AccountId: 011433970860
ContactId: 244560b2-1325-4032-9aca-c4ef8b1299fe
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 850039 ms
Total Talk Time (AGENT): 195235 ms
Total Talk Time (CUSTOMER): 353015 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/29/244560b2-1325-4032-9aca-c4ef8b1299fe_20250529T19:20_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, I'm checking on the status of some claims we submitted for our client.
[AGENT][NEUTRAL] OK, I can verify claim status for you and your name is?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] OK, and Ms. [PII], what is that policy number, please?
[CUSTOMER][NEUTRAL] OK, give me one second, it's gonna be 248-050-6.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK thank you one moment.
[AGENT][NEUTRAL] And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][NEUTRAL] OK. And what's the insured's name?
[CUSTOMER][NEUTRAL] Her name is [PII].
[AGENT][NEUTRAL] OK. And Ms. [PII], you're calling from?
[CUSTOMER][NEUTRAL] Uh, the broker's office, RJ Blanchard Benefit Services.
[AGENT][NEUTRAL] OK, and verify her date of birth for me, please.
[CUSTOMER][NEUTRAL] Gonna be [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and when was the claim submitted? Because I only show one claim has been received for her. Was this for a cancer policy?
[CUSTOMER][NEUTRAL] It's for her dependents. It's on the critical illness policy. It should have been two wellness claims. I submitted them in the OSC.
[AGENT][NEUTRAL] Oh, I'm sorry, credit card.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what are those, uh, dependents' names?
[CUSTOMER][NEUTRAL] [PII] and [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, I'm showing that claim for [PII] uh processes benefits of Max for the calendar year.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that was processed on the [PII]. Uh-huh.
[CUSTOMER][NEUTRAL] It was a wellness.
[CUSTOMER][NEUTRAL] Isn't it supposed to be one wellness per covered person on the policy?
[AGENT][NEUTRAL] See, let me pull up the plan.
[AGENT][NEUTRAL] Let me see if he's supposed to be uh.
[AGENT][NEUTRAL] Mm, see, I might have to transfer you to an examiner because uh.
[AGENT][NEUTRAL] Let me see
[AGENT][NEUTRAL] Yeah, because
[AGENT][NEUTRAL] It's per person total of 4 per uh family and let me look at the [PII].
[AGENT][NEUTRAL] And for [PII] it looks like it was for ER visit, which is not uh covered under the policy. I'm sure for a screening.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Looks like she had one, but that was last year. Uh, it looks like it they had processed it as benefits max for the plan here.
[CUSTOMER][NEUTRAL] And what did you say about [PII]?
[CUSTOMER][NEUTRAL] What does that mean? Like he submitted another wellness, so another wellness isn't able to be paid out?
[AGENT][NEUTRAL] Ma'am, um.
[AGENT][NEUTRAL] There's the benefits of Max, but
[AGENT][NEUTRAL] Let me, let me transfer you to an examiner so I can explain how they process this one because it shows it's in [PII] and I don't show any other claims for him for that date, but give me one moment, OK?
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], um, I have a broker on the phone, uh, calling about a claim for insured children, and there was one where, um, looks like the claim processes benefits of max for the plan year. It's on a, um, critical illness plan, but it's only showing that they've only used one wellness for last year, but not for this year, so I was confused.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh, what's the policy number?
[AGENT][NEUTRAL] 248-050-6.
[CUSTOMER][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] And it's on part 2.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] 1 per person up to 4 per family.
[AGENT][NEUTRAL] Yeah, and I saw that, but only so I didn't see any others that uh he had for this year. So I was kind of confused on it as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, it doesn't look like they've used any for 2025.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Child wellness screening. Let me see what that.
[CUSTOMER][NEUTRAL] Says exactly.
[CUSTOMER][NEGATIVE] This benefit has been exhausted for the plan here.
[CUSTOMER][NEUTRAL] Um, what?
[AGENT][NEUTRAL] Right. Yes, I was kind of confused.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] I didn't know if it was probably for some other reason.
[AGENT][NEGATIVE] Besides that, because it didn't look, look strange to me.
[CUSTOMER][NEUTRAL] It doesn't look like it. I'm gonna double check and make sure they didn't put in a wrong.
[CUSTOMER][NEUTRAL] Data service or something.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Like maybe they put 2025.
[CUSTOMER][NEGATIVE] But it actually shows 2024 on the claim and that's just an error with.
[CUSTOMER][NEUTRAL] You know what I mean?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] No, it's 2025.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] 3 24 25 wellness checkup and then.
[CUSTOMER][NEUTRAL] COVID, flu and RSV test.
[AGENT][NEUTRAL] First, I thought it was that maybe cause I saw COVID, but I don't know.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] If that would be covered or not, but I didn't know.
[CUSTOMER][NEUTRAL] Well, so for this policy, a health screening.
[CUSTOMER][NEUTRAL] Um, is like any type of wellness exam or test, so it can be a wellness test, a physical or any generally medically accepted screening test as an outpatient used to evaluate risk or promote prevention of a covered condition.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] So the fact that on the claim they put that they were there for a wellness exam um we typically you know don't ask for verification but they did submit an after visit summary.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And on that after visit summary, let me see I believe it says wellness.
[CUSTOMER][NEUTRAL] Specifically
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So yeah, because like I reviewed the benefits used.
[CUSTOMER][NEUTRAL] 02480506 for [PII] they've not used any of these, so this is a processing error so you can let them know that.
[CUSTOMER][NEUTRAL] I wouldn't say that we're gonna pay it. I would just say that the claim is gonna be reviewed like sent back for review.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because of it and then I'm, I'm fairly certain that this obviously is a payment because they haven't exhausted their benefits.
[CUSTOMER][NEUTRAL] Actually hang on let me.
[CUSTOMER][NEUTRAL] Let me make sure this is not plan year.
[CUSTOMER][NEUTRAL] Because that could be the difference.
[CUSTOMER][NEUTRAL] Yeah, any one plan year.
[CUSTOMER][NEUTRAL] That's the difference, OK, um.
[CUSTOMER][NEUTRAL] I'm gonna read this remark code again.
[CUSTOMER][NEUTRAL] Yeah, so.
[CUSTOMER][NEUTRAL] Plan year is not January to December. Plan year is from their effective date to the day before the anniversary of the next effective date. So when you look at this policy, they were effective on [PII], so it would, you would have to look for benefits for this policy from [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] To [PII] and it shows that they have used the screening.
[CUSTOMER][NEUTRAL] For that plan year, that's the difference, it's not calendar year.
[AGENT][NEUTRAL] OK. So since, um,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The date of service was before the [PII] or I'm sorry, [PII] of this year, then he's met it for the plan year.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Correct, and they there should be a definition for playing year in the policy. I can double check that really quick if if they're confused by that where you can kind of point them to that because under wellness benefits it will say total number of claims payable per plan year. There are no exception messages saying that this group or whatever um goes by calendar year and then um so that is under those benefits are under section 4.
[CUSTOMER][NEUTRAL] And then which is page I can give you the page number in the policy it's page 7.
[CUSTOMER][NEUTRAL] And then the definition for plan year is going to be found under section 10.
[CUSTOMER][NEUTRAL] Page.
[CUSTOMER][NEUTRAL] Where is it at?
[CUSTOMER][NEUTRAL] Alphabetical order. [PII], keep on going. OK, page 19 and it says the time period commencing on the policy effective date and ending the day before the next policy anniversary and thereafter each 12 month period commencing on the anniversary. So basically from effective date to the day before the the following year's anniversary effective date.
[CUSTOMER][NEUTRAL] So that would be that [PII] to [PII] they've already used one for date of service [PII] so this plan year is exhausted.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] All right, thank.
[CUSTOMER][NEUTRAL] That's that's the, that's the key word there.
[AGENT][POSITIVE] OK. All right. Thank you so much.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] All right, bye.
[CUSTOMER][NEUTRAL] All right bye bye.