AccountId: 011433970860
ContactId: 4fc44d3e-767f-4dea-9ead-9f5326e0fe78
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 955479 ms
Total Talk Time (AGENT): 493196 ms
Total Talk Time (CUSTOMER): 252746 ms
Interruptions: 3
Overall Sentiment: AGENT=0.5, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/09/4fc44d3e-767f-4dea-9ead-9f5326e0fe78_20250409T16:32_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, good morning. Uh, my name is [PII], and I was calling about an explanation of benefits I received that was a denial for my OB ultrasound, which I was told by my health insurance agent that would be covered.
[AGENT][NEUTRAL] OK, [PII], so you have a question regarding a claim that was processed but denied. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, ma'am. I can help you with that. And first off, what is a good callback number for you in case we're disconnected?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, thank you. And what is your policy number, please?
[CUSTOMER][NEUTRAL] 02561717
[AGENT][POSITIVE] OK, thank you if you'll give me a moment please to get your input.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And once I do, I will need to.
[AGENT][NEUTRAL] Verify several things with you first, for security information provided would be a verification of benefits and not a guarantee of payment.
[AGENT][NEUTRAL] So Miss [PII], if you'll first please verify your date of birth.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you. Also your home mailing address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. The phone number that we have on file for you is the same as the one that you provided for me, so that is your best contact number, is that correct?
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And then lastly your email address please.
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, Miss [PII], thank you for verifying all of your information. So one moment.
[AGENT][NEUTRAL] And what is the date of service, Ms. [PII]?
[CUSTOMER][NEUTRAL] Uh, so, three of them are kind of clumped together on this. Um, the first one is [PII].
[AGENT][NEUTRAL] Alright, let's
[AGENT][NEUTRAL] OK. And you said they're all on the same claim.
[CUSTOMER][NEUTRAL] Yeah, the other one is [PII], 24.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And there was one more?
[CUSTOMER][NEUTRAL] And the other one listed as 10, 8, 24, which I don't think they were that close together, but that's what's on here.
[AGENT][NEUTRAL] OK, so 108, 10:10 and 1221, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and do you have your claim number?
[CUSTOMER][NEUTRAL] Yes, the claim number is 358-072-3.
[AGENT][NEUTRAL] OK, thank you. So give me just a moment please to get that information pulled up.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, so yes ma'am, I can see that this claim was denied and I can see that it states uh benefits payable under this certificate are limited to those outlined in the schedule of benefits. This is not a covered loss under the plan. Therefore, no amount is payable for this expense.
[AGENT][NEUTRAL] Give me just one moment to pull up your policy information because this is a limited benefit plan.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So it does only cover certain services.
[AGENT][NEUTRAL] For just a moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I was supposed to cover all my pregnancy services. That's the only reason I signed up for the plan.
[CUSTOMER][NEGATIVE] And I've been paying for it.
[AGENT][NEUTRAL] OK, so let me look.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] OK, so yes, ma'am, on this specific
[AGENT][NEUTRAL] Policy that you are on, it does not have for.
[AGENT][NEUTRAL] For that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] This would be if you were admitted to the hospital or a physicians, you have benefits for physicians' offices that are urgent care or emergency room and therapy like physical speech or occupational therapy, but that, that is the, all of the benefits on this particular plan.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Now, if you have questions regarding what you enrolled for,
[AGENT][NEUTRAL] I can provide you the contact information.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] For member services.
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEGATIVE] Yeah, because they enrolled me for it's supposed to cover specifically my OB GYN appointments. I don't need this emergency insurance.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Um, and I was told when I called the plan that, OK, you submit a claim and then they um and they reimbursed you because my OB office only had agreed to 10% payment.
[AGENT][NEUTRAL] OK. So the
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. All right. So let me give you the number for members.
[AGENT][NEUTRAL] Services.
[AGENT][NEUTRAL] Because that is who you, that's who provided us with your enrollment information.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So they would be the ones that you would need to speak to and their phone number I actually have.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Two different phone numbers for them. I believe they kind of the same place, but I'll give you both of them, and I also have an email address Miss [PII], that I can give you for member services.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So just let me know when you're ready.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah, I'm ready.
[AGENT][NEUTRAL] OK, so the first phone number is [PII].
[AGENT][NEUTRAL] 877.
[AGENT][NEUTRAL] 247.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The other phone number is [PII].
[AGENT][NEUTRAL] 697.
[AGENT][NEUTRAL] 0026.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] And the email address for them.
[AGENT][NEUTRAL] It's kind of long. It's [PII].
[AGENT][NEUTRAL] At
[AGENT][NEUTRAL] The number 4.
[AGENT][NEUTRAL] Member services.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Again, that email address is [PII] and that is a numerical 4.
[CUSTOMER][NEUTRAL] OK. Yes, that's who I sent my claim to. Um, another question, a couple of questions, so while I have you, one of the ultrasounds, um, was, um, it was in an ER visit, so wouldn't that be covered because it was to look for appendicitis.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Let's see. Let me pull your let me get back to your information.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, on you, on this plan, it has emergency room benefits for outpatient accident and sickness treatment.
[AGENT][NEUTRAL] There are benefits on this plan for that. You could review for an emergency room visit.
[AGENT][NEUTRAL] And the benefit for an emergency room visit or benefit that's approved, if approved is $300 per day and a maximum of 2 days per calendar year per covered person.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I mean, I just don't really see why I'm paying $330 per month for something that's covering so little, so they told me it would cover OB and everything so I mean.
[AGENT][NEUTRAL] Let's
[CUSTOMER][NEUTRAL] And I need to talk to them. Um, do you have my other claims that they.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Sam.
[CUSTOMER][NEUTRAL] Email by chance? um.
[AGENT][POSITIVE] Yes, now I do understand.
[CUSTOMER][NEGATIVE] But I haven't received anything back on those yet.
[AGENT][NEUTRAL] There's only one other claim, there's only one other claim on file for you.
[AGENT][NEUTRAL] Uh, with APO and that claim was received back on [PII].
[AGENT][NEUTRAL] And this was for, it looks like multiple dates of service as well.
[AGENT][NEUTRAL] For
[AGENT][NEUTRAL] Key West HMA physician Management.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And it was for date of service of [PII] and also [PII].
[AGENT][NEUTRAL] And that claim was also denied and the reason for the remark.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] States in order to complete the processing of your claim, we need itemized statements of the services provided listing the diagnosis code or codes. OK.
[CUSTOMER][NEUTRAL] But like
[CUSTOMER][NEUTRAL] Which I did then.
[AGENT][NEUTRAL] Yeah, apparently we have not received that as of yet.
[CUSTOMER][NEUTRAL] OK, I did send that to that email they sent to the [PII] support at for [PII]. Do you guys don't have an itemized receipt for that?
[AGENT][NEUTRAL] For those for the 11, 6, and 12.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] No, ma'am. We have not yet received that.
[CUSTOMER][NEGATIVE] OK, yeah, it sounding like they did not.
[AGENT][NEUTRAL] They like I said, that claim, right, that claim and then the first one that we discussed are the only two that we have for you.
[CUSTOMER][NEUTRAL] OK, so you
[CUSTOMER][NEUTRAL] Don't have one from the hospital in [PII].
[AGENT][NEGATIVE] No, ma'am. We did not receive an itemized bill. No, ma'am. That's the piece of missing information that we don't have.
[CUSTOMER][NEUTRAL] And it's sounding like.
[CUSTOMER][NEUTRAL] OK, do you guys have a more direct email address for me to send my claims, or do I continue to do that customer support at [PII]?
[AGENT][NEUTRAL] Let me look at how your association is set up. um, I believe that you all do have to initially submit your claims to them. Let me look.
[AGENT][NEUTRAL] OK, so what I'm going to do, are you familiar with our portal called the online service center?
[CUSTOMER][NEUTRAL] No, I am not.
[AGENT][NEUTRAL] Has anyone
[AGENT][NEUTRAL] OK, so what I'm going to do is I will email you the user guide for how to.
[AGENT][NEUTRAL] To set up your portal with us you can your claims information into that portal.
[AGENT][NEUTRAL] And it does give you the instructions and the user guide of how to do that and that would be uploading it directly to us, OK? We just can't we can't accept claims via email due to security reasons.
[CUSTOMER][NEUTRAL] OK, and would that portal be the way I do the appeal if needed after talking to?
[AGENT][NEUTRAL] That is correct. Yes, ma'am. And mhm, and you, right, and you do have 180 days from the date of the decision to file your appeal, and you would just put to attention appeals department.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The people, OK.
[AGENT][NEUTRAL] On your documents. But yes, ma'am, that can be uploaded as well. So the email that you're gonna receive from me, Ms. [PII], and I'm gonna send that, it shouldn't, I'm gonna send it in a moment. It should not go to your junk or spam folder, but I would say if you haven't seen it within the next less than 10 minutes for sure. Um, you might want to check one of those, but the email will come from [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I will put APL online service center portal in your subject line so that you can recognize that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, for me, you're welcome. Would you like for me to try and connect you over to member services?
[CUSTOMER][POSITIVE] Um, sure, that would be great. Thank you.
[AGENT][POSITIVE] Or do you want to call them direct? OK. All right. Well, I'll be happy to do that. So is there anything else that I can help you with today first?
[CUSTOMER][POSITIVE] Um, no, that's it. Sounds like they need to get something straightened out, so thank you.
[AGENT][POSITIVE] OK. Well, you're welcome, Miss [PII] and thank you again for calling APL. I hope you have a very nice rest of your day.
[CUSTOMER][POSITIVE] I'll try. Thanks.
[AGENT][NEUTRAL] Uh yes, ma'am. So one moment and let me see if I can get you connected, OK?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Thank you for calling member services. All calls are recorded for quality assurance. Our hours of operation are Monday through Friday [PII] Central Standard Time. If you know your party's extension, please dial it now.
[CUSTOMER][NEUTRAL] For customer support, press 2. For agent support, press 3. For claim support, press 4. For provider support, press 5. Thank you.
[CUSTOMER][NEUTRAL] You are currently caller number 15, waiting to speak with a representative. The estimated hold time is currently 8 minutes. Thank you for your patience.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hi Ms. [PII], this is still [PII] at APL. So when I pressed the prompt to go, uh, which would be #2 on their automated attendant.
[AGENT][NEUTRAL] It says that the call is 15 in line with an approximate 8 minute hold time, so I didn't want to just drop you into that without letting you know that.
[CUSTOMER][POSITIVE] Oh, OK, I appreciate you letting me know.
[AGENT][NEUTRAL] OK, so do you, do you want me to connect you back over?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][POSITIVE] OK. Well, I'll be happy to do that. So one moment, please.
[CUSTOMER][POSITIVE] OK, thanks.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Thank you for calling member services. All calls are recorded for quality assurance. You are currently caller number.