AccountId: 011433970860
ContactId: 14860912-3894-4e8d-9ba6-b828876deee1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 999369 ms
Total Talk Time (AGENT): 337997 ms
Total Talk Time (CUSTOMER): 236577 ms
Interruptions: 4
Overall Sentiment: AGENT=0.1, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/14860912-3894-4e8d-9ba6-b828876deee1_20250117T15:38_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey, good morning, [PII]. My name is [PII] calling. How are you?
[AGENT][POSITIVE] I'm doing well. How are you?
[CUSTOMER][NEUTRAL] Good, good, uh, you want my policy number?
[AGENT][NEUTRAL] Um, yes, sir. May I have a good contact number in case we're disconnected though first?
[CUSTOMER][NEUTRAL] Sure, [PII].
[AGENT][POSITIVE] Thank you for that, and then your policy number whenever you're ready.
[CUSTOMER][NEUTRAL] OK, it's 021-92143.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][POSITIVE] Yep, sure, thank you.
[AGENT][NEUTRAL] You're welcome. And I have your policy here. I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] To
[CUSTOMER][NEUTRAL] OK, uh, [PII].
[CUSTOMER][NEUTRAL] My address is [PII].
[CUSTOMER][NEUTRAL] And what what else do you want?
[AGENT][NEUTRAL] Um, your email address?
[CUSTOMER][NEUTRAL] Oh, first initial E, last name [PII].
[AGENT][POSITIVE] Thank you for that and thanks for verifying. All the information provided is a verification of benefits, not a guarantee of payment. And how may I help you today?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Uh, can you look at [PII] for us? I don't think we turned in any wellness claim forms.
[AGENT][NEUTRAL] Oh, sure. Um, you want to see if any claims were.
[CUSTOMER][NEUTRAL] I think we totally forgot.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] One
[AGENT][NEUTRAL] And do you mind if I place you on just a brief hold? You want me to look for you and your wife as well?
[CUSTOMER][NEUTRAL] Uh, yes please, yes, OK, have you know what, can you, can you check [PII]? I think we did all of them for that year, but if you could check that.
[AGENT][NEUTRAL] OK, hold on one moment, OK?
[AGENT][NEUTRAL] [PII] and um [PII] to see if wellness claims have been received.
[CUSTOMER][NEUTRAL] Yeah, I know we send in like 3 in [PII], but you could check it, OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][POSITIVE] Take your time. Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So it looks like for um [PII] for you, we have one claim, um [PII], we have three.
[CUSTOMER][POSITIVE] It's all right.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] And for your wife, for [PII], we have 3, and for [PII], it looks like um she submitted.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] It's like, OK.
[AGENT][NEUTRAL] Is this, she submitted to.
[CUSTOMER][NEUTRAL] So she.
[AGENT][NEGATIVE] But they were denied.
[AGENT][NEUTRAL] Hold on, let me get that reason.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So that's only
[CUSTOMER][NEUTRAL] Of what you say that you as well.
[CUSTOMER][NEUTRAL] much.
[AGENT][NEUTRAL] For specialist.
[AGENT][NEUTRAL] I'm gonna reach out to claims on this one to see the, I mean, I see the denial reason, but
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I don't know if they're saying that it wasn't a physician or a covered.
[AGENT][NEGATIVE] It looks like it wasn't a covered um.
[AGENT][NEUTRAL] Not place of service, but you know how it's a specialist and then like the office.
[AGENT][NEGATIVE] So it looks like this wasn't a covered um.
[AGENT][NEUTRAL] I guess I could call it a physician. They're still physicians, it's just specialists, but let me double check for you, OK?
[CUSTOMER][NEUTRAL] OK. All right.
[AGENT][NEUTRAL] All right, so I'm gonna reach out to claims. Hold on one moment, OK?
[CUSTOMER][NEUTRAL] You
[CUSTOMER][POSITIVE] OK, sure, thank you very much.
[AGENT][POSITIVE] You're very welcome.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What's the difference between SP and and this is why claims need to do claims because we're not that on claims.
[AGENT][NEUTRAL] Now I got to try to figure this out because you can't call.
[AGENT][NEUTRAL] OK, so what's SPX? What's the difference?
[AGENT][NEUTRAL] And it doesn't
[AGENT][NEGATIVE] This is so annoying.
[AGENT][NEUTRAL] We have a whole claims department.
[AGENT][NEUTRAL] That processes claims.
[AGENT][NEGATIVE] No point in looking in the EOB because I already know the, the reason and don't get it.
[AGENT][NEGATIVE] What the heck? A screening benefit.
[AGENT][NEGATIVE] 2 for covered persons. I don't understand how we had paying out 3.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh, spouse?
[AGENT][NEUTRAL] Is that what that means, spouse?
[AGENT][NEUTRAL] I guess.
[AGENT][NEUTRAL] The spells, OK.
[AGENT][NEUTRAL] But still though, why wasn't it?
[AGENT][NEUTRAL] The total number of claims payable as I see benefits in any one year is subject to the.
[AGENT][NEUTRAL] is subject to the maximum number of estimates gaining benefit show. This benefit has been exhausted for all covered persons for this calendar year.
[AGENT][NEUTRAL] What?
[AGENT][NEUTRAL] So what did she do in [PII]?
[AGENT][NEGATIVE] I'm confused.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I'm calling claims.
[AGENT][NEUTRAL] I hate going against the grain, but I need help.
[AGENT][NEGATIVE] I'm gonna have to send a message in our chat, then send it, no, I'm not doing that. I'm getting help now.
[CUSTOMER][NEUTRAL] Bring
[CUSTOMER][POSITIVE] Thank you 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 doing?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][NEUTRAL] I'm doing good. I don't think I need to transfer. I just don't understand this claim. Can you look at something with me?
[CUSTOMER][NEUTRAL] Yeah, what's the policy number?
[AGENT][NEUTRAL] It is 219-214-3. It's for part two.
[CUSTOMER][NEUTRAL] OK, give me just a second here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All these names.
[AGENT][NEUTRAL] So those two claims for 2024.
[AGENT][NEUTRAL] Uh, I read the reason, so it's saying that the benefits were exhausted for the year, but she, I don't see any claims for 2024 that was paid out.
[CUSTOMER][NEUTRAL] Um, 8171, uh, give me just a second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, OK. Um.
[CUSTOMER][NEUTRAL] Well,
[AGENT][NEUTRAL] So was I, am I looking at this right or no?
[CUSTOMER][NEUTRAL] Yeah, you're looking at it right? Let me pull both these claims up. Hold on, let me make sure they're both entered on the claim form is 2024 and it's just not entered in the system is 2024, not 2023.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 3, OK.
[CUSTOMER][NEUTRAL] Give me just a second.
[CUSTOMER][MIXED] If my systems would work for me it would be great.
[AGENT][NEUTRAL] Oh, it's OK. So I'm looking at the 879.
[AGENT][NEUTRAL] To see what the claim, what was sent in.
[CUSTOMER][NEUTRAL] OK, this is the 883 and it's 2024, so what I would do is I know you'll have to send her a request now, right?
[AGENT][NEUTRAL] I don't know. I'm.
[AGENT][NEUTRAL] Uh, I'm sorry.
[CUSTOMER][NEUTRAL] I would just send her request.
[AGENT][NEUTRAL] I think so, but I'll figure it out, but yeah, it's a hub and then what?
[CUSTOMER][NEUTRAL] Yes, I would just send her request asking for those two claims to be reviewed because the remark code shows that those claims have been, um, the benefits have been exhausted for the calendar year and those were the first claims that they sent in for the wellness claims.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I will do that.
[CUSTOMER][NEUTRAL] So that's what I would do because it doesn't look they've been exhausted.
[AGENT][NEUTRAL] OK, I just, I was like, well, maybe I don't get it. OK. Well, I was just making sure.
[CUSTOMER][NEUTRAL] No, you're looking at it right.
[CUSTOMER][POSITIVE] No, you did good.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome. Bye bye.
[AGENT][NEUTRAL] Alright, bye bye.
[AGENT][NEUTRAL] Hello, Mr. [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Thank you again for holding. I apologize for that wait. So it wasn't um that it wasn't a covered provider. So I'm going to send both of her claims back that she submitted for [PII]. The the when I looked down a little more at the reason, it's saying that the benefit for the year was exhausted. So, um, when I called claims, I told them I didn't see anything for [PII] and she didn't either. So I'm gonna get these two to be reprocessed and um
[CUSTOMER][NEUTRAL] Yeah,
[CUSTOMER][NEUTRAL] Oh that's fine.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] Get a correct decision to you. I apologize for that.
[CUSTOMER][NEUTRAL] I'm sorry, you
[CUSTOMER][POSITIVE] That's all right. That's fine. No problem.
[AGENT][NEUTRAL] And then um for her, she also had 3 for [PII], I'm sorry, [PII]. She had 3 for [PII].
[CUSTOMER][NEUTRAL] I thought you could only have 2.
[AGENT][NEUTRAL] I thought so too. That's what it says, but we paid out 3, so I, I didn't want to mention it.
[CUSTOMER][NEUTRAL] Is it, isn't it 2 apiece?
[AGENT][NEUTRAL] We did, I looked at it and I'm like, well, it did say 2 on there, but 3 were paid out for you and her for [PII], so I, I, I'm just going, it's paid.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Oh my, right, yeah, whatever.
[CUSTOMER][NEUTRAL] OK, so for.
[CUSTOMER][NEUTRAL] 2024 we're.
[AGENT][NEUTRAL] Mhm. She has two claims.
[CUSTOMER][NEUTRAL] I did, I did.
[CUSTOMER][NEUTRAL] I did one, is that what you said? I think that's what you told me.
[AGENT][NEUTRAL] Let me see for you, for you.
[AGENT][NEUTRAL] Yes, you have one so far for [PII] that's been paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Was that for what you know it was for? Was it for dental or was?
[AGENT][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Or you might not be able to tell.
[AGENT][NEUTRAL] So it just tells me it was a screening, but it doesn't tell me like what kind.
[AGENT][NEUTRAL] Um, I can look on the claim form and see. Hold on one second.
[CUSTOMER][NEUTRAL] 41.
[CUSTOMER][NEUTRAL] I don't wanna duplicate something, you know, just.
[AGENT][NEUTRAL] Oh no, I understand. So I do have a data service. It was [PII], but let me see.
[AGENT][NEUTRAL] If I can tell.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Ma.
[AGENT][NEUTRAL] Hold on one moment, I'm just waiting for the documents to populate here.
[CUSTOMER][NEUTRAL] Is that we talk about that makes sense um.
[AGENT][NEUTRAL] Uh, this was a physical.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, that was a physical, OK.
[CUSTOMER][NEUTRAL] And then she you're you're sending the tube back through for [PII] you said right for her.
[AGENT][NEUTRAL] Yes, for your wife. Mhm.
[CUSTOMER][POSITIVE] OK, alright, so we're on the [PII]. OK, excellent I appreciate your help. Thank you very much.
[AGENT][POSITIVE] You're very welcome. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, you have a great day take care.
[AGENT][POSITIVE] You also, and thanks for calling APL. Have a great weekend.
[CUSTOMER][POSITIVE] OK thanks bye bye.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Mhm