AccountId: 011433970860
ContactId: 2b3af050-ab7f-4268-80b9-61d67f5dd850
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 487450 ms
Total Talk Time (AGENT): 213319 ms
Total Talk Time (CUSTOMER): 71234 ms
Interruptions: 0
Overall Sentiment: AGENT=1.2, CUSTOMER=-1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/10/2b3af050-ab7f-4268-80b9-61d67f5dd850_20250310T13:33_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, we recently submitted a claim for um group accident and it keeps getting denied, but we went through um your website to see what um place would be approved.
[AGENT][POSITIVE] OK, let me take a look at the claim. I'll be more than happy to help you. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII] [PII]
[AGENT][NEUTRAL] Thank you for that, and [PII], may I have your policy number?
[CUSTOMER][NEUTRAL] Pulling that up now.
[AGENT][POSITIVE] Sure, take your time.
[CUSTOMER][NEUTRAL] It is 254-507-7.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[AGENT][NEUTRAL] And can you verify your date of birth, your mailing and email address on file?
[CUSTOMER][NEUTRAL] [PII], [PII] [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So there's a few things I see. um, hold on, let me pull up the claim.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] OK, so it's saying that it was denied because of the place of service and you're saying that the place of service you, the place of service that you went to, you you saw it off of our website.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK. Was it the um the multi-plan website?
[AGENT][NEUTRAL] It's an accident policy. What what?
[AGENT][NEUTRAL] Like you went to APL's website and got a list of providers. I don't.
[CUSTOMER][NEUTRAL] Uh yes, ma'am.
[AGENT][NEUTRAL] Hospital indemnity. Hold on one moment. 77.
[AGENT][NEUTRAL] Do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] Our accident policies don't have a network. Wait a minute, this is confusing me.
[AGENT][NEUTRAL] A policies have a network.
[AGENT][NEUTRAL] So training. Why do I not know this?
[AGENT][NEUTRAL] Whatever.
[AGENT][NEUTRAL] Ain't my problem.
[AGENT][NEUTRAL] Um, dental claim certificate.
[AGENT][NEUTRAL] Cause what?
[AGENT][NEUTRAL] What's the
[AGENT][NEGATIVE] I'm gonna call claims. They're just gonna be mad because this don't make no sense to me.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] OK, wait. Let me go back to our EMRI. See, based on the information included on this platform, this service is not rendered in a covered place of service as outlined in the policy contract. What places of service are outlined in the policy contract?
[AGENT][POSITIVE] Wow.
[AGENT][NEUTRAL] I did not know.
[AGENT][NEUTRAL] What
[AGENT][NEUTRAL] A covered place of service.
[AGENT][NEUTRAL] What's considered a covered place of service.
[AGENT][NEUTRAL] 99213 is a.
[AGENT][NEUTRAL] Office or like urgent care.
[AGENT][NEUTRAL] Oh, are they saying because it was urgent care, it needs to be a hospital emergency room physician. I got it.
[AGENT][NEUTRAL] Got it.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK, thanks to.
[CUSTOMER][NEGATIVE] I'm uninstalling the game.
[AGENT][NEUTRAL] OK, hello, Mr. um [PII].
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. For a second, it took me a minute to see what was going on, but I had to pull up your policy documents because I'm like, what is the covered places of service? For the accident policies, because it's in relation to an accident, it only covers like the emergency room or the physician office if you were to go to the emergency room after an accident, 72 hours after an accident or a doctor's office 30 days, within 30 days.
[AGENT][NEUTRAL] Because it's an urgent care, that's not an emergency room or physician office, so that's what the denial reason is saying, it wasn't a covered place of service. This is different than like a medical policy. You, you will have urgent care, but this is an accident policy, so it's in relation to an accident and emergency room or doctor's office or dental emergency dentals on here also.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK. So if you think.
[CUSTOMER][NEUTRAL] Um, would you be able to tell me how much we owe for, um,
[CUSTOMER][NEUTRAL] That um the urgent care visit.
[AGENT][NEUTRAL] Uh, I mean, I can look on the bill that you sent in with the insurance company, so I, I don't know what they charge you, but I can look and see on the bill that you sent in if it gives a total.
[CUSTOMER][POSITIVE] Yes. Yes, please.
[AGENT][NEUTRAL] Or you can call them and see what you owe. OK, hold on one second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it looks like the total charge on this bill was $232.07.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're very welcome. Well, was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No, ma'am.
[AGENT][POSITIVE] Alright, well, thanks so much for calling APL. I hope you have a great day.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Bye-bye.