AccountId: 011433970860
ContactId: 55a5317b-f37d-4b26-9051-52b19a4bcb47
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 894359 ms
Total Talk Time (AGENT): 386198 ms
Total Talk Time (CUSTOMER): 239626 ms
Interruptions: 2
Overall Sentiment: AGENT=0.5, CUSTOMER=1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/55a5317b-f37d-4b26-9051-52b19a4bcb47_20250416T12:57_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], good morning. This is [PII] in [PII]. How are you?
[AGENT][NEUTRAL] Hey, [PII]. How are you today?
[CUSTOMER][POSITIVE] Doing great, doing great.
[AGENT][POSITIVE] Good. Well, how can I help you this morning?
[CUSTOMER][NEUTRAL] Just trying to see um on one of our customers would processed on one of our claims.
[AGENT][NEUTRAL] Sure, you need me to check claim status on a member, is that correct?
[CUSTOMER][NEUTRAL] Please, yes, ma'am.
[AGENT][NEUTRAL] Yes, sir. I can help you. So go ahead and give me your callback number, [PII].
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Thank you and the member's policy number?
[CUSTOMER][NEUTRAL] It's 258-024-5.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK thank you one moment while I get the member's information pulled up.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK, and then the information provided would be a verification of benefits and not a guarantee of payment. What is the patient's name, [PII], and their date of birth?
[CUSTOMER][NEUTRAL] [PII] in [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. And then if you'll verify the group name and your email.
[CUSTOMER][NEUTRAL] It's South Louisiana Medical Associates and it's [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. So one moment.
[AGENT][NEUTRAL] And what's the date of service [PII] and total bill amount for her?
[CUSTOMER][NEUTRAL] Mm, let's see.
[CUSTOMER][NEUTRAL] This last claim, I think the date of service is [PII].
[AGENT][NEUTRAL] Of this year?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And do you have the bill amount?
[CUSTOMER][NEUTRAL] It should be the one I just processed yesterday, um.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] To on the bill might say 13,946.
[AGENT][NEUTRAL] 13 9 46.
[CUSTOMER][NEUTRAL] Yes ma'am, it's the end of the claim number is 22523.
[AGENT][NEUTRAL] I see.
[AGENT][NEUTRAL] OK, all right, just one moment.
[AGENT][NEUTRAL] OK, so there were two dates of service on this policy, I mean, I'm sorry, on this claim, [PII], um, there was 1 for 31 that claim, that part of it was denied.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see what the reason on that was.
[AGENT][NEUTRAL] For the [PII] data service, it states the hospital admission benefit is payable. When admitted to a hospital and combined as an inpatient, this benefit is not payable for outpatient treatment, emergency room treatment, or a stay of less than 18 hours in an observation unit. So that was for the 31.
[AGENT][NEUTRAL] You know, on the.
[AGENT][NEUTRAL] 33 let me pull that because it's also on the same claim, but just one second.
[AGENT][NEUTRAL] OK, so on that we did.
[AGENT][NEUTRAL] We did pay a benefit of 1700 even.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we pay the admission benefits and the 2 nights in the hospital. I, I was reading this bill. I was trying to understand, she, it says she was in there at the top from.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] 32 to 35, so I guess the first day.
[CUSTOMER][NEUTRAL] They had just said they were just observing her.
[AGENT][NEUTRAL] They had her as observation. Correct. They did not have her as an inpatient. So, yes, there was a 900, um, now, on the surgery.
[CUSTOMER][NEUTRAL] OK, that's fine.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see, that part of it has been denied, so let me look.
[AGENT][NEUTRAL] No benefits are payable for any loss resulting from or caused, whether directly or indirectly by artificial insemination, in vitro fertilization, test tube fertilization, sterilization, tubal ligation, or vasectomy, and reversal thereof. So that was the surgery part was not.
[AGENT][NEUTRAL] That was the 924. 50 charge.
[CUSTOMER][NEUTRAL] I've never heard of that before.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Never heard of this before, so she had a baby.
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] Mhm. But uh, did, did she have a tubal ligation?
[CUSTOMER][NEUTRAL] And they're saying
[CUSTOMER][NEUTRAL] They're asking how she got pregnant.
[AGENT][NEUTRAL] No, no, no, no. Did she, if this indicates that she may have had like a tubal or
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] Uh, some type of cerebral sterilization.
[AGENT][NEUTRAL] Like she had her tubes tied or something like that. I don't know. It's sterilization though is not covered.
[CUSTOMER][NEUTRAL] I don't, I don't know.
[AGENT][NEUTRAL] Under this policy.
[CUSTOMER][NEUTRAL] But the actual having of the baby, which is the surgery they're actually claiming on is the actual birth of the baby, not the, if there's anything else on there after the fact, you know what I mean?
[AGENT][NEUTRAL] Right. See, right, but it was all on there, so it's all gonna get reviewed.
[CUSTOMER][NEUTRAL] You see what I'm saying?
[AGENT][NEUTRAL] So on the hospital benefit, it, there was a $1500 benefit paid on the hospital admission benefit, and then the daily hospital benefit paid $200.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I see another claim that was on here and I'll, I'll deal with the surgery part, um, do.
[CUSTOMER][NEUTRAL] There was a claim before that that says 116.
[CUSTOMER][NEUTRAL] It ends in 524.
[AGENT][NEUTRAL] Alright, give me just a second there.
[AGENT][NEUTRAL] Let me, let me make one more remark on this 11 2nd, [PII].
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] And I've never had anything with a pregnancy. All my pregnancy claims normally go super smooth. That's why I was trying to figure out what um what they were trying to say on there. So basically, what I understand some women do is when they have the baby, they know it's their final baby while they're in there, they'll do like a tubes tied or something like that, but that's
[AGENT][NEUTRAL] Right, and that's not covered.
[CUSTOMER][NEUTRAL] Two surgeries that happen at the same time. Right. But the actual birth of the baby is covered, correct? Like the surgery to remove the baby, whether it be C-section or regular birth?
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] It's in my opinion that like a vaginal delivery is not considered surgery.
[CUSTOMER][NEUTRAL] You see what I'm saying they did it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That's my understanding.
[AGENT][NEUTRAL] Uh, if it were a C-section, yeah, that would be different, but yeah. So, OK. Alright. So give me just a second to pull up that other claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I'll I'll check on that, no problem.
[AGENT][NEUTRAL] And you said it was ending in 24, OK.
[AGENT][NEUTRAL] This is for 114?
[AGENT][NEUTRAL] So 1:15.
[CUSTOMER][NEGATIVE] It it's not letting me pull it up. It says no files on my side because I can't see the EOB.
[AGENT][NEUTRAL] OK, let's see so.
[CUSTOMER][NEUTRAL] But I know it says they received 116.
[AGENT][NEUTRAL] OK, so on that claim it was.
[AGENT][POSITIVE] Goodness.
[AGENT][NEUTRAL] OK, it shows that that was denied and let me pull the remark.
[AGENT][NEUTRAL] Again, this goes back to the same remark as at first when I read you about the hospital admission benefit is payable when admitted to a hospital and confined as an inpatient. This patient isn't, I mean, this benefit is not payable for outpatient treatment, emergency room treatment, or a stay of less than 18 hours in an observation unit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] On that one, OK, so that was the one. Now what would they normally pay the $100 hospital or urgent care, I'm sorry, ER or urgent care benefit there?
[AGENT][NEUTRAL] Mm. Now, [PII], um, on that, I would have to let you speak to one of the examiners on that.
[AGENT][NEUTRAL] To look at the information that was received.
[CUSTOMER][POSITIVE] OK, sure, that'd be perfectly fine.
[AGENT][NEGATIVE] Cause it, it said, well, it says no, emergency room treatment is listed in this remark. It's not being covered.
[AGENT][NEUTRAL] Uh, well, under the hospital admission benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The same
[CUSTOMER][NEUTRAL] Yeah, under the admission, but this plan is built in ER and urgent care benefits.
[CUSTOMER][POSITIVE] That's why I said this one seems kind of funny and then the other one.
[AGENT][NEUTRAL] OK, so let me
[CUSTOMER][NEUTRAL] There's something else there's another that's the same claim number, OK.
[AGENT][NEUTRAL] Yeah, it's 3 line items under the same, right, uh-huh. 258.
[CUSTOMER][NEGATIVE] It just shows up 3 times.
[AGENT][NEUTRAL] Maybe there were 3 separate things sent in for that. I'm not sure.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] 3 uploads for that same claim. I'm, I'm pulling up this policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, the way it's built, they get $50 twice a year if they go to the doctor, $100 twice a year if they go to the ER, the urgent care.
[AGENT][NEUTRAL] Right, let's see, let's see, this is $100 for emergency room. It's $100 per day, maximum of 1 day per calendar year per covered person. Urgent care is $100 per day, maximum of 2 days per calendar year per covered person.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] So this was an emergency room visit?
[CUSTOMER][NEUTRAL] I can't see it on here, but um.
[CUSTOMER][NEUTRAL] I thought that it was normally I can see it, but it's where it says view file it says no files, so for some reasons.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, OK, I don't know.
[CUSTOMER][NEUTRAL] Now let me see it.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] See what I can see.
[AGENT][NEUTRAL] According to the note, it was observation. It, I don't see.
[CUSTOMER][NEUTRAL] OK, I found some of it. OK, I found some of this this was an accident.
[AGENT][NEUTRAL] I don't see ER, yeah, I don't see.
[CUSTOMER][NEUTRAL] I found that she fell. She fell while she was pregnant.
[CUSTOMER][NEUTRAL] The, it happened on [PII]. She had an injury, so this may have fell under her accident plan, but they're still supposed to pay on the hospital twice, um, because I do these all the time, let's see.
[CUSTOMER][NEUTRAL] Take a look.
[CUSTOMER][NEUTRAL] I got the 2nd attachment on the email right here.
[AGENT][NEGATIVE] It's not at all.
[CUSTOMER][NEUTRAL] It may have been processed under the accident plan possibly.
[AGENT][NEUTRAL] Just says, says overnight observation. I don't.
[AGENT][NEUTRAL] I'm not seeing.
[AGENT][NEUTRAL] I just, I'm not seeing [PII] where it shows emergency room.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] On the, on this information, um.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] Yeah, I, I don't see that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I will go find my notes and I'm gonna go try to find the um.
[CUSTOMER][NEUTRAL] The Actual itemized bill because I see some different diagnosis and stuff but I don't see the itemized bill on here so.
[AGENT][NEUTRAL] Yeah, I'm not saying.
[CUSTOMER][POSITIVE] I will uh I will work on that, no problem.
[AGENT][POSITIVE] OK. All right. Well, is there anything else at the moment? Oh, sure. You're very welcome. So uh that's it for this morning. Well, call us back if you have anything else we can help you with. You're certainly welcome. It's always a pleasure to speak to you. You're welcome and I hope you have a great day, [PII].
[CUSTOMER][POSITIVE] I, I appreciate you.
[CUSTOMER][NEUTRAL] That's it.
[CUSTOMER][POSITIVE] Yes ma'am, I appreciate you.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Yes, sir. Thank you too.
[CUSTOMER][POSITIVE] Take care bye bye.
[AGENT][POSITIVE] Bye bye. You too. Bye-bye. Thank you for calling APL.
[CUSTOMER][POSITIVE] Thank you.