AccountId: 011433970860
ContactId: 2a637981-d47a-4452-8ac2-2dbbc57b9eb3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 953929 ms
Total Talk Time (AGENT): 299943 ms
Total Talk Time (CUSTOMER): 366541 ms
Interruptions: 1
Overall Sentiment: AGENT=0.9, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/19/2a637981-d47a-4452-8ac2-2dbbc57b9eb3_20250319T22:13_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Um, hi, good afternoon, sorry, this is [PII], and I am calling.
[CUSTOMER][NEGATIVE] Because, um, I submitted a claim and um it's from something from um December, and I don't know why I, I submitted twice and it I, I haven't received my, you know, that I received for my gap insurance, I should receive um like a $25 and I had, I haven't received it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, Ms. [PII], I
[CUSTOMER][NEUTRAL] And uh
[AGENT][POSITIVE] Yes ma'am, continue you can continue.
[CUSTOMER][NEUTRAL] I'm sorry. Yes.
[CUSTOMER][NEUTRAL] Um, no, that I received a letter to, um, that it says um
[CUSTOMER][NEUTRAL] Like, um, physician outpatient treatment, it says that, and it says 0. And um
[AGENT][NEUTRAL] OK. Mhm.
[CUSTOMER][NEUTRAL] Yeah, that's what he said.
[AGENT][NEUTRAL] OK. Ms. [PII], what is your um policy number?
[CUSTOMER][NEUTRAL] The policy number is 010.
[CUSTOMER][NEUTRAL] 70427
[AGENT][NEUTRAL] OK, let me look your policy up real quick and we can um get your claim information for you.
[CUSTOMER][POSITIVE] OK thank you.
[AGENT][NEUTRAL] You're very welcome. And what is your date of birth?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you, ma'am. And can you please verify your address, phone number and email address that is on the policy, please?
[CUSTOMER][NEUTRAL] Yes, it's [PII]. The phone number is [PII] and my email address is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you. I appreciate you verifying your policy for me.
[AGENT][NEUTRAL] On that letter that you received, does it have a claim number or a reference number on it?
[CUSTOMER][NEUTRAL] I'll tell you.
[CUSTOMER][NEUTRAL] Yes, it, it says, um, the claim number says um 357.
[CUSTOMER][NEUTRAL] 1651.
[AGENT][NEUTRAL] OK, let me look that up real quick.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You've got a few remarks here that I can read to you of um things that are needed. One is
[AGENT][NEUTRAL] We have received your claim and it's acknowledged. However, in order to provide further consideration of this loss, this policy will need to support documentation to evidence the accident or sickness. So we need um diagnosis codes from itemized bills or um super bills.
[AGENT][NEUTRAL] Even hospital notes or discharge summaries stating that this claim is for accident or sickness.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Because the poly only.
[CUSTOMER][NEUTRAL] OK. Um, I, I, I
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I've provided that um twice already.
[CUSTOMER][NEGATIVE] Let me see, let me look into my email. Because I always submitted, like I did, I never open up an account. I know it's faster, but for some reason, when I try to open up the account on the internet, it asked me for the social security number, but it does, it says it doesn't exist, so like I never, like, when I'm working, I never have time to call at that time when, and when I come home it's too late. So I would submit it through the, the email that you guys have for claims.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And I, I, uh, I submitted already twice. Let me see when was the last time I sent it.
[AGENT][NEUTRAL] Right. Let me look and see.
[CUSTOMER][NEUTRAL] Cause I, I
[AGENT][NEUTRAL] Let me check it so that you can check and see and we can see if we've um done anything since you submitted it the last time. I do see something was reported on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it's asking for the same thing for
[AGENT][NEUTRAL] Something to be sent in stating that it's for diagnosis is for accident or sickness because the policy only covers for accident or sickness.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] I sent it on, on um on the [PII] and also send it back again on [PII].
[CUSTOMER][NEUTRAL] This is for a doctor's visit because I know I'm allowed to get reimbursed because um for the co-pays, $25. If I spend $75 which is my um
[CUSTOMER][POSITIVE] My copay for the special uh specialist, they will reimburse me, I, I believe into my policies is up to 4 times if I'm not, if I'm not wrong.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, OK, so what they're needing in in order to do that.
[AGENT][NEUTRAL] Is the diagnosis that it was accident or sickness. And then also um.
[AGENT][NEUTRAL] There were several things that your um primary insurance covered, so there wouldn't be a benefit payable because the primary insurance provided full benefits.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] Then there's also a remark on here that benefits are payable only if your major medical insurance provider provides benefits. If this claim is later paid by your major medical insurance, please send explanation of benefits showing benefits were paid.
[CUSTOMER][NEUTRAL] I don't get it because um
[CUSTOMER][NEUTRAL] I think they're mixing up, this claim is OK, let me tell you, um.
[CUSTOMER][NEUTRAL] In this claim, there's several things that I, I have done like, uh, on [PII], which has nothing to do with the office visit because on [PII] I did a colonoscopy, and that's already been um taken care of. I paid, I paid my co-pay to, to the place and also then I had something on the [PII] also that I had, I went to the hospital, but on the, on the [PII], which is the one.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That I, I went to follow up with the doctor after I did my colonoscopy and everything, which I paid in full at the office $75 so that I provided everything that they did the, the, the diagnosis code and the and the.
[CUSTOMER][NEUTRAL] It's, it's called the diagnosis code and the procedure code.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Because I send all the documentation, as I usually do my claims, but I don't know why it's not um.
[CUSTOMER][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Let me see something. I think it's because because on the [PII] I'm, I'm trying to see here in, uh, while I'm talking to you my attachment that I submitted.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, I provided the, the receipt, the, you know, the form which I, I provided the codes, the procedures and the diagnosis code with the
[CUSTOMER][NEUTRAL] Explanation of benefits for my, my main insurance. That's what I usually do. But I don't know if they're mixing it with the, with the other with the other claims from the other dates, because [PII] is my um gastroenterologist.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEGATIVE] And that was already taken care, um, because I went to his office on the on the on the [PII] and I went back on [PII], but the one on the [PII] hasn't been reimbursed, and that's the one that I'm, I'm just looking for, which is a $25 bill for my co-pay.
[AGENT][NEUTRAL] OK, so what I'm going to do, um, because there's just only I can only say how the claim was processed. I can't see all the paperwork that goes with it. um, what I'm gonna do is I'm gonna get somebody from the claims department, Gisela, to call you back.
[AGENT][POSITIVE] And um go over with you what exactly needs to be sent in compared to exactly what we've received because you're saying you've sent in everything that you should have sent in so we're gonna make sure that we get some extra help for you can I have somebody call you back at that number that you gave me?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, when we verified your policy, OK, I'm gonna put you on a quick hold while I, um, send in a request for somebody to give you a call back, OK?
[CUSTOMER][NEUTRAL] Sure. Yes.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] And I'll be right back. You're very welcome.
[CUSTOMER][POSITIVE] OK, thank you very much.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK Miss [PII], this is [PII] back with you again. I have sent in that request for you to get a phone call back from a claims examiner and they should be calling you back within 24 hours.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, no problem. OK. One more question. I, uh, is there, is there a way that you can check in my policy? How many doctors visit, um, I should be able to uh receive reimbursement for the $25? I believe it's 4, but I'm not sure.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me look real quick.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Let me pull, I'm gonna go ahead and just pull in your complete policy and look at it and read it.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] It's gonna take just a minute because it has to load and then I'll have to scroll through and read and find what it is that I'm looking for for your office visits, OK?
[CUSTOMER][POSITIVE] Thank you. Appreciate it. Not a problem.
[AGENT][POSITIVE] You're very welcome.
[CUSTOMER][NEUTRAL] Let me help you.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] Yes, it is for, um, treatment in hospital outpatient facility, freestanding emergency care clinic, urgent care facility, or physician's office, $25 per visit, maximum of 4 visits per covered person per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, perfect. Yeah, so this, this, this one in particular will be my 4th 1.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because I already had um 3.
[CUSTOMER][NEUTRAL] But this one is the one that um I don't know, uh I think like all the claims were like submitted at the same time.
[CUSTOMER][NEUTRAL] Like, although places were submitting, so the, the dates are being mixed up, I guess, so it will be helpful if someone, uh, if I can speak with, with the claim department like you said, because
[CUSTOMER][POSITIVE] Um, maybe they would tell me what else they need, they need from me, because this one is just the office visit and I, I just provided everything that I always provide.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] OK. I really appreciate your help, so. I appreciate it. I'll wait for, for the call.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Yes ma'am, and I enjoyed helping you, Miss uh [PII]. I hope that you'll get that call soon. Um, we are open until [PII] during the week, um, that Central time, and then we open at [PII]. So if it's gonna be a call, it'll be in the next 30 minutes for today. If not, it'll be after [PII] tomorrow morning.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, no problem. Thank you very much. I appreciate your help.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Well, we appreciate you and you have a good night and thank you for calling APL.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you. You too. Bye-bye.
[AGENT][NEUTRAL] Mm bye-bye.