AccountId: 011433970860
ContactId: 1112bb0e-8fe7-4a43-a992-26b7997532eb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1157010 ms
Total Talk Time (AGENT): 419235 ms
Total Talk Time (CUSTOMER): 158814 ms
Interruptions: 1
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/20/1112bb0e-8fe7-4a43-a992-26b7997532eb_20250520T14:37_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I have a question. Um, I had put a claim two different claims for wellness, and then I got supposed an email that it was it was um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It was
[CUSTOMER][NEUTRAL] I guess I don't know it was paid.
[AGENT][NEUTRAL] They were denied? Oh, paid? OK.
[CUSTOMER][NEUTRAL] No, it was paid I think but then when I go and look at online I'm confused because now it took away one and then the other one that was showing that I thought was paid is not paid, so I'm a little confused.
[AGENT][NEUTRAL] OK, I can look those claims up for you. Um, what's your name and a good callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Can you um give me your policy number?
[CUSTOMER][NEUTRAL] Uh hold on.
[CUSTOMER][NEUTRAL] Let me see if I can see my policy number. Hold on.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] If you don't have it I can look you up by your social security number if that helps.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, [PII].
[AGENT][NEUTRAL] OK. Hold on one moment. Sorry, one moment.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, you said start over please.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 62.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 8983.
[AGENT][NEUTRAL] Give me just a moment while I pull it up.
[AGENT][NEUTRAL] And you said and
[AGENT][NEUTRAL] What was your first name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, it looks like you have 3 policies with us. Which one were you trying to submit your claim for?
[CUSTOMER][NEUTRAL] Well, the wellness, I guess goes to the.
[CUSTOMER][NEUTRAL] The critical and the accidental both.
[AGENT][NEUTRAL] OK. OK. We'll have to look up one at a time.
[AGENT][NEUTRAL] So let's go with your group accident one first.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So there were 2 types. There was for the colonoscopy.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the other one was for uh what was it called?
[CUSTOMER][NEUTRAL] Uh, let me see if I remember the other one, hold on.
[CUSTOMER][NEUTRAL] Like a sleeping test that I had to do neurology neuroimaging study.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, real quick, can I get you to verify your account real quick? Um, what's your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And your mailing address and phone number?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me check.
[AGENT][NEUTRAL] Do you have your claim numbers or the date of service?
[AGENT][NEUTRAL] For one of them?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] One of them was [PII].
[AGENT][NEUTRAL] OK, of this year correct?
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] OK, let me, let me look on that one for you real quick.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] Looks like that one was denied. Let me see what's going on.
[AGENT][NEUTRAL] Give me just a moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Just a moment. It's taking my computer some time.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Looks like it was denied due to a data entry error, so give me just a moment while I look that up, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What was the other date of service? And let's look up your second claim.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Or do you have the claim number?
[CUSTOMER][NEUTRAL] It was in November. I don't have.
[CUSTOMER][NEUTRAL] Uh, yes, I do. Hold on.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, that one is 366 I'm 3601289 1239 forgive me.
[AGENT][NEUTRAL] 360 1239.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me look that one up real quick.
[AGENT][NEUTRAL] OK, that one's not on this policy, so we'll go with that one in just a second, um.
[AGENT][NEUTRAL] I'm still waiting to hear back on that other one. Let me look at your other policy and look up these claims and see which one that's on.
[AGENT][NEUTRAL] Because you have 3, OK.
[CUSTOMER][NEUTRAL] So let me tell you what happened when I, I had submitted, I had submitted to the first time, but when I went to check, apparently one of them never went through and the operator told me resubmit it, so I don't know if they did resubmit and it's counting as a duplicate. I'm not sure.
[AGENT][NEUTRAL] Yeah, that's what I'm wondering because of the data entry error, um, it does show that you submitted one the the first one for [PII].
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Was the one for April, was that your colonoscopy?
[CUSTOMER][NEUTRAL] Uh, yes.
[AGENT][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] Let me pull up your other policy and see if maybe that data error was due to it being submitted through the wrong policy because you have 3 with us.
[AGENT][NEUTRAL] And I can understand how it'd be very confusing on which one you should submit the claim on, so give me just a moment.
[AGENT][NEUTRAL] Let me see if it was just submitted under the wrong.
[AGENT][NEUTRAL] Policy number?
[AGENT][NEUTRAL] Give me just a moment while I look this up for you.
[CUSTOMER][POSITIVE] Mhm thank you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, sir.
[AGENT][NEGATIVE] Wouldn't be for this policy.
[AGENT][NEUTRAL] Let me look at your other policies. You have, you have 3 of them, so give me just a moment while I go through each one of them and make sure.
[AGENT][NEGATIVE] It wasn't because it was submitted through the wrong policy number.
[CUSTOMER][POSITIVE] Mhm, appreciate it.
[AGENT][NEUTRAL] You said the other one ended in 1239. OK, let me see why that one was.
[AGENT][NEUTRAL] OK, so the one you gave me that was 360-1239, that claim was denied because the calendar year maximum for the wellness expense benefit has been met for the year. The benefit will not be payable again until next year. Um, if you, if you disagree with that decision made regarding your claim, you do have the right to appeal the claim decision.
[AGENT][NEUTRAL] Um, your written appeal should be submitted to our office within 90 days of the date of the claim decision.
[AGENT][NEUTRAL] Um, and I can tell you when that is in just a moment. If you have additional information on this claim, um, just let me know. So you have 90 days from the time that claim was submitted.
[CUSTOMER][NEUTRAL] So how does it work?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So how does it work because I've never used this plan so like if I do a physical and other stuff I'm only doing I could only do one and that's it.
[AGENT][NEUTRAL] Um, it depends on your deductible and your calendar year maximum. Let me check and see.
[AGENT][NEUTRAL] Let me pull up that policy and see what you have for that one.
[AGENT][NEUTRAL] Yes, so it looks like on the policy you submitted the for the um.
[AGENT][NEUTRAL] For this claim, the 360-1239, it looks like you had already met that um because you have health you have wellness benefits.
[AGENT][NEUTRAL] Uh, it looks like you can do a maximum of wellness visits, one per covered person. Uh, you get the health screening or the mammography or vaccine. Um, it looks like you spent that $50 for a health screening already.
[CUSTOMER][NEUTRAL] Oh OK, got it now OK.
[AGENT][NEUTRAL] And I can tell you when that, yeah, and it was from something that you did on [PII], OK, so that's that one.
[CUSTOMER][NEUTRAL] That's fine.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] The other one, let's go back to that policy because.
[AGENT][NEUTRAL] That one is a little different.
[CUSTOMER][NEUTRAL] So for example, let's say, so for example if I do if I do the teeth cleaning or the vision, my my yearly eye exam, I've already covered, I've already been already by submitting the first one I already did for the year, correct?
[AGENT][NEUTRAL] So you don't have vision through us, um.
[AGENT][NEUTRAL] We don't have vision. There might be vision benefits say if you were injured in an accident on your policies, there might be vision screenings for that, but that isn't a part of your policy wellness visit.
[AGENT][NEUTRAL] Um, since I am seeing that you're submitting these, are you submitting these through the online portal or are you submitting these through, OK, so on your portal you can see your policy number and your policies. If you go to your policy certification, especially for this one, if you're wanting to know what screenings are covered, um, it looks like on your policy certification you'll go to schedule of benefits which is page 20.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And it has everything right there and then.
[AGENT][NEUTRAL] What I just gave you, oh no, this is the wrong one, so sorry, um, so whenever you look at your policy certificate, your policy certificates, go to schedule of benefits and they'll show you what all is covered. um, you shouldn't have to read the whole pages and everything if you just go to that schedule of benefits, it'll show you, I believe there was a health screening, a mammography, and then a vaccine, um, and you can only do one per calendar year.
[AGENT][NEUTRAL] Off that policy so say you wanted to do a.
[CUSTOMER][NEUTRAL] So one of those 3.
[AGENT][NEUTRAL] Those are the three that are offered through your policy, but say you did your your wellness screening already, if you wanted to do a mammography, you would need to wait until next year if you wanted that $50 applied.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh OK now I got it, OK.
[AGENT][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] No I that OK.
[AGENT][NEUTRAL] It was just for those 3 that I had mentioned on that specific policy. Um, I didn't look at your other policies just yet.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, that's fine. I can read the other policies and I could probably understand better.
[AGENT][NEUTRAL] OK, and then.
[CUSTOMER][NEUTRAL] Um, I just didn't know the status of them.
[AGENT][NEUTRAL] The other one, it is different um.
[AGENT][NEUTRAL] Let me pull
[AGENT][NEUTRAL] Let me pull up your other one real quick.
[AGENT][NEUTRAL] Um, for that last, that first policy that you gave me.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see what's going on with that other one because it is a it is different.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then for the wellness screening, the one that you did on.
[AGENT][NEUTRAL] [PII] I believe.
[AGENT][NEUTRAL] Whenever we had the data error it was submit, I guess it was submitted twice.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it's for the same uh it's for the same reason so it's all on the same policy it just had a different claim number on it so it whenever it gets submitted it goes to the policy that it needed to go to and since it was a wellness screening.
[AGENT][NEUTRAL] It had already been met, it just had a different claim number, yeah, so it is all the same it looks like 11 of the denials was just in a different, it was on a different policy.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] OK, is there anything else I can help you with?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] No, I appreciate your help.
[AGENT][POSITIVE] Alright, thank you so much for calling APL and have a great day.
[CUSTOMER][NEUTRAL] You too bye bye.