AccountId: 011433970860
ContactId: 2910bffb-d22b-4015-bda5-7acd086161ac
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 450019 ms
Total Talk Time (AGENT): 184745 ms
Total Talk Time (CUSTOMER): 220697 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/03/2910bffb-d22b-4015-bda5-7acd086161ac_20250203T14:09_UTC.wav
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[AGENT][NEUTRAL] This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, this is [PII]. I have an insured on the line and she wants to speak to someone about a couple of claims, um, that she says we should have received in January.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Policy number is 1973189.
[AGENT][NEUTRAL] OK, thank you. And um her name and
[CUSTOMER][NEUTRAL] Um, [PII], let me see. [PII], and she was transferred me to me from the care team and so they fully verified her.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And uh did she um
[AGENT][POSITIVE] OK, uh, yeah, if you'll just send her over, um, [PII], it's [PII], right? If you'll just send her over, uh, yeah, I'd be glad to talk to her.
[CUSTOMER][NEUTRAL] Yes, uh-huh.
[CUSTOMER][NEUTRAL] OK, and um uh it's really hard to hear her, but I tried to explain to her to set up her account on the online service center and she give you her claims and stuff and she said she tried to, but it wouldn't go any further because it wouldn't accept her policy number and I told her multiple times that she did not need her policy number to set up that account and I don't know that. So anyway, just to let you know I tried to get her to set it up.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I, I don't know, but it is hard to hear her. Just let you know, OK.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][POSITIVE] OK, yeah, thank you. Yeah, no problem.
[CUSTOMER][POSITIVE] OK. But here she comes. Thank you.
[AGENT][POSITIVE] Appreciate it. Thank you.
[AGENT][NEUTRAL] Yeah, my name is [PII]. I'm in the claims department. I understand that there are, there is a claim that was submitted in January that you have a question about.
[CUSTOMER][NEUTRAL] Yeah, um, yeah, I, well, I was in the hospital, so I wanna see what is it that you're covering and what is it that you're not covering.
[AGENT][NEUTRAL] OK, um,
[AGENT][NEUTRAL] So we received a, a, we received one claim in January.
[AGENT][NEUTRAL] Uh, it's for, um, West Side Hospital for data service, uh, [PII]. Now that's, that's the, the last claim that we received, is it?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] What was it?
[CUSTOMER][NEUTRAL] It's from west side from the service.
[AGENT][NEUTRAL] Yes, is that the one that you're looking for?
[CUSTOMER][NEUTRAL] No. What is this one again for Westside what?
[AGENT][NEUTRAL] OK, we received a claim.
[CUSTOMER][NEUTRAL] What is the dental service?
[AGENT][NEUTRAL] You um you we received a claim in January.
[AGENT][NEUTRAL] Last month.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For, for West Side Hospital.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that's [PII] with with with the date of service. Now, if that's not the one that you're looking for, um, what date of service are you looking for? uh?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] OK, OK, well, that booking is extremely late.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Uh, yeah, the one I was looking for is January of this year, so you probably, I, I don't know if I have to set up a plan with you or not. Uh, I was in the hospital.
[AGENT][NEUTRAL] OK, now, we haven't received that yet. Um, so that's, so this is the last one that we have. Uh, I don't, I'll just check again. I don't have anything for [PII]. Now, um, sometimes it takes them a little bit of time to get those filed through your major medical and then to us.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] But no, I don't, I don't have anything for January of this year.
[CUSTOMER][NEUTRAL] OK. Yeah.
[CUSTOMER][NEUTRAL] Yeah, so, um.
[CUSTOMER][NEUTRAL] Do, do you cover anything of emergency room is that?
[AGENT][NEUTRAL] For emergency services, yes, uh, we do. Um, now, if you're saying that you went to the emergency room, is that correct?
[CUSTOMER][NEUTRAL] I went to the emergency room twice, yes, I went on [PII].
[AGENT][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] And then I went back on [PII]. On [PII] I was admitted.
[AGENT][NEUTRAL] Right, um, so what we do for outpatient services such as that, we pay up to $500 per calendar day.
[AGENT][NEUTRAL] And so that is what, uh, uh, as soon as we receive the claim, um, that is, uh, your benefit. It's $500 per calendar day and we're just, uh, and that's uh for the, the emergency room, the doctor, whatever it is that that was done. So as soon as we receive that, um, we can go ahead and get it processed. It's just that we haven't received anything for, for December or January yet.
[CUSTOMER][NEUTRAL] OK, and so, and, OK, so let me just look at probably gonna be a lot of claim coming in maxing out whatever I get here.
[CUSTOMER][NEUTRAL] Um, so the one for [PII] will be billed to 20245 out of that allowance, right?
[AGENT][NEUTRAL] Well, that's true, but your, your allowance, you, you, you don't have a calendar year balance. What you do is you have a daily balance. So it, it doesn't matter whether it was in December or January, um, it's still going to pay out $500 per day. So you, you don't really have a calendar year balance that you have to look at. It's just a daily balance of $500.
[AGENT][NEUTRAL] So each, so for the one in December, it's $500 for the one in January, it's $500 it's just $500 each day.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So, OK, so.
[CUSTOMER][NEUTRAL] And that's for the emergency room.
[AGENT][NEUTRAL] Well, that's for any outpatient services.
[CUSTOMER][NEUTRAL] Because I, on my thing.
[AGENT][NEUTRAL] Yeah, that's for any outpatient service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, OK. All right. And then, um,
[CUSTOMER][NEUTRAL] I am
[CUSTOMER][NEUTRAL] So, but then I was admitted so the in hospitals, OK, so I'm confusing because I'm seeing that in hospital max of 4000, um.
[CUSTOMER][NEUTRAL] So also they will go ahead and give towards my stay in the hospital. I was in there for a
[CUSTOMER][NEUTRAL] In 8 days, 8 to 9 days I can't quite remember.
[AGENT][NEUTRAL] Right, they'll treat that as two separate events, yeah.
[CUSTOMER][NEUTRAL] I went in on a Thursday.
[CUSTOMER][NEUTRAL] OK, OK, and the two emergency room is 2 separate beds, OK, alright, uh, outpatient service.
[CUSTOMER][NEUTRAL] Alright, now also, um.
[CUSTOMER][NEUTRAL] There's a lot going on.
[CUSTOMER][NEUTRAL] I'm on
[CUSTOMER][NEUTRAL] Yeah, uh, where I'm being fed diagnosed, I've been, I've been feed through IV.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That's well if I can keep that, um.
[CUSTOMER][NEUTRAL] Do they pay anything off the pharmacy?
[AGENT][NEUTRAL] Uh, not for your pharmacy. Not for your pharmacy, no.
[CUSTOMER][NEUTRAL] For that?
[CUSTOMER][NEUTRAL] OK. Um.
[CUSTOMER][NEUTRAL] What about home health aid? Do they pay anything for that?
[AGENT][NEUTRAL] Uh, no, no, this is, this is for, uh, hospital services only.
[CUSTOMER][NEUTRAL] And diagnostic. OK, alright, and then I have some MRI's and then, OK, um.
[CUSTOMER][POSITIVE] Alright, not a problem. Thank you. This helps me a lot and I will try to get this time while again.
[CUSTOMER][NEUTRAL] And get them there, OK.
[AGENT][NEUTRAL] Oh, OK, OK.
[AGENT][POSITIVE] Well, thank you very much. I it.
[CUSTOMER][POSITIVE] Alright thank you I appreciate it.
[AGENT][POSITIVE] If there's nothing else I can help with, thank you very much for contacting ATL. Have a good day, [PII].
[CUSTOMER][NEUTRAL] OK.