AccountId: 011433970860
ContactId: 4fa91108-0450-4855-9ba6-43044ef63249
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 541760 ms
Total Talk Time (AGENT): 249904 ms
Total Talk Time (CUSTOMER): 279091 ms
Interruptions: 3
Overall Sentiment: AGENT=0.1, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/4fa91108-0450-4855-9ba6-43044ef63249_20250109T15:01_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is. How may I help you?
[CUSTOMER][NEUTRAL] Um, yes, I have, um, I'd like to inquire about a claim response that I got back and see if I can get some clarity on it.
[AGENT][NEUTRAL] Yes sir, I can help you with your with your um status of your claim. Can you please give me your name and your callback number just in case our call is disconnected?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure, my name is [PII] and my phone number is [PII].
[AGENT][NEUTRAL] Thank you, [PII]. And what is your policy number?
[AGENT][NEUTRAL] Or your certificate number?
[CUSTOMER][NEUTRAL] 24
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] Yeah, policy number is 2479217.
[AGENT][NEUTRAL] OK, let me pull that in for us.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, [PII], can you verify your date of birth for me, please, sir?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And then I'm also going to need for you for security reasons to verify your address, phone number, and email address that we have on the policy for you.
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[CUSTOMER][NEUTRAL] And um I'm not sure what email you have. It's either gonna be [PII] or [PII].
[AGENT][NEUTRAL] I've got one [PII].
[CUSTOMER][NEUTRAL] Oh, [PII]. OK.
[AGENT][NEUTRAL] Oh yes sir, alright, and then the um.
[CUSTOMER][NEUTRAL] So I've got 3 I use.
[AGENT][NEUTRAL] That's OK. And then the phone number that you gave me, if our call is disconnected, is that your cell phone number, sir?
[CUSTOMER][NEUTRAL] Yes, it is.
[AGENT][NEUTRAL] OK, thank you [PII] I appreciate you verifying that information for me. What is the claim number that's on your letter?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, the claim number that I'm inquiring about is 247, 0 no, that is my, let's see, claim number.
[CUSTOMER][NEUTRAL] Oh, claim number is 354.
[CUSTOMER][NEUTRAL] 9092
[AGENT][NEUTRAL] OK, let me look that claim up for you real quick.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And it was just denied, but I wanted to inquire about that that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the reason why it was denied is because the outpatient benefit for the calendar year was met.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] So here's the, here's the and maybe I'm not understanding how this policy works this the first time we've done this, um, this was back in [PII], um, that was the day Ascension Hospitals got hacked and so I have been on the phone. This was my son's hospital. He was admitted to the hospital.
[CUSTOMER][NEUTRAL] I've been on the phone for months and months and I finally got them to process this with Blue Cross after months of calls, um, so.
[CUSTOMER][NEUTRAL] In sending this.
[CUSTOMER][NEUTRAL] We had not met our deductible when the service was done and I have never claimed any of the
[CUSTOMER][NEGATIVE] Um, $3000 towards hospitalization and so that's why I'm presenting it now is I'm, yes, I'm not paying the hospital, but I'm still stuck paying other.
[CUSTOMER][NEGATIVE] $3000 out of my pocket towards other deductibles because I didn't get any of the hospitalization coverage. But when this was when the date of service.
[CUSTOMER][NEGATIVE] He had not met his deductible.
[CUSTOMER][POSITIVE] And the first sign of getting paid, we did get reimbursed for the um the 3000 that I'm allotted for um.
[CUSTOMER][NEUTRAL] Outpatient and testing.
[CUSTOMER][NEUTRAL] And that was, that was done, uh, in June, so it was done a month later which shows that I did, you know, I hadn't met that deductible at that time. So am am I misunderstanding something? Am I not, um, am I not like um supposed to get that money towards.
[CUSTOMER][NEGATIVE] The hospitalization that I never received.
[AGENT][NEUTRAL] OK. Uh, so what I'm going to need to do is
[AGENT][NEUTRAL] I'm not actually in the claims department so I'm going to need to send an email over to the claims department to let them know that they need to investigate this for you and have somebody call you back.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh huh
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Oh.
[CUSTOMER][NEUTRAL] Am I understanding the policy correctly though if if there's.
[CUSTOMER][NEUTRAL] You know, an allotment on both sides of that that regardless of if I meet the deductible I still would, I don't know I I guess I'm just confused maybe uh.
[CUSTOMER][NEGATIVE] That would be disappointing if I didn't get that money back.
[AGENT][NEUTRAL] Right, I understand, right, I understand and uh looking at and this is just to give you coverage verifying your coverage, it's not a guarantee of payment, but looking at your policy for your family, you have, and you said that your child was inpatient, is that correct?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, mhm.
[AGENT][NEUTRAL] OK, so you have a maximum for everybody in the family per calendar year of $9000.
[AGENT][NEUTRAL] Um, which is like $3000 per person looking at this, um, the max.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's 3000. So, and that
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That is for anything that has gone towards the deductible for the whole year.
[AGENT][NEUTRAL] And I can't see.
[CUSTOMER][NEUTRAL] Right, so my understanding was that it was 3000 towards inpatient and an additional 3000 towards outpatient.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Which is why I took a $7500 deductible because I assumed I could get up to $6000 that's what I was told by our beneficiary, so.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, so the, um,
[CUSTOMER][NEUTRAL] Hm, and you're saying that's not the case.
[AGENT][NEUTRAL] Right, so the outpatient max is also $3000 you're correct on that. Depending on the codes, um, the diagnosis codes and procedure codes that the primary insurance sends us from your primary care, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] On the claim that they send in that is what we based it on is their procedure and and um diagnosis codes what they paid compared to what you would owe I can't see your paperwork that is sent in to be able to investigate it, to look at it to make sure you know that what you're saying, you know, corresponds with what they sent in.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, I see. OK.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So I'll have to um go ahead and let the claims examiner look at it and have one of them call you back so that you guys can go over it together.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, and yeah, and it is showing that we don't owe anything but that's because they finally filed it um 7 months later so OK so yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, sir.
[AGENT][NEUTRAL] Oh my, OK.
[AGENT][NEUTRAL] OK. All right, but I'll definitely get somebody to call you back at the number that you gave me, the [PII] and um.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] That way you can get a response about this.
[CUSTOMER][NEUTRAL] OK, and is that something that would probably happen before the weekend or?
[AGENT][NEUTRAL] Now, it could be
[AGENT][NEUTRAL] It could be up to 24 hours and which would put us, we're closed on the weekend so if you don't get any response today you should probably hear something back on Monday to give that 24 hour time frame for them to be able to investigate and pull everything in they need to.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] I see. OK. All right, well thank you so much for your help. OK, alright, and, and will this go.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You're welcome, [PII]. It's gonna be a Bruce. It's gonna.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I'm sorry, the email you had on file was [PII], so that if they would send anything it would come there, but they'll call.
[AGENT][NEUTRAL] Uh yes sir, that's correct, yes sir, but somebody will call you.
[CUSTOMER][NEUTRAL] OK, all right.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] OK. You're welcome, [PII]. You have a wonderful day and thank you for calling APL. All right, bye-bye, sir.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] You too.
[CUSTOMER][POSITIVE] OK, good.