AccountId: 011433970860
ContactId: 10ac7281-f609-4f29-a47e-a4fd51fcaf93
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 626119 ms
Total Talk Time (AGENT): 223524 ms
Total Talk Time (CUSTOMER): 371211 ms
Interruptions: 6
Overall Sentiment: AGENT=0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/14/10ac7281-f609-4f29-a47e-a4fd51fcaf93_20250514T15:38_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII]. How are you? This is [PII].
[AGENT][NEUTRAL] Hi so how are you?
[CUSTOMER][POSITIVE] Hey, I'm good and you?
[AGENT][POSITIVE] Doing well thank you.
[CUSTOMER][NEUTRAL] Good, good. Um, I have a member on the line, um, that she's calling because she believes that we did not process the claim, um, correctly. Um, so the policy number is 408307.
[CUSTOMER][NEUTRAL] And it's gonna be in part one, and Mr. [PII] and I have um Ms. [PII], but Mr. [PII] is there as well.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me pull that up.
[CUSTOMER][NEUTRAL] OK, and is the most recent claim.
[AGENT][NEUTRAL] And then for Mr. [PII], right?
[CUSTOMER][NEUTRAL] Mhm, yes.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Looks like a wellness claim for a couple different data service and he's saying we didn't pop up correctly.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, she's
[CUSTOMER][NEUTRAL] Uh, she, she or he is, both of them, they're looking for the San Francis Medical Center benefit, which is the hospital confinement benefit for 328 to 45. Um, she said that is a specified disease and that's what she was trying to get benefits for the specified disease benefit under the policy.
[CUSTOMER][NEUTRAL] I went ahead and pulled the benefits and I do see that but uh yeah I'm not sure exactly why I didn't pay or if it's something payable or what happened there. So um she's just confused. She, she said that she thought that she was gonna get that paid.
[AGENT][NEUTRAL] OK, let me
[CUSTOMER][NEUTRAL] The payment for the specify the seats under that one.
[AGENT][NEUTRAL] Take a look.
[AGENT][NEUTRAL] OK, I'm gonna pull the claim image up and um everything's been verified correct?
[CUSTOMER][NEUTRAL] Everything has been verified. The callback number is the same one in the system.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And let's see, and that's the [PII]?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm. Yes, yes.
[AGENT][NEUTRAL] OK, and this is for um.
[AGENT][NEUTRAL] For [PII], correct?
[CUSTOMER][NEUTRAL] Yes, [PII], but I have Ms. [PII] on the line again, Mr. [PII] is there as well. OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it's both Mr. and Mrs. [PII], OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes. Mhm.
[AGENT][NEUTRAL] OK, I'm gonna pull up those claim documents. You can go ahead and send them through. Thank you. Everything's been verified correct?
[CUSTOMER][NEUTRAL] You're ready? Let me know when you're ready. OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, you're welcome. Everything's been verified. OK, yes, thank you. You're welcome. Now, but thank you for holding and being patient for me, Mr. and Mrs. [PII]. I got Ms. [PII] on the line, and she's gonna assist you with that claim, OK? It's just an examiner.
[AGENT][POSITIVE] Great. Thank you so much.
[CUSTOMER][POSITIVE] OK, OK, thank you.
[AGENT][NEUTRAL] Hi, hi, Mr. and Mrs. [PII], how are you?
[CUSTOMER][NEUTRAL] Huh, OK.
[AGENT][NEUTRAL] My name is [PII]. I'm on the claim support team so I'm taking a look at the documents now, so I understand there was a question about the um hospital confinement uh that was submitted.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] Yeah, yeah, it's, it's under the specified disease policy that we have and I don't know if you, if there is something that
[CUSTOMER][NEUTRAL] Uh, anyway, he had one of the specified diseases that's listed in the policy book. So that's, and I sent in, I've talked to
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I can't tell you how many different people, and I did everything they told me to do. Um, he had, his policy is, uh, in our book under specified diseases is number 28, tuberculosis. So when I told the previous person, she told me to get a specific form from the hospital, which I did, and I had that, it has initials down at the very bottom corner of the form.
[CUSTOMER][NEUTRAL] And I sent that in along with some other stuff from the hospital. So, um, I, it's my understanding that there are benefits payable for that. So now, you can tell me why there is or isn't.
[AGENT][NEUTRAL] OK, yes, so I'm looking at what you're looking at and I'm a little bit um.
[AGENT][NEUTRAL] What I'm gonna need to do with this particular um claim, Mr. [PII], is I'm gonna send it back to be reviewed so he was um in the hospital from [PII], correct? those eight days looks like?
[CUSTOMER][NEUTRAL] Yes, ma'am. Yes, ma'am.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I had no idea.
[CUSTOMER][NEUTRAL] That we even
[CUSTOMER][NEUTRAL] There was such a thing, uh, in this policy book, and I don't know why. I was, I, I don't know why I was looking through it. Um, maybe to get some in a telephone number or something, and I just kept looking, but I didn't realize that we had a specified disease policy that was taken out in [PII], uh, but we do, so.
[CUSTOMER][NEUTRAL] Anyway,
[CUSTOMER][NEUTRAL] That's why I submitted all of the stuff for the tuberculosis.
[AGENT][NEUTRAL] OK, so I'm just looking at some information, so bear with me for just a moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, in, in our booklet actually is a copy of the.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Um, the, you know, the, the policy number page and the type of coverage, the age of my husband, the method of payment, policy benefits, uh, etc.
[AGENT][NEUTRAL] Right, and I'm looking at the reason code for the denial it's saying.
[CUSTOMER][NEGATIVE] Those are difficult to understand on the back of the thing with the check when you get it. It says, it doesn't really give you any explanation. It says, it just lists, well, here it is. It says one thing it says it's the duplication of previously submitted expenses.
[AGENT][NEUTRAL] Yes, yes.
[CUSTOMER][NEUTRAL] Uh, it's my understanding that I, I, I did fax everything, but it did not go through. So then I sent a certified copy of everything. So I had not previously submitted any expenses for tuberculosis.
[CUSTOMER][NEUTRAL] The calendar year maximum on the wellness benefit has been met. That would be with regard to the prostate cancer. Um.
[AGENT][NEUTRAL] Yeah, those were the wellness benefits, um, like the screening that that's payable under your plan. Yeah. Mhm.
[CUSTOMER][NEUTRAL] I don't
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah. Yes, you, you're right. This, yeah, this check is that I got is only for the wellness benefit. You're right. It doesn't, it doesn't have anything to do with the tuberculosis.
[AGENT][NEUTRAL] Right. Mhm.
[CUSTOMER][NEGATIVE] But, but this thing back here says it's, it's not.
[CUSTOMER][NEUTRAL] payable because it wasn't caused by cancer. And that has nothing to do with. Yeah, my, my husband said it said something about it wasn't caused by cancer, but But that, that policy does. But the policy, unless it's in the fine print or somewhere, uh, that you don't, cancer doesn't cause, uh,
[AGENT][NEUTRAL] Right, cancer, right, right. I see that. Mhm.
[CUSTOMER][NEUTRAL] Tuberculosis.
[CUSTOMER][NEUTRAL] None of these diseases on here that are under specified diseases are caused by cancer like diphtheria. Uh, OK, I can go on polio, the RI syndrome, all that is, yeah.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so I'm just looking over the documents, so bear with me for just a moment.
[CUSTOMER][NEUTRAL] I told you not to lose this. Did you cut it off?
[CUSTOMER][NEUTRAL] No, I
[CUSTOMER][NEGATIVE] Well it's not coming back on.
[AGENT][NEUTRAL] OK, so if I, if I can um have you um.
[CUSTOMER][NEUTRAL] There it is.
[AGENT][NEUTRAL] If it's OK with you, Mrs. [PII], what I'm gonna do is I'm going to send an inquiry to the adjuster that processed the claim and ask her to review that particular um line on that benefit for the hospitalization, um, and if you'll allow me a little bit of time to reach out to her and I can give you a call back and, and give you a resolution to this and that best number to contact you at [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's fine.
[CUSTOMER][NEUTRAL] Yes, ma'am. Uh, I don't always have my phone at my ear and we're going.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] To [PII] next week. So, I mean, I hope you'll put a note, try recalling or leave me a message or send me a, uh um email or something. I'll see that. I mean not um anyway.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] OK, well, I'm hoping it won't, will be today, um, um, it may be a little bit later on today.
[CUSTOMER][NEUTRAL] OK. And I'm, I'm gonna be at a funeral part of the day, so that's fine, that's fine.
[AGENT][NEUTRAL] OK, and is it OK to leave a voicemail? Do you have a voicemail?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, yes, I do. I don't know, wait a minute, I'm not sure it's set up when I hang up from you, I'm gonna make sure it's set up.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, um, and like I said, it what I'm gonna do, it shouldn't be too long. I'm gonna send that message now and I should have, like I said, some kind of a response and I'll just call you back and just kind of give you an update just to let you know um.
[AGENT][NEUTRAL] If there was anything else that's needed, I don't think there should be anything else, but again, I'm gonna send it to the examiner so if there is something I'll call you back and let you know. But at this point we're just gonna kinda call it a claim review for that benefit for the consignment to the hospital. Um, did you have any other questions?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, but you do understand.
[AGENT][NEUTRAL] Oh yes, ma'am. Mhm.
[CUSTOMER][POSITIVE] No, but I was gonna ask you, you understand what I'm trying cause I've gone over this so many times. OK. All right. So I appreciate your time and I'll, I'll await the call.
[AGENT][NEUTRAL] I do. Uh-huh.
[AGENT][POSITIVE] You're welcome, Mr. [PII]. Hopefully we can get this resolved for you today and like I said, um, I'll be giving you a call back uh in a little while or later later this afternoon and like I said, if um if needed, I'll just leave a message for you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] OK, you're so welcome. Bye bye. Thank you. You too. Thank you, Mrs. [PII]. Thank you for calling A.
[CUSTOMER][POSITIVE] Bye-bye. Bye-bye. Have a good day. Bye-bye.