AccountId: 011433970860
ContactId: 38564647-099b-419d-920d-37b352504453
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 581640 ms
Total Talk Time (AGENT): 195899 ms
Total Talk Time (CUSTOMER): 229540 ms
Interruptions: 0
Overall Sentiment: AGENT=0, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/05/38564647-099b-419d-920d-37b352504453_20250605T18:18_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello [PII], this is [PII]. Um, I've been going to the doctor. Uh, I, I had a couple of appointments and you guys are respecting the, the claim. So what's going on?
[AGENT][NEUTRAL] OK, I can help you with those claims.
[CUSTOMER][NEUTRAL] Why is this happening?
[AGENT][NEUTRAL] Um, give me just a moment. Can I get your name one more time and a good callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you so much. And what is your policy number?
[CUSTOMER][NEUTRAL] Oh, I don't know. Uh, oh, here it is. 02582675.
[AGENT][NEUTRAL] And just to confirm, I have 02582675?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, give me just a moment to look that up.
[AGENT][NEUTRAL] Can I get you to verify your date of birth for me, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the address we have on file for you?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you so much let me see what's going on here um.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Looks like you're getting denied because your benefit maximum for that date of er for your dates of services for the ones that are denied, uh, the benefit maximum was met.
[AGENT][NEUTRAL] If you like, I can go over some of that with you and we can go over what you, what your policy.
[CUSTOMER][NEUTRAL] What?
[CUSTOMER][NEUTRAL] Yeah, I mean, I, this year, this year, this year.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The first time that I used the, the, the, the Benefit, I went to the doctor to make a, because I have an accident and I have a pain in my back, and he runs some X-ray and then he prescribed me some medication. It was the first.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEGATIVE] I don't know, the first appointment I did through you guys, it's not possible that I maxed out, because I never used it.
[CUSTOMER][NEUTRAL] How could I maxed out.
[AGENT][NEUTRAL] OK, don't know what
[CUSTOMER][NEUTRAL] If I never used it before.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] My appointment was.
[CUSTOMER][NEUTRAL] [PII]. So how could I be maxed out on [PII]?
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Let me put you on a brief hold and I'm gonna see if someone from claims can help you with this um because I'm yeah give me just one moment OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], it's [PII] with the APL care team. Um, I have a Gonzalo on the line. He is questioning why his claims keep getting denied. Um, I, it, it shows that he's meeting the benefit maximum, um, and he's saying that he's only visited one time and he doesn't know why they keep getting denied and I, I can't do any more research on why they're getting denied.
[CUSTOMER][NEUTRAL] OK, what was the policy number?
[AGENT][NEUTRAL] Uh, policy number is 25.
[AGENT][NEUTRAL] 82675
[AGENT][NEGATIVE] I am showing that 2 claims have been um paid and then all the rest have been denied. um.
[AGENT][NEGATIVE] But I'm just not able to see why.
[CUSTOMER][NEUTRAL] OK, let me take a look here.
[AGENT][NEUTRAL] That was his hospital indemnity plan. He made it sound like it's an accident though, so I'm wondering if, if they file a claim under their hospital indemnity and it ends up being an accident policy, are they allowed to, does it go, do we transfer it over to the correct policy or do they need to resubmit?
[CUSTOMER][NEUTRAL] Um, normally we would check to see if they have another policy and then we would just move it over for it to be reviewed under both. Um, I can check real quick to see if they've.
[AGENT][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, uh, yeah, I do see that he did file a claim this year for his accident policy too. Um, let me see.
[AGENT][NEUTRAL] Yeah, the one he gave me is his hospital indemnity policy, so I didn't know if.
[AGENT][NEUTRAL] Uh, we need to give them more research or if you need to get more information from him as to if it needs to be processed through the other claim. I, I don't know, he gave me the, the hospital indemnity policy and.
[AGENT][NEGATIVE] I was told we can't research in care team shouldn't be researching into claims.
[AGENT][NEUTRAL] Um, and frankly, I would, I would know what to.
[AGENT][NEUTRAL] Look for all I can give him is the benefit amount, and he's wondering how.
[CUSTOMER][NEUTRAL] Uh, sure.
[CUSTOMER][NEUTRAL] OK, yeah, I'm just taking a quick look, so I just know what to tell him as soon as you transfer him over.
[AGENT][NEUTRAL] That's OK.
[AGENT][POSITIVE] I enjoy learning from you guys, especially if I end up transferring and it shouldn't be transferred. I, I want to know if I'm doing it right or wrong.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] No one's told me so far that I've done it wrong, but I want to, to make sure and then I kind of wanna know the processes too, so, um, that I can better understand next time someone calls.
[CUSTOMER][NEUTRAL] Oh sure, so let me see, so from what I'm seeing we've already paid there's like a maximum um benefit for that data service and so that was already paid and so that's why it's being denied because he keeps sending it more information for the same data service, um, so I can go ahead and let him know that that the maximum benefit for that data service has already been maxed.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, yeah, and I told him, I gave him the claim remark and he was like not understanding how it could have been maxed out after one visit.
[CUSTOMER][NEUTRAL] Yeah, it's just because we pay a maximum for like the office visit 2 $75 per visit and so that's what was paid.
[AGENT][NEUTRAL] OK, um, I'll, I will go ahead and transfer him over to you um I will I'll introduce you first just so that he knows it's not the voices aren't the same, so give me just a moment.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So, yeah.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Hi [PII], I have [PII] from uh claims and she's gonna be able to help you with that information, OK?
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] OK, thank you so much.
[CUSTOMER][POSITIVE] Good afternoon, this is [PII], and how can I help you today?
[CUSTOMER][NEUTRAL] Uh, I went to the doctor in January and you guys rejected the claim.
[CUSTOMER][NEUTRAL] So I have to pay for that bill. Uh, the lady before you told me that I maxed up the my account. How could it be if it's the beginning of the year?
[CUSTOMER][POSITIVE] Sure I can help you with that, yeah, tell me all the claims that I have with you.
[CUSTOMER][NEGATIVE] If you reject them all, cause I, I, I'm gonna have another bill coming.
[CUSTOMER][NEUTRAL] And I am seeing the paperwork that you sent to me on for [PII] or, or something like that, that says that you are paying 0. So, are you rejecting all my claims? What, what, what's the deal?
[CUSTOMER][NEUTRAL] Sure I can help you with that. Um, so I do see that we had so far we have paid um two claims, um, one that was released on [PII] for the data service [PII], um, for your outpatient sickness visit, um, so that was paid at $75.
[CUSTOMER][NEUTRAL] Um, that was released on [PII] and then there was a second claim that was paid, um, it looks like that benefit was released on [PII] for the date of service of [PII], um, for that outpatient sickness benefit as well for $75. OK.
[CUSTOMER][NEUTRAL] So, so for that outpatient sickness benefit under.