AccountId: 011433970860
ContactId: 1b91f3fd-6d5e-46ad-8c82-4b1fbda9fb0e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 578030 ms
Total Talk Time (AGENT): 320102 ms
Total Talk Time (CUSTOMER): 185123 ms
Interruptions: 4
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/07/1b91f3fd-6d5e-46ad-8c82-4b1fbda9fb0e_20250507T13:20_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] I just, uh, I filed the claim, um, I just wanna see what the status of that is.
[AGENT][NEUTRAL] OK, so you're the insured and you're calling to check claim status for yourself, is that correct?
[CUSTOMER][NEUTRAL] Yes
[AGENT][POSITIVE] Yes, I can help you with that. And who am I speaking with, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And Mr. [PII], what is a good call back number for you in case we're disconnected?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you and your policy number.
[CUSTOMER][NEUTRAL] 02201436.
[AGENT][NEUTRAL] OK, thank you. Give me a couple of moments please to get your information pulled up. Once I do, I will have to verify several things with you first.
[AGENT][NEUTRAL] For security and then want any information that's provided Mr. [PII] will be a verification of benefits and not a guarantee of payment. So first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And then also your home mailing address please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Your zip code?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. The phone number that we have on file for you is the same as the one you gave me, so that is your best contact number that we should have, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you and lastly your email address and this does appear to probably be your work email.
[CUSTOMER][NEUTRAL] Yeah, because I'm the administrator also it's a [PII].
[AGENT][NEUTRAL] OK, thank you and Mr. [PII], what is the data service that you're calling about?
[CUSTOMER][NEUTRAL] I'm sorry, the the.
[AGENT][NEUTRAL] The date of service on your claim.
[CUSTOMER][NEUTRAL] Oh, when I filed the claim?
[AGENT][NEUTRAL] No, sir, whenever you had your treatment that you're filing the claim for.
[CUSTOMER][NEUTRAL] Oh yeah, it was back in [PII].
[AGENT][NEUTRAL] Do you have a specific
[CUSTOMER][NEUTRAL] I have the claim number if you.
[AGENT][NEUTRAL] OK, you can give me that.
[CUSTOMER][NEUTRAL] You need the claim number?
[AGENT][NEUTRAL] You can.
[CUSTOMER][NEUTRAL] 35 35 97 587.
[AGENT][NEUTRAL] OK, thank you. So yes, sir, I do see that this claim has been processed. Um, this claim was actually.
[AGENT][NEUTRAL] This claim went through processing on yesterday so if you're not able to see your explanation of benefits in your portal yet, you should be able to see that this afternoon but this claim has been denied.
[CUSTOMER][NEUTRAL] Yeah, that's
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yes, that's the purpose of my call why?
[AGENT][NEUTRAL] OK. So one of them, uh, and all of your, all of these remark codes that I'm fixing to go over with you, Mr. [PII], are also on page two of your explanation of benefits. But the first one is that office visits are not covered.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] By the policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, there is another code that states the service is not covered when performed in a doctor's office or clinic.
[AGENT][NEUTRAL] On [PII].
[CUSTOMER][NEUTRAL] It wasn't in a doctor's office or clinic, it was in a hospital.
[AGENT][NEUTRAL] On this was for data service 6:[PII].
[AGENT][NEUTRAL] That was the office visit and some form of treatment.
[AGENT][NEUTRAL] In the office.
[AGENT][NEUTRAL] On [PII].
[CUSTOMER][NEUTRAL] OK, but I, OK, but I had surgery.
[AGENT][NEUTRAL] There's multiple dates of, yes, there's multiple dates of service on this claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Now, for [PII].
[AGENT][NEUTRAL] It does one of the denial codes or two of the denial codes for the outpatient part on the data service 624. It states that receipt of your claim is acknowledged. However, in order to provide further consideration of this loss under this policy, we will need supporting documentation to evidence the act in sickness.
[AGENT][NEUTRAL] Supporting documentation may include that we're needing a diagnosis code for that data service.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] Essentially I mean you have.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] But what I sent you was the insurance, OK, the details of the insurance, you can't get more detail than that and it has the, the, the codes.
[AGENT][NEUTRAL] The explanation, yes, so the explanation of benefits does not have the diagnosis code.
[CUSTOMER][NEUTRAL] Um, OK, unless I'm, I'm losing my mind.
[AGENT][NEUTRAL] Uh, they, they have procedure.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] I, I what I sent to you.
[CUSTOMER][NEUTRAL] Claim process codes, isn't that the same?
[AGENT][NEUTRAL] No, sir.
[AGENT][NEUTRAL] You have procedure codes and as to what they did, and then you have diagnosis code which is the why and we're in need of the diagnosis code.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] And and where do I get that from?
[AGENT][NEUTRAL] OK, if you, that may, yes, you can get that from the facility or you could, should be able to get that also from your provider of service.
[CUSTOMER][NEUTRAL] The hospital?
[CUSTOMER][NEUTRAL] Um, the insurance company, my insurance company.
[AGENT][NEUTRAL] No, sir, you're a doctor.
[CUSTOMER][NEUTRAL] Yeah, the doctor or the hospital, so I need diagnosis codes.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Correct. And then we also need an itemized hospital bill with the admission, discharge dates and times. That's for the [PII] data service.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, so diagnostic, diagnostic codes.
[AGENT][NEUTRAL] diagnosis, no diagnosis codes.
[CUSTOMER][NEUTRAL] Diagnosis codes and an itemized hospital bill.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Correct. That includes your admission and discharge dates and times.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I think if I can get those.
[AGENT][NEUTRAL] And then once you do get that information, Mr. [PII], you can just upload that into your portal like you did this claim and you won't be able to, you won't be able to add it to this existing claim number so you're just gonna upload it almost like if you were uploading a a new claim, but the system will recognize that this was information we were missing for these dates of service.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, so, um.
[CUSTOMER][NEUTRAL] So do I go to my portal?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And I go to my portal and then I upload a new.
[CUSTOMER][NEUTRAL] A new um
[CUSTOMER][NEUTRAL] I don't know, uh, upload the file.
[AGENT][NEUTRAL] Yes sir, you would do it just exact yes sir you would just upload this information that we're missing directly into your portal just like you uploaded all of this information that we've reviewed.
[CUSTOMER][NEUTRAL] Just upload your file.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, alright, um, and just uh for my knowledge, what's the um.
[CUSTOMER][NEUTRAL] What's the, the coverage that I have?
[CUSTOMER][POSITIVE] That I'm eligible for refund if I get all everything in.
[AGENT][NEUTRAL] Your outpatient benefit maximum for covered outpatient services per calendar year is $1000 with no deductible.
[AGENT][NEUTRAL] And an inpatient hospitalization is the maximum benefit for inpatient per calendar year is $1500.
[AGENT][NEUTRAL] With no deductible.
[CUSTOMER][NEUTRAL] OK, so the potential is 2500.
[AGENT][NEUTRAL] For inpatient and yes for your inpatient is 1500 and outpatient is 1000 per calendar year.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][POSITIVE] OK, outpatient, so, OK, um, I'm good.
[AGENT][NEUTRAL] And there is, and there is a copy of your policy certificate, Mr. [PII], in your portal. You click on your policy number, it'll download that PDF and those benefits are in your policy as well.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, the uh policy number. OK, OK, alright, thank you, uh, back to work.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, well, you're certainly very welcome.
[AGENT][NEUTRAL] I understand. Is there anything else I could help you with this morning?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No, that's it. Thank you, bye.
[AGENT][POSITIVE] OK, well, you're welcome and thank you again for calling APL. I hope you have a great day.
[CUSTOMER][NEUTRAL] OK bye.
[AGENT][NEUTRAL] Bye-bye.