AccountId: 011433970860
ContactId: 4aa517d8-846a-4e2b-bbae-185acc762cf0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 324200 ms
Total Talk Time (AGENT): 162810 ms
Total Talk Time (CUSTOMER): 93635 ms
Interruptions: 1
Overall Sentiment: AGENT=1.4, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/20/4aa517d8-846a-4e2b-bbae-185acc762cf0_20250520T14:24_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. Uh, I had submitted a claim, uh, form.
[CUSTOMER][NEUTRAL] Uh, last month on the [PII], and I was following up with that. I did contact PHCS and they said I needed to talk to you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, I can check on that claim for you. Uh, look, can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Thank you. And then do you have your policy number?
[CUSTOMER][NEUTRAL] Uh, the member ID?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh it is 6821.
[CUSTOMER][NEUTRAL] 45,550
[AGENT][NEUTRAL] Uh, one moment.
[AGENT][NEUTRAL] All right, [PII], just gonna verify some information really quick. Uh, can I get your date of birth, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and then can I get your mailing address?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] Perfect. Last thing I need is the email address we've got on file for you. uh, looks like it is a Hotmail account.
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][POSITIVE] Awesome thank you so much for verifying all of that. OK, so I do see we received a claim [PII] and looks like that completed processing on [PII]. Give me just a moment, let me check that status. So we did pay a benefit of $300 and that was sent, uh as a check in the mail and let me see when that was issued. Give me just a moment.
[CUSTOMER][NEUTRAL] I did receive that.
[AGENT][POSITIVE] Oh you did OK awesome.
[CUSTOMER][NEUTRAL] Yeah, I guess I'm just questioning why, why it was, you know, fully covered or at least.
[AGENT][NEUTRAL] Did you have further? Oh sure.
[AGENT][NEUTRAL] Oh, the amount.
[AGENT][NEUTRAL] I see. OK, yes, so let's take a look.
[AGENT][NEUTRAL] So it does state that the calendar year maximum for that benefit had been exhausted with this payment. So that $300 did meet the maximum payable.
[CUSTOMER][NEUTRAL] So I didn't have them.
[CUSTOMER][NEUTRAL] So I had a max payout but not a not a max.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Out of pocket
[AGENT][NEUTRAL] Correct, uh, so this policy, it was a limited indemnity medical plan, so it is a bit different, um, than traditional major medical. There was no co-pays or anything like that. It pays a set dollar amount per covered procedure or office visit, sometimes, uh, with a calendar year maximum, sometimes with a daily maximum.
[CUSTOMER][NEUTRAL] OK. Alright.
[CUSTOMER][NEUTRAL] First I've heard of that.
[AGENT][NEUTRAL] It is a bit different.
[AGENT][NEUTRAL] It's a different kind of uh policy that's for sure. So this was for.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well
[AGENT][NEUTRAL] Let's see. Accident sickness, uh, outpatient surgery, um, and yeah, the maximum benefit was $300. So that was, that would meet that.
[CUSTOMER][NEUTRAL] So and that was for the calendar year or that was for that bill that specific claim?
[AGENT][NEUTRAL] Both, so for this policy it is limited to one per calendar year.
[CUSTOMER][NEUTRAL] One what per calendar year?
[AGENT][NEUTRAL] For this particular benefit, so again, this falls under the uh accident sickness outpatient surgical benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the
[CUSTOMER][NEUTRAL] So the claim that I sent in was like 2500 and some.
[CUSTOMER][NEUTRAL] So the max benefit on that was 300.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] Oh, that's terrible.
[AGENT][NEUTRAL] It is a bit different. Um, limited indemnity medical plan is what this one is, the type. So it is very different than traditional major medical.
[CUSTOMER][POSITIVE] That's, that's pretty.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, anything else that I should be doing or can do to try to.
[CUSTOMER][NEGATIVE] Get anything more from a benefit standpoint out of this I mean that's like nothing.
[AGENT][NEUTRAL] Sure, so I mean if there were anything else, I would always encourage anyone to um submit any sort of if any thing that you got from treatment, uh those itemized statements, go ahead and send all of that to us, um, and see, you know, if it's possible that you could get anything additional.
[CUSTOMER][NEUTRAL] But and I did send all that with that email.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I got the different forms that were requested from SSM Health.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] And they should be in there with all the codes and everything.
[AGENT][NEUTRAL] OK, then it's possible that this is the only thing that we were able to pay.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, then I will get it taken care of from there then.
[AGENT][NEUTRAL] Alright, was there anything else I could help you with, [PII]?
[CUSTOMER][NEUTRAL] Not at this time.
[AGENT][POSITIVE] Alright well thanks for giving us a call have a great rest of your day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thanks bye bye.