AccountId: 011433970860
ContactId: 18fede6f-d2ee-4733-b329-ea8fc7c804c8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 497880 ms
Total Talk Time (AGENT): 341079 ms
Total Talk Time (CUSTOMER): 102174 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/25/18fede6f-d2ee-4733-b329-ea8fc7c804c8_20250325T15:40_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII] and I'm trying to figure out why a claim um was denied on my account.
[AGENT][NEUTRAL] Sure, I can get that claim pulled up and we can get some clarification on that denial. uh [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. And this was for your individual policy, correct?
[CUSTOMER][NEUTRAL] Uh huh, I have a claim number if that helps.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, actually, what was your last name first, if you don't mind?
[CUSTOMER][NEUTRAL] It's 35 0.
[CUSTOMER][NEUTRAL] That's fine. Bowling, [PII]
[AGENT][NEUTRAL] OK, thank you and then I'm sorry, I can go ahead and take that claim number.
[CUSTOMER][NEUTRAL] It's like 3567854
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK thank you one moment.
[AGENT][NEUTRAL] OK, and then I'm just gonna verify some information really quick, [PII]. Can I get your date of birth, please?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and can I get your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect. Last thing I need is the email address we've got on file for you. Uh, looks like it is a [PII] account.
[CUSTOMER][NEUTRAL] Uh huh, it's [PII] [PII].
[AGENT][NEUTRAL] Got it. OK, thank you so much for verifying all that information, [PII]. OK, so for this claim, it does state that all of the payable benefits were applied to your uh policy deductible of $500.
[CUSTOMER][NEGATIVE] What does that mean? I don't understand.
[AGENT][NEUTRAL] Sure, so this policy does have a deductible. Uh, let me get that pulled up here. Give me just a moment.
[AGENT][NEUTRAL] So it does operate on a calendar year basis so it all does reset as of [PII] so for your outpatients that does have a $500 deductible that has to be met before the benefit payable amount can be used, so you have a benefit amount of $4500 per calendar year, but that $500 deductible has to be met first. So that's where this um this benefit went towards that $500. Does that make sense?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, so it doesn't, it doesn't, my policy doesn't cover MRIs, blood work or anything like that for copays?
[AGENT][NEUTRAL] No, no, it's not that it wasn't covered and that's where I know it's a bit confusing and I apologize for that um it says denied as in you did not get a benefit amount paid to that service it is covered that amount just went towards your deductible, so that was um $256.51 that went towards that $500.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can you tell me how much I have left?
[AGENT][NEUTRAL] Sure, um,
[CUSTOMER][NEUTRAL] To meet that 500?
[AGENT][NEUTRAL] Yes, so I'm sorry, I cannot, I'm good at a lot of things. Math is not one of them. Give me just a moment. I need to calculator.
[AGENT][NEUTRAL] Looks like it paid just over half of that.
[CUSTOMER][NEUTRAL] Oh I didn't know if there was anything else of mine that had hit.
[AGENT][NEUTRAL] Um, this is all I've got for the calendar year. Again, it does reset, um, every calendar year, um, so this is the only thing I've got so far. So that was 256 51, so that leaves um $243.49 left of that $500 deductible.
[AGENT][NEUTRAL] And then once that has been met then it.
[CUSTOMER][NEUTRAL] OK, can you check my sons as well?
[AGENT][NEUTRAL] Sure, so I did just pull up your entire policy for the calendar year. Uh, this is the only claim I have on file for the year of [PII].
[CUSTOMER][NEUTRAL] OK, um, I, I wanted to see 2024 for my son because I feel like we owed a lot more than we should have, so I'm just trying to get.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, sure.
[AGENT][NEUTRAL] Let's take a look.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So as of last year we only had a few claims um and that all of those went towards that deductible so we didn't actually get to pay a benefit amount so you had uh $63.78 that went towards deductible and Weston had $150 towards that deductible.
[AGENT][NEUTRAL] And that was all of the claims that we had for last year.
[CUSTOMER][NEUTRAL] Which is crazy because he had a hospital in the.
[AGENT][NEUTRAL] Um, you mean, uh, inpatient?
[CUSTOMER][NEUTRAL] No outpatient towards the 500.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Oh, that, but the all we had towards that $500 for Weston was that $150. Did you want me to take a look at that?
[CUSTOMER][NEGATIVE] He broke both of his arms.
[CUSTOMER][NEUTRAL] Please, that's that's what I'm getting at.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I do see several um so again I'm just looking at all of it does look like we've received several claims, uh, last year for [PII] and it appears that we're missing some information so and it does look like the providers are the ones that filed all of these claims um so there is no timely filing limit if you'd like um you can get that information or have them give us that uh that information.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And we can pay these benefit amounts um look I see one this was for, um, [PII], uh Radilogy consultants of Tulsa that was for $25.75 and that is showing it denied as we were missing the primary EOB.
[CUSTOMER][NEUTRAL] OK. What do you?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So as this is a secondary medical policy we do need to have uh the primary EOB that information showing, you know, essentially what they did pay and so that information was just missing so that's why that one was denied um give me just a moment let me. Uh huh.
[CUSTOMER][NEUTRAL] So you just need the EOB from community care.
[AGENT][NEUTRAL] That was um radiology consultants of Tulsa um and then this I see another one here, yeah, this was a really big one that's also missing the primary EOB this was.
[AGENT][NEGATIVE] Also for [PII], this is Saint Francis Hospital and that amount was $2,769 even and we just didn't pay anything because we need, we're missing that information.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So if I were you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So do I just upload the files to these?
[AGENT][NEUTRAL] You absolutely can. Do you have access to our online portal?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] That's where I'm at right now.
[AGENT][POSITIVE] Perfect yes absolutely that's going to be the quickest and easiest way to get claim information to us um I will say it, uh, if you've not uploaded claims that way it does have to be uh on a desktop or a laptop computer uh that doesn't really have much support for mobile devices perfect. OK, yes, just so you don't run into any issues I would definitely go back um and look because it does look like there's quite a bit payable um that we were just missing information.
[CUSTOMER][NEUTRAL] Yeah, I'm on my work
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, OK, so I will just go in and you guys may get more information than you want, but at least you guys will have it.
[AGENT][NEUTRAL] No, no, that's, that is perfectly fine. We don't mind sifting through that, um, so once you upload it, it gets to us very quick from our portal, um, but it can take about 7 to 10 business days for claim information to process. It may not take quite that long and of course you can view the status on the website or you're more than welcome to give us a call as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, alright, I will get these uploaded thank you so much.
[AGENT][POSITIVE] All right, you are very welcome. I know that was quite a bit of information. Did you have any other questions for me, [PII]?
[CUSTOMER][POSITIVE] No, I'm good. Thank you.
[AGENT][POSITIVE] Alright thank you I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] You too. Bye bye.
[AGENT][POSITIVE] Thank you, bye bye.