AccountId: 011433970860
ContactId: 1cf9c349-dba3-4c23-8c66-84c18a6207cd
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 525260 ms
Total Talk Time (AGENT): 347477 ms
Total Talk Time (CUSTOMER): 144015 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/1cf9c349-dba3-4c23-8c66-84c18a6207cd_20250416T21:18_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] over in customer care. How are you?
[AGENT][POSITIVE] I'm good. How are you, [PII]?
[CUSTOMER][NEUTRAL] I am good. Um, I have an insured on the line who has a question about things that have been paid on a claim, and I was hoping you could help him with that.
[AGENT][NEUTRAL] OK, uh, what's that policy number?
[CUSTOMER][NEUTRAL] Uh, policy number is 254.
[CUSTOMER][NEUTRAL] 5851.
[CUSTOMER][NEUTRAL] For [PII] and [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, is there, is it just that one claim that was paid or she's looking at [PII] and herself?
[CUSTOMER][NEUTRAL] No, it's just the one that was paid processed today for [PII]. She's wanting, so I gave her the, yeah, so I gave her the uh benefit payment information. It was just done.
[AGENT][NEUTRAL] For [PII]
[CUSTOMER][NEUTRAL] Um, and she's like, well, what exactly are they paying for? Well, because it was just done. I mean, I don't, I'm not familiar with these like codes and there's no explanation of benefits, so I'm not sure.
[AGENT][POSITIVE] Yeah, OK, uh, yeah, I can definitely um.
[AGENT][NEUTRAL] Help them with that.
[CUSTOMER][POSITIVE] OK, I appreciate you thank you do you want our callback number?
[AGENT][POSITIVE] No problem.
[AGENT][NEUTRAL] Yeah, just in case.
[CUSTOMER][NEUTRAL] OK, it's [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright, here comes [PII], thanks.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] [PII], my claim was completed today and she told me it was for $1600 and I'm trying to find out what is that for?
[AGENT][POSITIVE] OK, um, I would be happy to help you with that. I'm looking at it now. This is for Mr. [PII], correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. All right, so it looks like we have a hospital admission that took place on [PII].
[AGENT][NEUTRAL] Um, so that benefit for the admission itself is $1250.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, you do have a confinement benefit, but that is not payable on the same day that the admission was there and since he was only there for one night, um, that benefit was not paid. However, we also saw that he had surgery, so surgery was paid at $300.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And anesthesia is 25% of that $300 so we paid anesthesia at $75. So that brings your total to $1625.
[CUSTOMER][NEUTRAL] So what, it, it was knee surgery, so why, what kind of surgery are you that paid 300?
[AGENT][NEUTRAL] Um, let me get the claim pulled up so I can see what it is they have exactly.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] So, let's say, they use the diagnosis codes for pain in the left knee and then um
[AGENT][NEUTRAL] Yeah and then other mechanical complications other than so yeah they they were paying for.
[AGENT][NEUTRAL] The issues with his knee, the, the pain and accident that occurred.
[AGENT][NEUTRAL] For his knee.
[CUSTOMER][NEUTRAL] OK, so y'all aren't paying for the surgery.
[AGENT][NEUTRAL] No, we did, um, but so this particular.
[AGENT][NEUTRAL] I feel, I, I've spoken with you before, right?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, uh, OK, that's what I was thinking. I was like, I feel like I've talked to her about this, OK.
[AGENT][NEUTRAL] Because we weren't sure exactly.
[CUSTOMER][NEGATIVE] No, but you never talked to him. We, it just, it just finished today. And so, I mean, I'm, I'm, I'm, I'm wondering why they didn't pay for knee surgery.
[AGENT][NEUTRAL] Yeah, I think we just were trying to figure out yeah so um I think we were trying to, we were discussing that the last time we spoke that we weren't really sure what type of um surgery they were going to pay it would depend on what the examiner saw so and how like the information that we had how all of that lined up. So what they did because like I said it's not a bone.
[AGENT][NEGATIVE] They didn't pay for any type of fracture or dislocation or anything like that because it was the device, the mechanical device, the metal in his knee that was the issue. And um so they paid it under that other um inpatient surgery for repair. So it is a surgical repair, but it's not, it doesn't qualify for any of the other surgeries that are listed under the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Now, what about physical therapy and home health?
[AGENT][NEUTRAL] So, physical therapy, um, there is a benefit for that. There is not a benefit for home health though under this policy.
[CUSTOMER][NEUTRAL] OK. So physical therapy, how much do you, how much is, is paid for that?
[AGENT][NEUTRAL] It is $50 benefit, um, and then let's see how many you get.
[CUSTOMER][NEUTRAL] Is it
[AGENT][NEUTRAL] They're usually like anywhere between 5 and 10, so I just wanna confirm.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] There it is, OK, uh, benefit is payable up to 10 days per plan year per covered person. So up to 10 days is payable based off of your policy.
[CUSTOMER][NEUTRAL] OK, up to 10 days.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And what about the devices and medical equipment?
[AGENT][NEUTRAL] Yes, so any type of appliance um that he received like a walker or a cane or anything like that we would just need um the bill from where you purchased that from like a DME place and um for didn't he get a walker or did he get a wheelchair?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] He got a walker, but um we went and they, they prescribed it, but we just went and bought it ourselves.
[AGENT][NEUTRAL] OK, so we would need something that shows they were prescribing that for him, uh, well, let me double check myself because I don't want, I don't wanna say that and then it's like you don't actually have to go through the trouble um because some of them do require proof of like the prescription and um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But let me double check that benefit for you, um.
[AGENT][NEUTRAL] But that is a benefit that we would pay we would just need like, just like anything else we would need to bill to show that that was purchased because of this, you know what I'm saying?
[AGENT][NEUTRAL] Uh, let's see
[CUSTOMER][NEUTRAL] Yeah, so y'all pay up to 10.
[AGENT][NEUTRAL] For physical therapy, mhm. And then for the appliance, OK, it says, um, for each day, a physician prescribes a medical appliance to aid a covered person as a result of a covered accident. Um, the amount paid determined on the top of appliance prescribed, so you know, it lists the different kinds and then if more than one is prescribed on the same day, only the highest is payable.
[CUSTOMER][NEUTRAL] 10 visits to the physical therapist.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it has to be prescribed within 90 days after the accident and then it's, you get one of those per plane year per person. So, and that's a benefit. So we do have to have proof of prescription even if you didn't purchase it from a DME store.
[AGENT][NEUTRAL] We just have to show that they were prescribing that for him and that it was purchased because it was a prescription, you see what I'm saying?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, and that is a $125 benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and I need to get the bill from from um.
[CUSTOMER][NEUTRAL] I need to get the bill from the physical therapist. You need the bill?
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes ma'am. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, thank you so much. OK, you have a good day. Bye.
[AGENT][POSITIVE] You're so welcome.
[AGENT][POSITIVE] Yes, ma'am, you too. Bye bye.
[CUSTOMER][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] Bye-bye.