AccountId: 011433970860
ContactId: 23a56a27-95d2-4a15-9cf8-b976f4224590
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 959679 ms
Total Talk Time (AGENT): 259509 ms
Total Talk Time (CUSTOMER): 254984 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/23a56a27-95d2-4a15-9cf8-b976f4224590_20250429T13:15_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][POSITIVE] Well, good morning, [PII]. It's [PII]. How are you today?
[AGENT][NEUTRAL] Good morning. Fine. How are you?
[CUSTOMER][POSITIVE] I'm good thank you um I have an insured on the line, very nice man, and I've gone over his um claim that he called about.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] I, I mean, honestly, the um
[CUSTOMER][NEUTRAL] The denial is very vague. I told him about the appeal and everything, but he's just wanted to know what else he needs to submit or exactly what that means. Again, I think it's a vague term, but um the policy number, [PII] is 228.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What's the policy number?
[CUSTOMER][NEUTRAL] 376 9
[CUSTOMER][NEUTRAL] This is Mr. [PII].
[CUSTOMER][NEUTRAL] And it's on claim 359.
[CUSTOMER][NEUTRAL] 483 5.
[CUSTOMER][NEUTRAL] We just processed it yesterday.
[CUSTOMER][NEUTRAL] We paid him $100 for a visit, but then we did not have the surgery. And I when I, I read that entire remark to him.
[AGENT][NEUTRAL] OK, let me take a look.
[CUSTOMER][NEUTRAL] And he said this was an accident. He had hurt his self, I believe he said moving furniture, but don't quote me on that. It was something in his house, doing, yeah, something in his home.
[AGENT][NEUTRAL] OK, let me see what we what was sent in.
[AGENT][NEUTRAL] OK, so it looks like he had a surgery for his knee.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, let me see if we got anything that shows that it was due to an accident cause that could be the issue. Let's see.
[AGENT][NEUTRAL] Mm, diagnosis code does not say that this is the result of an accident. Let me keep looking.
[CUSTOMER][POSITIVE] Oh wow.
[AGENT][NEUTRAL] Yeah, the arthroscope.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Trying to see if he sent us something that shows us that it was an accident. So far, what I'm looking at is what we have is not saying it was an accident, so let me keep looking.
[AGENT][NEUTRAL] Those are the surgery charges.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. The surgery was done.
[AGENT][NEUTRAL] In a surgery center.
[AGENT][NEUTRAL] OK, this other [PII] has a a diagnosis different.
[CUSTOMER][NEUTRAL] Yes, so that's, he just wanted to know, you know like what he would need to cement as far as for.
[CUSTOMER][NEUTRAL] You know, and appeal, but he wants to just understand better why, why it was denied.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Mm, let me look at the policy verbiage real quick.
[CUSTOMER][NEUTRAL] OK, that's
[CUSTOMER][POSITIVE] He's real nice, so.
[CUSTOMER][NEGATIVE] I'm like, you know, some that can be very upset about it. He just
[CUSTOMER][NEUTRAL] He just wants to know, understand what he needs to do to.
[CUSTOMER][NEUTRAL] What to get, you know, that, you know, I think you understand what I'm saying. I feel like I'm falling all over myself this morning, [PII]. Yes.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I feel, and I've been typing with 10 times today.
[CUSTOMER][NEGATIVE] Jeez, struggling.
[CUSTOMER][NEGATIVE] The struggle is real over here at my house today in my office area.
[AGENT][NEUTRAL] Just looking real quick at what the policies verbiage says real quick on this procedure, on this benefit.
[AGENT][NEUTRAL] This is the outpatient surgical repair.
[AGENT][NEUTRAL] Yeah, I'm gonna have to check a little further on this particular one cause I do see that there's two different diagnosis codes listed here and I, I have to reach out to [PII] to get some clarification regarding the benefit on this one.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So would you like to tell him that you're going to do that and to call him back or do I need to go through the whole spin in the hub to have this claim researched since
[CUSTOMER][NEUTRAL] I've already talked to you.
[AGENT][POSITIVE] That's fine, however you wanna do it. You can send them to me and I can let them know we uh check into it a little further and give him a call back.
[CUSTOMER][NEUTRAL] OK, that's just entirely up to you instead. I mean, since we, you know, you've looked at it and you've pulled all this up.
[CUSTOMER][NEUTRAL] For this one, since you're gonna, would you rather just tell him that?
[AGENT][NEUTRAL] That's fine. I can tell him.
[CUSTOMER][NEUTRAL] OK, well, he's fully verified. The phone number in line would be the one to call him back on. That's his only contact number.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK [PII], well thank you so much for looking at that. I appreciate your help with this one.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] All right have a great day if I don't talk to you again.
[AGENT][NEUTRAL] You too.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Bye-bye.
[AGENT][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] All right, bye-bye.
[AGENT][NEUTRAL] Claims department, this is [PII].
[CUSTOMER][NEUTRAL] Hey there this is played there.
[AGENT][NEUTRAL] Hi, Mr. [PII]. You have some questions regarding the procedure that was performed on [PII]. Is that correct?
[CUSTOMER][POSITIVE] Yes ma'am, that's absolutely.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Altogether this procedure like.
[CUSTOMER][NEUTRAL] It was a $700 MRI which I didn't claim because I didn't see anywhere where the MRI was on there.
[CUSTOMER][NEUTRAL] Is there an X-ray at the doctor's office.
[CUSTOMER][NEUTRAL] I had an ACL replaced along with other.
[CUSTOMER][NEUTRAL] Torn ligaments in my knee that were repaired.
[CUSTOMER][NEUTRAL] And I've come out of pocket like $3700 for the surgery.
[CUSTOMER][NEUTRAL] And I'm showing that y'all are only pay like giving me $100 for a doctor's visit.
[AGENT][NEUTRAL] OK. Let me take a look.
[CUSTOMER][NEUTRAL] And I'm also in physical therapy for the next 6 months.
[CUSTOMER][NEGATIVE] Which is costing me $40 a pop 3 times a week.
[CUSTOMER][NEUTRAL] You know, like you just gonna.
[CUSTOMER][NEUTRAL] I'm trying to see what the point of having this policy is.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, um, give me one moment while I take a look at the information it received. Give me one moment, please. Gonna put you on a brief hold.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Good morning.
[AGENT][NEUTRAL] Do you have a moment to look at a claim with me?
[AGENT][NEUTRAL] It's on policy 2283769.
[AGENT][POSITIVE] On a clay Bel Air.
[AGENT][NEUTRAL] And it's on that claim 34 I mean 359-4835 that we recently paid on the [PII].
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] On that procedure code for the 327-25.
[AGENT][NEUTRAL] I have the insured on the phone. He's wanting to know why it wasn't paid. I was looking at the explanation and also looking in the policy um benefits for the surgery, and I guess I'm a little confused, so I'll just need some clarification on that particular.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Um, I had it pulled up. I muscles looking at the wrong outpatient surgery.
[AGENT][NEUTRAL] Let me go back to it.
[AGENT][NEUTRAL] You keep looking cause I kept looking on the outpatient surgery, but
[AGENT][NEUTRAL] Surgery, surgeries.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Is
[AGENT][NEUTRAL] You said what?
[AGENT][NEUTRAL] OK. I see that on the inpatient one. Let's see.
[AGENT][NEUTRAL] Oh yeah, yeah, it does. The surgery must be performed by a physician with it. OK, so that's what it is. OK, that's what.
[AGENT][NEUTRAL] I said, so that's what it is because of the 90 days. OK, OK, that makes sense then, because I was like, mm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. OK, that makes sense cause I was like, what am I not looking at, but that's, that's, that's it.
[AGENT][NEUTRAL] I didn't scroll all the way down to see the 90, the 90 day part, so, OK.
[AGENT][POSITIVE] Well, thanks for clarifying that for me.
[AGENT][NEUTRAL] All right, bye.
[AGENT][NEUTRAL] Thank you for holding, Mr. [PII]. So it looks like in regards to that particular date of service for the [PII], that policy is only covered if the services were rendered within 90 days and it looks like you're outside of the 90 day time frame for that benefit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, but
[CUSTOMER][NEUTRAL] That's only because when I, I, it happened in December. I went in February.
[CUSTOMER][NEUTRAL] They couldn't, that was the earliest we can schedule the surgery. So like how is that even fair?
[CUSTOMER][NEUTRAL] Like I can't control what day they scheduled the surgery for.
[AGENT][NEUTRAL] Mhm. You do have the option to submit it in an appeal in regards to it, but the policy outlines that it has to be within 90 days after the covered accident occurs.
[CUSTOMER][NEUTRAL] But like
[CUSTOMER][NEUTRAL] From February, whatever date I went to the office.
[CUSTOMER][NEUTRAL] So [PII], like.
[CUSTOMER][NEGATIVE] I'm just sucked in that aspect because that's when they scheduled my surgery.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You know, like that should not even be a question in my opinion, like.
[CUSTOMER][POSITIVE] I got it clean about within the amount of days.
[AGENT][NEUTRAL] Yeah, if you disagree with that decision, yeah, you can submit an appeal in regards to that, and they can further review it.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so how do I go about doing this? Because I mean, it's
[AGENT][NEUTRAL] Just sub you submit the appeal um in writing, um.
[CUSTOMER][NEGATIVE] You know, for lack of a better word, just bullshit, you know.
[AGENT][NEUTRAL] So you can just submit the appeal in writing to let them to for further review regarding that.
[CUSTOMER][NEUTRAL] So do I just email these people?
[AGENT][NEUTRAL] And just submit it to our claims.
[CUSTOMER][NEUTRAL] OK, I can't just like.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I guess I'll be sending you then.
[AGENT][NEUTRAL] OK. Is there anything else I can assist you with today, Mr. [PII]?
[CUSTOMER][NEUTRAL] Cause I mean
[CUSTOMER][NEGATIVE] No, I mean, I just, I just don't see the point of having this policy if it's not gonna.
[CUSTOMER][POSITIVE] Benefit me, you know what I'm saying, in any way, shape or form.
[AGENT][NEUTRAL] I understand that.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] That'll be all. I'll be sending in the bill.
[AGENT][POSITIVE] OK, well thank you for calling APL. You have a good day.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Bye.