AccountId: 011433970860
ContactId: 37335f56-94fb-4cfc-8fc1-e9990973690d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 347549 ms
Total Talk Time (AGENT): 159913 ms
Total Talk Time (CUSTOMER): 196845 ms
Interruptions: 2
Overall Sentiment: AGENT=0.2, CUSTOMER=1.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/06/37335f56-94fb-4cfc-8fc1-e9990973690d_20250106T15:58_UTC.wav
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[AGENT][POSITIVE] Thank you for calling American Public Life. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] uh in the care team. I've got Miss [PII] she's a broker on the phone with the insured, um, [PII]. Let me give you the policy number.
[AGENT][NEUTRAL] OK, hold one moment, sorry, you said her name is [PII]?
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] Yeah, [PII] is the is the um contact person for the group, yes ma'am.
[AGENT][NEUTRAL] Broker.
[AGENT][NEUTRAL] OK. And what is the policy number?
[CUSTOMER][NEUTRAL] It's 2217.
[CUSTOMER][NEUTRAL] 5442.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And they are calling about claim number 3,427,220.
[CUSTOMER][NEUTRAL] I read the remarks to them they had maxed their benefits for the day and explained that was $500 500 dollars per calendar day, but she still has further questions about.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Why we didn't pay.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I'm transferring her on over to you guys so you can explain it to her further.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, you can send her over.
[CUSTOMER][POSITIVE] OK, thank you bye bye.
[AGENT][NEUTRAL] Bye.
[AGENT][NEUTRAL] Thank you for calling American Public Life. Am I speaking with [PII]?
[CUSTOMER][POSITIVE] Yes you are.
[AGENT][NEUTRAL] Hi, [PII], this is [PII], uh, in the claims department and [PII] explained you had some additional questions, uh, in regards to um why the claim was denied.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes, because it says here she says that it was an outpatient service when we have $500 per person per calendar day for covered services, and when she received the invoice, the invoice says that the insurance paid a portion and APL paid $0.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, so, uh, as, um, I'm not sure if she explained, uh, this policy for outpatient services pays $500 per day. So prior to the claim that was denied, we had already received the claim for data service [PII], in which we paid the $500. So she had exhausted her benefits for this date. Yes, ma'am.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] For that day, so, so [PII], alright, so she had.
[CUSTOMER][NEUTRAL] So she has another bill apart from this, where's that other bill? What do you know what procedure that was because it says here gastro yeah it says gastrointestinal procedure 43251, and then gastrointestinal procedure. Go ahead.
[AGENT][NEUTRAL] Let me take a look at it.
[AGENT][NEUTRAL] OK, so it's.
[AGENT][NEUTRAL] It's not based on the procedure, it is based on the date of service and so the hospital, the surgical center had already submitted their claim in which we made a payment of $500 to the surgical center. So she had exhausted her $500 for
[CUSTOMER][NEUTRAL] So there's another bill apart from this one because this bill says that she the total was the total was $2,813 and insurance covered 2556 points. So there's another bill apart from this one for the [PII], is that what you're saying?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes, ma'am. Um, uh, like I said, the hospital, the surgical center, Baptist Surgery and endoscope, they submitted their claim prior to the doctor's claim, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The hospital.
[CUSTOMER][NEUTRAL] As well, OK, let me ask her. Let me, let me ask her to Obilique for that it is a kind of uno. OK, here she just showed it to me.
[CUSTOMER][NEUTRAL] OK, there's another one here.
[CUSTOMER][NEUTRAL] That's for, uh, let me see, there's another one here, Telemimo.
[CUSTOMER][NEUTRAL] No, no, no, it's different. There's another bill here.
[CUSTOMER][NEUTRAL] Uh, bill, you want the bill ID?
[AGENT][NEUTRAL] Is it a data service? What is the data service?
[CUSTOMER][NEUTRAL] [PII] as well, but here it says APL 0 again.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] Again, we've already paid. The charges are coming after the hospital. The hospital filed their claim first for this data service. So once we paid $500 to the hospital, anything that comes after the hospital's bill for the same data service will be denied, maximum benefits have been exhausted.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, let me see if she has a hospital goutin also build the lopi.
[CUSTOMER][NEUTRAL] You get a big time I think.
[CUSTOMER][NEUTRAL] OK, well, I, I wanna know what hospital, but she didn't get it done at the hospital. She had it done at a at outpatient service.
[AGENT][NEUTRAL] Correct. The surgical center, as I stated, that is their claim that we paid $500 to the facility, which is the outpatient surgical center.
[CUSTOMER][NEUTRAL] Right, but I'm her, no, I understand what you're saying, but we have 3 bills in front of me. All 3 bills show that she's receiving because clearly if you're being, if we're getting an invoice, right, whatever the hospital, uh, whatever the hospital had claimed, we should see it as well. I don't see any of the bills here that says the APL paid $500. That's what I'm saying.
[AGENT][NEUTRAL] OK, so we can send out an explanation of benefits for the surgical center's bill.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEGATIVE] Right, because I, I have 3 bills. She just showed me 3 bills and all of it says APL 0, APL 0, APL 0. So clearly it must be another bill that she doesn't have that shows that they put 500, you know what I'm saying, you know what I'm saying.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right. We can submit, uh, we can send her an, uh, a copy of the explanation of benefits. Uh, this one was paid, uh, in February. Uh, that benefit was exhausted [PII], uh, to the surgical center. So I will go ahead and uh request that it be sent out to her. Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] Yeah, cause I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Perfect, right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][POSITIVE] OK, thanks
[CUSTOMER][POSITIVE] Thank you so much. Thank you.
[CUSTOMER][POSITIVE] Oh, I'm good thank you so much.
[AGENT][POSITIVE] You're welcome. You have a wonderful day, [PII]. Thank you for calling APL. Bye-bye.
[CUSTOMER][POSITIVE] Oh, OK. All right. Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] OK, bye-bye. OK. 86.