AccountId: 011433970860
ContactId: 2ba7ffa4-f872-4688-b30e-6fc110096287
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1672849 ms
Total Talk Time (AGENT): 623549 ms
Total Talk Time (CUSTOMER): 300827 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.1, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/04/2ba7ffa4-f872-4688-b30e-6fc110096287_20250604T20:12_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi. Um,
[CUSTOMER][NEUTRAL] I had um
[CUSTOMER][NEUTRAL] Uh, some claimified um from hospital.
[CUSTOMER][NEUTRAL] And uh these are major claims um and those are I uh I can see that those are um.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Not, um,
[CUSTOMER][NEGATIVE] Yeah, those are denied.
[CUSTOMER][NEUTRAL] So I would like to um discuss about that.
[AGENT][NEUTRAL] OK, well, I'll be more than happy to help you with your claims and the denial reasons. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure. Um, my name is [PII].
[CUSTOMER][NEUTRAL] [PII] Last name [PII]
[AGENT][NEUTRAL] Thank you. May I have your policy number?
[CUSTOMER][NEUTRAL] Um, it is.
[CUSTOMER][NEUTRAL] 025
[CUSTOMER][NEUTRAL] 86425
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you verify your date of birth, your mailing and email address on file?
[CUSTOMER][NEUTRAL] Yes, um, date of birth [PII].
[CUSTOMER][NEUTRAL] Email address, um,
[CUSTOMER][NEUTRAL] Yeah, that I cannot remember.
[AGENT][NEUTRAL] OK, can you verify the mailing address on file?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And the email address on file is a Yahoo email?
[CUSTOMER][NEUTRAL] Uh, is it, um,
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And all the information provided is a verification of benefits, not a guarantee of payment. And would this be the three claims that were received on [PII]? Well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Actually, there's quite a few.
[CUSTOMER][NEUTRAL] Uh, no, these are the claim from um.
[CUSTOMER][NEUTRAL] From actually April through May.
[AGENT][NEUTRAL] OK, are you asking to go through all the claims that have been processed in April and May, or do you have particular dates of service that you like to go over?
[CUSTOMER][NEUTRAL] Yeah, it's these are all same related to same event all these.
[CUSTOMER][NEUTRAL] All these are related to the same incident.
[AGENT][NEUTRAL] So you're just wanting to go over all your denied claims?
[CUSTOMER][NEUTRAL] Yeah, um, I mean, um.
[CUSTOMER][NEUTRAL] Uh, so it, it seems like that, uh, you know, almost all of them were denied, and uh I think the total payment amount is, uh, total bill amount is about over 300,000.
[AGENT][NEUTRAL] OK, so I, so I, so are you wanting me to like give you the claim number and the denial reason and explain the denial reasons for each one that's denied?
[CUSTOMER][NEUTRAL] Well, yeah, I mean, um, you know, who are not the covers looks like, you know, uh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, so the
[CUSTOMER][NEUTRAL] Uh, you know, almost.
[AGENT][NEUTRAL] OK, so the first claim that was denied, uh, we received it on [PII].
[AGENT][NEUTRAL] 2025.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, it's claim number 3597072.
[CUSTOMER][NEUTRAL] One moment please. I'm logging, I'm trying to log into online.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And I'm not sure.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I can log in online.
[AGENT][NEUTRAL] Mhm. You can log in online, but now we are having issues with the online service center since our new launch. So let me know how it works for you.
[CUSTOMER][NEUTRAL] OK, uh, I'm logging in online.
[CUSTOMER][NEGATIVE] Uh, it says it cannot find my account.
[AGENT][NEUTRAL] Right, it's having some issues because of the new launch, so that's one of the issues. Um, are you using your username and password?
[CUSTOMER][NEUTRAL] My email address because that seems like that's what they're.
[AGENT][NEUTRAL] You use your email?
[AGENT][NEUTRAL] These
[CUSTOMER][NEUTRAL] That's what they're asking for.
[AGENT][NEUTRAL] Do you see the um link or the button that says create OSC profile?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Create what profile?
[AGENT][NEUTRAL] Yes, it should say create OSC.
[AGENT][NEUTRAL] Profile should be right under the password.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII] profile.
[AGENT][NEUTRAL] Yes, hold on, let me go to the website so I can give you the exact wording. Hold on one moment. So it says create your OSC account, right under login.
[CUSTOMER][NEUTRAL] OSC
[AGENT][NEUTRAL] So go to the main page like where you click log in.
[AGENT][NEUTRAL] Like start from the beginning.
[CUSTOMER][NEUTRAL] Yeah, I see it. Yeah, I see it. 330 yeah.
[AGENT][NEUTRAL] You see it?
[AGENT][NEUTRAL] Yes, and then you're going to click insured and follow those steps.
[CUSTOMER][NEUTRAL] I see it.
[CUSTOMER][NEUTRAL] Oh, I see. OK.
[CUSTOMER][NEUTRAL] I think I tried previously in group.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] I know why, because
[CUSTOMER][NEGATIVE] It's like the option insured does nothing.
[CUSTOMER][NEUTRAL] Oh next.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Ah, it says no user is found.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] When I said, oh, last name I see yeah I got it.
[CUSTOMER][NEUTRAL] Because it's one's last name.
[CUSTOMER][NEGATIVE] I still says no user is found.
[AGENT][NEUTRAL] OK, and what type of it's the website um that we just launched and we're having some issues with it. So since you've already um tried to go through the steps, I'll go ahead and forward that part over to IT. Um, what type of browser are you using?
[CUSTOMER][NEUTRAL] What is going on?
[CUSTOMER][NEUTRAL] Um, I'm using Google Chrome.
[AGENT][NEUTRAL] OK, and I'll let them know and did you, would you prefer an email back with assistance or a call?
[CUSTOMER][NEUTRAL] Um, call is fine.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And now in terms of the claims that you want to go over, um, are you just wanting to, like we were, just give you the claim number and why it was denied?
[CUSTOMER][NEUTRAL] Yeah, and actually, you know, I, I, I'm wondering, you know, why are these denied, why did, why not, because it's a big deal, it's a big event and nothing seems like, you know, was, uh, except just only few items just slightly covered.
[AGENT][NEUTRAL] OK, so first you, this is a hospital indemnity policy, so it's a limited medical policy. So it's not like a major medical or Blue Cross Blue Shield. It is a limited medical policy, um, but I can definitely go over all over the claims with you and let you know why they were denied.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, so, um, the first one was [PII], we received it on [PII].
[AGENT][NEUTRAL] And that claim number is 35,970.
[AGENT][NEUTRAL] 72
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the claim was denied because it was not a covered place of service?
[AGENT][NEUTRAL] So let me see what this is saying. Hold on one moment.
[AGENT][NEUTRAL] So the policy covers treatment by a physician um in a physician's office, clinic, urgent care, or emergency room.
[AGENT][NEGATIVE] So it's saying according to the paperwork that we received, this wherever this took place is not a covered place of service.
[CUSTOMER][NEUTRAL] So what is the covered place of service?
[AGENT][NEUTRAL] Um, the physician's office or clinic?
[AGENT][NEUTRAL] Urgent care
[AGENT][NEUTRAL] Or emergency room.
[AGENT][NEUTRAL] And this is um listed as inpatient hospital.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, the next one, hold on one moment.
[CUSTOMER][NEUTRAL] Do you know the amount?
[CUSTOMER][NEUTRAL] For this claim.
[AGENT][NEUTRAL] Um, looks like $336.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then let me see the next one, hold on one moment. And again, just for the call, the information provided is a verification of benefits, not a guarantee of payment. Um, so the next claim we received on [PII].
[AGENT][NEUTRAL] And that's claim number 359.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 70.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 84
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And hold on one moment. Um, hold on one moment, I'm waiting for it to come up.
[CUSTOMER][NEUTRAL] Amount.
[AGENT][NEUTRAL] This is an ambulance charge um for $2,336.13.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 2300.
[AGENT][NEUTRAL] And this
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] You said ambulance charge for $2,336.
[AGENT][NEUTRAL] Mhm. $2,336.13.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And this one was denied because the policy does not provide an ambulance expense.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Next one is [PII], we received it.
[AGENT][NEUTRAL] Um, policy number 35, I'm sorry, claim number 359.
[AGENT][NEUTRAL] 7078.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The total charge is $290.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And it was denied because it's not a covered place of service.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one moment. 78.
[AGENT][NEUTRAL] The next one was received on [PII].
[AGENT][NEUTRAL] Claim number is 359.
[AGENT][NEUTRAL] 7082.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the total for this, oops, hold on one moment, I clicked on the one above it.
[AGENT][NEUTRAL] Total for this is $620.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] This was denied because the calendar year maximum for diagnostic services has been met.
[CUSTOMER][NEUTRAL] What is the maximum?
[CUSTOMER][NEUTRAL] You know
[AGENT][NEUTRAL] Hold on one moment, yes, hold on one moment.
[AGENT][NEUTRAL] Let me see if I can pull it up this way. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, it's coming up now. Hold on one moment.
[AGENT][NEUTRAL] OK, for diagnostic testing, the policy will pay up to $250.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, and the next one, hold on one moment.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Next one we received on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that claim number is 3604054.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the total for this claim is, oh, hold on one moment.
[AGENT][NEUTRAL] This one has multiple lines on on 1 2nd.
[AGENT][NEUTRAL] $120.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] This is denied because benefits um payable under this policy are only the um those outlined in the schedule of benefits, so this is not a covered.
[AGENT][NEUTRAL] Charge or these are not covered charges.
[CUSTOMER][NEUTRAL] Outline under what?
[AGENT][NEUTRAL] Labs are not covered by the policy.
[CUSTOMER][NEGATIVE] Uh, outlined and not covered.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] You said benefit.
[CUSTOMER][NEUTRAL] Payable only outline under something.
[AGENT][NEUTRAL] Yeah, I was reading the the the now reason. It's saying that it's not a covered it's not a covered service on this policy.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So when we need it it says benefit payable only after then what?
[AGENT][NEUTRAL] Benefits payable under this certificate.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] are limited to those outlined on the schedule of benefits.
[CUSTOMER][NEUTRAL] OK, schedule of benefit.
[AGENT][NEUTRAL] So that's saying
[AGENT][NEUTRAL] Yes, we only pay for what's listed on your schedule of benefits. The schedule of benefits is what lists all of your coverage. So they're saying that this is not listed on the coverage, labs are not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one moment, let me get the next one for you.
[AGENT][NEUTRAL] The next one we received on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim number is 360.
[AGENT][NEUTRAL] 4069.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this total, hold on one second.
[AGENT][NEUTRAL] $391.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And it was denied.
[AGENT][NEUTRAL] Hold on.
[AGENT][NEUTRAL] It's not a covered um diagnostic test.
[AGENT][NEUTRAL] This policy specifies um diagnostic tests to MRI, CT scans, and colonoscopy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All of the diagnostic tests are not covered under this policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, the next one was received on [PII].
[AGENT][NEUTRAL] That's claim number 360.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 4071.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the claim was denied because it's not a covered place of service.
[CUSTOMER][NEUTRAL] So if it, what is the amount?
[CUSTOMER][NEUTRAL] What is the amount, please?
[AGENT][NEUTRAL] Oh, I just had a whole conversation on mute. I'm so sorry. The amount is $156.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And did you hear the denial reason?
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Yeah, I did.
[AGENT][NEUTRAL] OK. Um, so I don't, I think it turned on by itself. I don't know what just happened. I'm sorry.
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] And let me get the next one for you. Hold on one moment.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] The next one is, uh, we received it on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Claim number 36069.
[AGENT][NEUTRAL] 47
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the total for this one was $231.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And it was denied because the calendar year max was met for diagnostic services.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Um, the next one was denied for the same reason, we received it on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that claim number is 3606951.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the total for this one, hold on one moment.
[AGENT][NEUTRAL] It's $1,181.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, the next one.
[AGENT][NEGATIVE] was received on [PII]. It was denied for the same reason.
[AGENT][NEUTRAL] Um, that claim number is 3606956.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the total was $231.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The next one is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that policy number is 36093008.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The charge is $237.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it was denied because the policy pays no benefits for charges made by a doctor inpatient.
[AGENT][NEUTRAL] So the next, along with the one I just gave you, the next two, they were all received on [PII]. They were all denied for the same reason. I'm gonna give you the total and the claim number for the last two.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, so the first one is 3609309.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the total, hold on one moment.
[AGENT][NEUTRAL] It's $474.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The last one is uh claim number 3609313.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that charge was $290.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that's all the denied claims that we've processed for you.
[CUSTOMER][NEUTRAL] And other claims.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Other claims
[AGENT][NEUTRAL] How about claims?
[CUSTOMER][NEUTRAL] Did you put
[CUSTOMER][NEUTRAL] Do you have any other claims other than what you mentioned me?
[AGENT][NEUTRAL] You have the pay claims.
[CUSTOMER][NEUTRAL] Paid claims?
[AGENT][NEUTRAL] Yes, you said you wanted to go over the claims that were not paid for, that were denied. So we went over all of those and then you asked if there's any other claims, yes, the paid claims, the ones we paid on.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, uh, how can I see those paid claims? Like online, is it gonna be available?
[AGENT][NEUTRAL] Yes, um, once they get everything together with the online service center, you'll be able to see the in or the um claims that have already been processed up to a year, and you'll be able to see all the claims that are currently processing if there if there were any.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So that's what I need.
[CUSTOMER][POSITIVE] Uh, that's really what I need.
[AGENT][NEUTRAL] Right, well, we already know that there's an issue with the website. So once that gets corrected, you would be able to access it. You just can't access it now because we're having the technical issues.
[CUSTOMER][NEUTRAL] OK, and you said someone is gonna look up and call me.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][POSITIVE] OK, all right. I'll wait for the call then. Thank you.
[AGENT][POSITIVE] You're welcome. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] OK. Bye-bye.
[AGENT][POSITIVE] Thanks for calling APL. Bye bye.