AccountId: 011433970860
ContactId: 18d40f16-c322-48fc-8075-ff5383682998
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 443660 ms
Total Talk Time (AGENT): 183324 ms
Total Talk Time (CUSTOMER): 147551 ms
Interruptions: 0
Overall Sentiment: AGENT=0.1, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/25/18d40f16-c322-48fc-8075-ff5383682998_20250325T16:36_UTC.wav
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[AGENT][NEUTRAL] Morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Um, this is [PII]. What do you need to pull up my account?
[AGENT][NEUTRAL] And if you have the policy numbers now.
[CUSTOMER][NEUTRAL] 02544970
[AGENT][NEUTRAL] OK. May I have a call back number just in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] For security, may I have your date of birth, mailing address and email address on file?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Um, address [PII] and [PII].
[AGENT][NEUTRAL] Mhm
[AGENT][POSITIVE] OK, thank you. And how may I assist you today, Mr. [PII]?
[CUSTOMER][NEUTRAL] Um, there's a couple claims that I guess got submitted and I'm trying to understand this is, is.
[CUSTOMER][NEUTRAL] The reason it was declined is um saying because it was done in the office I mean.
[CUSTOMER][NEUTRAL] So this policy pays nothing if a procedure is done in in the doctor's office.
[AGENT][NEUTRAL] Mm.
[AGENT][NEGATIVE] This one doesn't have office benefits.
[CUSTOMER][NEUTRAL] So if if the price.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Um, I guess that's my question is I had a procedure done in the office last June and my primary health paid some but they did not pay at all and.
[CUSTOMER][NEGATIVE] I submitted it and that's that's what the paper says so I'm just trying to understand this because that's incredibly frustrating.
[AGENT][NEUTRAL] OK, let me check and see exactly what are the benefits. I know the office visits are not covered, like the one that we just got um from Jacksonville dermatology, uh, they're just charging the office visit co-payment, which does not cover, so that was denied, stating that it's not covered. Um, let me see if we cover procedures done in the office. Bear with me just a second. Let me pull your documents.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I understand the dermatologist and like regular copays, but if there's a like if there's a procedure.
[CUSTOMER][NEUTRAL] On top of
[CUSTOMER][NEUTRAL] Um, but this procedure was, it was a colposcopy.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And to me it just doesn't make sense because so I'm, I, I'm high risk I I have high risk HPV cells so they had to do this procedure to test for cancer cells. I mean to me that's not just a normal regular everyday office visit. It's not like I had a pap smear or um obviously it was something separate.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Yeah, um.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Well, this one does have the
[CUSTOMER][NEUTRAL] I mean it's not like a
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I was just gonna say it's not like a uh MRI or something that you would do out outpatient. I mean the doctor does it right there in his office. I mean I can't control that, but I'm trying to understand why it's something that would not be covered.
[AGENT][NEUTRAL] Well, the reason this one was not covered, I'm just talking about the one that I'm looking at, which is the claim that I see here that we just processed, OK? The one we just received was only for the office visit. It doesn't have any other charges, but the office visit, which it was denied because the office visit is not covered.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now, under the coverage of the policy, and this is not a guarantee of payment, just a verification of coverage, um you do have an office treatment writer. The office treatment rider is to pay um if you have any procedures done in the office.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Other than the office visit itself.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So once we receive the claim for the procedure, we can go ahead and process the, that um charge, but right now, we have not received any other claims. The only one we received was the office visit co-payment.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] That you're saying that's from the dermatologist though, right?
[AGENT][NEUTRAL] Yes, mhm.
[CUSTOMER][NEGATIVE] OK, so what I'm talking the the procedure I'm talking about is from [PII], it's in there and it was denied.
[AGENT][NEUTRAL] 0 24. Let's see.
[AGENT][NEUTRAL] From June. OK, so this policy started [PII]. Let me go to an old policy. You probably have one.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yeah, OK, you did have an old policy, so let me go back to that 11 moment.
[AGENT][NEUTRAL] OK, so there are gonna be two separate policies. OK, one is started on [PII] and the other one started on [PII].
[AGENT][NEUTRAL] And the other one is from [PII]. OK, so let me look at the benefits on this 11 moment.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Port.
[AGENT][NEUTRAL] Mm OK. And it looks like this one didn't have any benefits for office treatment. So yeah, this one didn't have benefits for office treatment or office visit. The new one does.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So it doesn't matter what's done in the office if nothing's covered.
[AGENT][NEUTRAL] If it was before [PII], and it's not covered because you didn't have that writer at that time, the rider was added to the group on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Lovely, OK, um, I guess that answers the question then.
[AGENT][NEUTRAL] Mhm. Is there anything else I may help you with today? Any other questions?
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Me.
[CUSTOMER][NEUTRAL] Nope, I don't think so. I think that answers it.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] No
[AGENT][NEUTRAL] All right. Well, thank, thank you for calling APL. You have a good day. If you have any other questions, just feel free to call us back, OK? But yeah, that, that is the reason it was not paid because you didn't have that writer at that time, OK?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] Got it, thank you.
[AGENT][POSITIVE] You're welcome. Have a good day. Bye-bye, Miss [PII].
[CUSTOMER][NEUTRAL] You too bye bye.