AccountId: 011433970860
ContactId: 34748ef7-3d4b-43bc-982e-4ffc24716531
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 722599 ms
Total Talk Time (AGENT): 208941 ms
Total Talk Time (CUSTOMER): 164463 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/14/34748ef7-3d4b-43bc-982e-4ffc24716531_20250514T17:26_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII] and I'm calling on behalf of um the broker's office to assist an employee in uh claim status.
[AGENT][NEUTRAL] OK, well, I can definitely help you with the claim status, and [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Let's get the policy number.
[CUSTOMER][NEUTRAL] 2572267
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes ma'am, the number is [PII] and I'm getting his date of birth right now.
[AGENT][POSITIVE] Mhm, take your time.
[CUSTOMER][NEUTRAL] Sorry, my computer is acting up on me. Keeps logging me out.
[AGENT][POSITIVE] Oh, take your time. It's fine. There's no problem at all.
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the um data of service and the total bill for the claim?
[CUSTOMER][NEUTRAL] Yes, um, so the first I'm calling about two different ones. Uh, the first one is, uh, data service 312 to 312 of 25.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, total benefits I'm showing paid out, um, was 1100.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] 312 of 2025 and the total, the total bill is $1100?
[CUSTOMER][NEUTRAL] Oh, I'm sorry, it's 3.
[CUSTOMER][NEUTRAL] It's 3:12 to 313 of 2025 and on the EOB that was paid out to him was $1100.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Well, let me see.
[CUSTOMER][POSITIVE] Mhm, and I actually have a claim number if that helps.
[AGENT][NEUTRAL] OK, yeah, because I'll have to try to look for, yeah, what's the claim number that you have?
[CUSTOMER][NEUTRAL] OK, 359-058-87.
[AGENT][NEUTRAL] And I was literally looking at that one. It just, I was just trying to determine the total bill. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me look at this one.
[AGENT][NEUTRAL] Oh, we paid out $1100. OK, OK, OK. So for this um claim we received on [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, ma'am. Uh, my question was.
[CUSTOMER][NEUTRAL] It shows
[CUSTOMER][NEUTRAL] For the ER benefit, it states that.
[CUSTOMER][NEUTRAL] Um, outpatient treatment due to a sickness is not covered under this policy, but under the hospital policy, it's for accident and or sickness.
[AGENT][NEUTRAL] Let me take a look at the benefits. Hold on one moment.
[AGENT][NEUTRAL] Do you mind if I place you on just a brief hold?
[CUSTOMER][POSITIVE] Yeah, no problem.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh right.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh, this one.
[AGENT][NEUTRAL] It's ER, so wait a minute.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] That's the difference.
[AGENT][NEUTRAL] OK, hello, [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] All right, thanks so much for holding. I apologize for that wait. So, the accident and sickness surgery benefit is for both accident and sickness, but the outpatient accident treatment benefit, which covers the emergency room physician's office, urgent care, that's just accident, outpatient accident. So that's the difference between those two.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] I, I'm gonna have to get with the agent because I think that this was written by mistake.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] This is the first time we're hearing of this.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Yeah, because usually our hospital policies that we that they built.
[CUSTOMER][NEUTRAL] All the benefits are for accident and sickness.
[CUSTOMER][NEUTRAL] For all the groups that we deal with, um.
[CUSTOMER][NEUTRAL] OK, I'm gonna have to get with him on that.
[CUSTOMER][NEUTRAL] Um, and then was there a surgery benefit paid out for either this claim number or um.
[CUSTOMER][NEUTRAL] Uh, I have another claim number you can reference to to double check.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's um 359.
[CUSTOMER][NEUTRAL] 6604.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] That's admission. Hold on one moment.
[AGENT][NEUTRAL] All right, Ma, hold on.
[AGENT][NEUTRAL] There it is.
[AGENT][NEUTRAL] No, that's not a surgery. Hold on one moment. I'm just going through the claims.
[CUSTOMER][POSITIVE] Yeah, no, take your time.
[AGENT][NEUTRAL] OK, so for 359-058-7, I'm not showing a surgery code was uh surgery um benefit was used. I'm gonna go to the other one now.
[AGENT][NEUTRAL] And neither um it wasn't on the other one as well, the 6604.
[AGENT][NEUTRAL] No, um, surgery benefit was used.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, OK, so the only thing that was paid out so far for his hospital policy for all his claims, um, what would be.
[CUSTOMER][NEUTRAL] 1500, is that correct? Total?
[AGENT][NEUTRAL] The total, hold on one second.
[AGENT][NEUTRAL] Uh, it's just for this year?
[AGENT][NEUTRAL] The total that's been paid out?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on, no it's more than that.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So, all together, we paid out a total of $2600 for his hospital policy.
[AGENT][NEUTRAL] For 2025.
[CUSTOMER][NEUTRAL] OK, can I get a breakdown of that payment?
[AGENT][NEUTRAL] OK, um, the hospital admission benefit has used $1000 in total.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The major diagnostic, which one is this, 1 or 2? OK, major diagnostic exam benefit. I'm gonna try to pronounce this, including electro.
[AGENT][NEUTRAL] I don't even know how to pronounce this hologram and and then this part is uh.
[AGENT][NEUTRAL] Written off S T E C T. Um do you see that there? I don't, I don't know how to pronounce it. I'm sorry. I paid out $100.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I see it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The hospital confinement benefit paid out $400.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see what this one stands for.
[AGENT][NEUTRAL] Accident
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Accident and sickness surgery benefit paid out $1000.
[AGENT][NEUTRAL] And wait, does that have a D at the end? No. There's this one. And minor diagnostic exam.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Amount paid out $100.
[CUSTOMER][POSITIVE] OK perfect thank you so much for your help.
[AGENT][POSITIVE] You're very welcome. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] That was it.
[AGENT][POSITIVE] Alright, well thanks for calling APL [PII]. I hope you have a good day.
[CUSTOMER][POSITIVE] You too. Thank you. Bye.
[AGENT][POSITIVE] You're welcome. Bye bye.