that I provide a verification of benefits and not a guarantee of payment. What is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh, [PII], [PII].
[AGENT][POSITIVE] All right, thank you.
[CUSTOMER][NEUTRAL] And we actually filed under, she was in a car accident, we filed under and she had surgery filed under her accident and her hospital plan, so you'll probably see multiple claim numbers in there.
[AGENT][NEUTRAL] Well, I'm on that policy number you gave me is only the accident, so I can only see accident claims under that one.
[CUSTOMER][NEUTRAL] OK, that's fine.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So give me just a second.
[AGENT][NEUTRAL] What's the data service, uh, sure, no, that's fine.
[CUSTOMER][NEUTRAL] Hold on one second, I'm sorry.
[CUSTOMER][NEUTRAL] AJ, I'm on the phone with the home office. I'll call you back in 5 minutes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hey, I'm sorry, um, I don't have data service. I see claim number is 81.
[AGENT][POSITIVE] Yeah, that's all right.
[CUSTOMER][NEUTRAL] One of the ones I see is ends in 813.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, 36, let's see.
[AGENT][NEUTRAL] 3605813. All right, let's see.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK. So that one's showing as denied. Let me pull the reason.
[AGENT][NEGATIVE] This has got multiple dates of service on it.
[AGENT][NEUTRAL] OK. So for the [PII].
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Data service that one says in order to complete the processing of your claim, we need itemized statements of services provided listing the diagnosis code.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's one of the remarks.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Then also for that same data service.
[AGENT][NEUTRAL] For the physical therapy portion, it says we will pay the physical therapy benefit amount shown in the schedule of benefits for each day, a covered person. Well, this is a long one. Receives physical therapy from an individual, excuse me, person received physical therapy from a physical therapist in such individual's office or clinic.
[AGENT][NEUTRAL] As the result of a covered accident. This benefit is payable up to the number of days per plan year for each covered person as defined in the policy certificate. This benefit has been exhausted for this covered person for this plan year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm not
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That's for the 12, um.
[AGENT][NEUTRAL] Let's say
[AGENT][NEUTRAL] And then there's another remark that's also, it states the, we need the enclosed claim form completed by the insured, giving a detailed description of the accident or diagnosis of sickness.
[CUSTOMER][NEUTRAL] Uh, I'm thinking a lot of these letters have crossed paths because if you look in there we have a, uh, the claim form and everything so I'm thinking maybe the person it could have crossed, you see what I'm saying?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and OK.
[CUSTOMER][NEUTRAL] Because the claim forms uploaded.
[AGENT][NEUTRAL] For the group accident?
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] I'm looking at it it's uh uploaded onto the APL site.
[AGENT][NEUTRAL] OK, so what I'll under this policy number. Is that correct?
[CUSTOMER][NEUTRAL] Correct, this is linked to the accident, uh, policy.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so what I'll have to do, [PII], on this one because the dates, because it's got this date range, I can only see the remarks for each data service and what it's saying that we're needing for those. So for like if I'm going in chronological order here for [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's another for physical therapy.
[AGENT][NEUTRAL] Uh, this states on here, we will pay the physical therapy benefit amount show this one's a little different than the other one.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Physical therapy must follow initial treatment in a hospital emergency room or other medical facility for the covered accident. At this time, we have no documentation, which indicates that physical therapy began following initial treatment in a hospital emergency room or other medical facility for the covered accidents.
[AGENT][NEGATIVE] Or accident, no benefits are payable for this service, yeah.
[CUSTOMER][NEUTRAL] I think the confusion
[CUSTOMER][NEUTRAL] On this form is that it says date of accident [PII] and the stuff you're reading is before that date.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] You see what I'm saying?
[AGENT][NEUTRAL] Correct. So,
[CUSTOMER][NEUTRAL] I wonder if this is two separate accidents.
[AGENT][NEUTRAL] Yeah, because according to this, yes, based on [PII], all of this is for an accident. I mean, it reads as
[AGENT][NEUTRAL] Cause you have said the accident date is [PII].
[CUSTOMER][NEUTRAL] It said that on the claim form, but I'm looking at this, these bills, and it states [PII] so I'm wondering if they put the wrong date on the claim form accidentally, you see what I'm saying?
[CUSTOMER][NEUTRAL] Because this lady was in a car that flipped over on the interstate. Somebody hit her and ran and left the scene and she flipped over multiple times and was in bad shape. But I want, but I wonder if
[AGENT][NEUTRAL] Uh.
[AGENT][POSITIVE] God bless her.
[CUSTOMER][NEUTRAL] Either this is two separate claims or she put the wrong date on the form because there is a [PII].
[CUSTOMER][NEUTRAL] Bill that's got a bunch of stuff on it. I bet you the.
[CUSTOMER][NEUTRAL] I'm gonna have to call her.
[AGENT][POSITIVE] Yeah, because a lot, because all of these, can you see the remarks on the client? I mean, I, I'll be happy to read each one of them to you, [PII]. So like for the, so I went over the 12.
[CUSTOMER][NEUTRAL] Because there is a bill
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] All right. The next day the service on here is for 2:11.
[AGENT][NEUTRAL] And that has two denial remarks. One states that we need the enclosed claim form completed by the insured, giving a detailed description of the accident.
[AGENT][NEUTRAL] Or diagnosis of sickness.
[AGENT][NEUTRAL] And then also,
[AGENT][NEUTRAL] The one that I just was reading about, um.
[AGENT][NEUTRAL] We will pay the physical therapy benefit amount shown in the schedule of benefits for each day a covered person receives physical therapy from a physical therapist in such individual's office or clinic as a result of a covered accident.
[AGENT][NEUTRAL] Such physical therapy must follow initial treatment in a hospital, emergency room, or other medical facility for the covered accident. At this time, we have no documentation which indicates that physical therapy began following initial treatment in a medical facility for the covered accident. No benefits are payable for this service.
[AGENT][NEUTRAL] Those are the two remarks for 2:11. Then it jumps up to
[CUSTOMER][NEUTRAL] OK, I'm thinking
[CUSTOMER][NEUTRAL] The, the
[AGENT][NEUTRAL] A 2:15 data service.
[CUSTOMER][NEUTRAL] There's a big bill from December, yeah, go ahead, I'm sorry.
[AGENT][NEUTRAL] That one is, well, the one for 2:15 is asking.
[AGENT][NEUTRAL] For the claim, the, I'm sorry, itemized statements of services provided listing the diagnosis code or codes.
[AGENT][NEUTRAL] And also in order to complete processing of this claim, please provide the toxicology report for this incident.
[AGENT][NEUTRAL] That's for 2:15.
[CUSTOMER][NEGATIVE] Oh this is a mess, OK.
[AGENT][NEUTRAL] Uh, then it goes up because there's a lot of data service. So then the next data service on this same claim.
[CUSTOMER][NEUTRAL] This
[AGENT][NEUTRAL] Uh, it's for 2:25.
[AGENT][NEUTRAL] And there's one line item for that date and that one says in order to complete the processing of your claim, we need itemized statements of services provided listing the diagnosis codes.
[AGENT][NEUTRAL] Then it goes to 226.
[AGENT][NEUTRAL] Same remark about needing the itemized statements.
[AGENT][NEUTRAL] Listing diagnosis code.
[AGENT][NEUTRAL] Same thing for 227.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And also for 3:25.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright, I'm gonna place a call to her so I can get some more details.
[AGENT][NEUTRAL] And that's all of this claim.
[AGENT][NEUTRAL] Yeah, that's all of this, that's everything on this one. So there was a total of 3 line items for [PII].
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] 2 for [PII].
[AGENT][NEUTRAL] 2 for [PII].
[AGENT][NEUTRAL] And then 1 for 225, 26, 27, and 325.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I'm gonna go try to make sense of it and get all the details together. I might have to resubmit some stuff more organized because uh I think there's just some confusion on what's going on. So I'm gonna get her on the phone. I'll get all the dates down again and we'll start from scratch on the accident.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Oh goodness. OK. Was there anything else, [PII], that I could help you with at the moment?
[AGENT][NEUTRAL] Now
[CUSTOMER][POSITIVE] Um, no, that's it. I appreciate your time.
[AGENT][POSITIVE] You are certainly welcome as always, and if there's anything else that we can help you with, give us a call and thank you again for calling APL. I hope you have a great day. Maybe I'll be talking to you later.
[CUSTOMER][POSITIVE] Thank you. You too. Yes, ma'am. Thank you. Have a good day.
[AGENT][POSITIVE] OK, [PII]. You're welcome. You too. All right. Bye-bye.
[CUSTOMER][POSITIVE] Thank you bye bye.