AccountId: 011433970860
ContactId: 58f76433-4b86-4f62-90b5-d356fd3c46c6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 951280 ms
Total Talk Time (AGENT): 288513 ms
Total Talk Time (CUSTOMER): 353295 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/17/58f76433-4b86-4f62-90b5-d356fd3c46c6_20250317T20:28_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] You said your name is [PII]?
[AGENT][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] Oh, OK. No, I have a niece named [PII] as well.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] My name is [PII], and I wanna ask some questions about, I guess some appointments that I went on. I have the APL insurance and I received the check.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I need to question like a physical therapy appointment that they did not, I guess, account for.
[CUSTOMER][NEUTRAL] Some of my payment and I thought I had 5 appointments.
[AGENT][NEUTRAL] OK, I can check on that for you, Miss [PII]. Um, may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you. And do you have the policy number?
[CUSTOMER][POSITIVE] Yes, I do.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 05, no ma'am I'm sorry, sorry.
[CUSTOMER][NEUTRAL] Start over.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 02590118
[AGENT][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] Alright, may I have um your date of birth, mailing address and email address for verification?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] What do you need? What else?
[AGENT][NEUTRAL] Mailing address and email address on file. Mhm.
[CUSTOMER][NEUTRAL] Address
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, so I do see some benefits here and you said that there's some that we did not cover.
[CUSTOMER][NEUTRAL] Yeah, I mean like on the set, do you have everything pulled up like I do as far as what what what they sent me a check for?
[AGENT][NEUTRAL] OK, um, I have some info. Let me go ahead and pull the same explanation of benefits that you're looking at. Let me pull the document you're looking at, OK, one moment.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Alright, oh, that's the claim.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, I'm so sorry, it's taking a little bit to pull up.
[CUSTOMER][POSITIVE] No, take your time.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so here it is. OK, so I'm looking at the same document that you are.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK. I just want to question [PII].
[AGENT][NEUTRAL] OK. So, um, and the what
[CUSTOMER][NEUTRAL] That was the office visit?
[AGENT][NEUTRAL] Of.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, so the
[CUSTOMER][NEUTRAL] [PII]. Mhm.
[AGENT][NEUTRAL] Mhm, for that one we pay $50 which is the maximum benefit for an office visit.
[CUSTOMER][NEGATIVE] I don't see it on my end in reference to it being paid.
[AGENT][NEUTRAL] Are you looking at
[CUSTOMER][NEUTRAL] Oh, wait a minute, wait a minute.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. They had the 1st 10, but then I, OK, I see it. So I can scratch that one out. OK. The second one.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII]. That's physical therapy.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII]. OK, so we pay that one, let's see.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] On the [PII] of
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We pay $50 for that one for [PII].
[CUSTOMER][NEUTRAL] $15 no.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] For what date you have?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] That's physical therapy.
[AGENT][NEUTRAL] OK. We have one for $15 which is for the physical therapy, and then we have one for the office visit, which is the $50. So we have the office visit and the physical therapy.
[CUSTOMER][NEUTRAL] OK, for the [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]. OK, let me check [PII].
[AGENT][NEUTRAL] OK, so that one was denied. OK, so let me see why this one. OK, so that one did not pay because with the payment of the other ones that we send out the calendar year maximum has been exhausted.
[CUSTOMER][NEUTRAL] What's the max? I thought I'd get 5.
[AGENT][NEUTRAL] OK, let me check and see.
[CUSTOMER][NEUTRAL] Yeah, I get 5 physical therapy office visits.
[AGENT][NEUTRAL] OK. Let me check and see how many you can get a year for physical therapy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Physical speech, occupational therapy, physical therapy, $15 per day, max of 5 days.
[AGENT][NEUTRAL] Mhm. Yes, that is correct. Let me see when we pay the other ones. Let me go ahead and pull the history on the payments. One moment.
[CUSTOMER][NEUTRAL] There were 3 that were paid, looking at it from
[CUSTOMER][NEUTRAL] My
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] OK, so on that one, I'll have to probably send it back to the examiner because I do also see 3.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, uh, I'll have um two options. Either I can send it back to the examiner or I can try to get them on the line for you. Which one would you like me to do?
[CUSTOMER][NEUTRAL] Which one is convenient for you? How long will the examiner be on the line? I mean, how long will it take you?
[AGENT][NEUTRAL] OK, um, to request for this to be reviewed, I just send the request in, and, um, so it will be 24 to 48 hours before they go ahead and check on the claim and see if they need to reprocess. Um, if I put you through an examiner, they probably will tell you the same thing or give you a little bit more information if they have any other information to give you. So I don't know which one would you like.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, go ahead and, um,
[CUSTOMER][NEUTRAL] Sure, go ahead and transfer me.
[AGENT][NEUTRAL] OK, so let me get a specialist, claims specialist on the line.
[CUSTOMER][NEUTRAL] And can you also, yeah, is there a number that just in case we get disconnected?
[AGENT][NEUTRAL] It's gonna be the same number and you just ask for the claim uh uh specialist.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so let me get that support team, current support team on the line, one moment, OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Deering.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], how are you? This is [PII].
[CUSTOMER][POSITIVE] I'm good how are you so?
[AGENT][NEUTRAL] I'm good, I'm good, thank you. I have a question. Are, are you, um, is the claim support also handling right now the HI and the accident, right?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, good. All right. I have a member on the line with an HI and um she submitted a claim and it looks like she's saying that it's not fully paid that um we pay only 3 physical therapists and it's supposed to be 5.
[AGENT][NEUTRAL] And yeah, I told her I can send her a request to have it reprocessed and she said she wants somebody in the claims department to assist her.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, can I get that policy number?
[AGENT][NEUTRAL] Yes, 2590118.
[CUSTOMER][NEUTRAL] OK, so 21.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] OK, we pay up to 5 at $15.
[CUSTOMER][NEUTRAL] Each $15 per visit.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Max is 5, OK.
[CUSTOMER][NEUTRAL] Sorry, I'm just trying to get my thoughts together.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, I did check on it too just to make sure, but yeah, I only found 3 as well, so I'm like.
[CUSTOMER][NEUTRAL] OK, did, did you happen to notice when you were looking if there were 5 dates that could be paid?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Um, yeah, we denied, um, I think we denied two of them, saying that she used the maximum which that will not be true if we only paid 3.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right, OK, so PT we paid 17 of 25, 113.
[CUSTOMER][NEUTRAL] And 1:15.
[CUSTOMER][NEUTRAL] And then we did not 120.
[AGENT][NEUTRAL] The 120. Mhm. So just one more, I guess, yeah, I was just checking.
[CUSTOMER][NEUTRAL] And 220 I guess.
[AGENT][NEUTRAL] Mhm. Oh yeah. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah and it doesn't look like we've paid anything prior to this, nor did she have a policy prior to this, so.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I mean I'll talk to her but it looks like this needs to be sent back for review.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, that's the, yeah, I told her that that's what probably we need to do, but she still wanted to ask, talk to you, so let me go ahead and transfer her, OK? All right, thank you. Here she comes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, that's fine sure.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][POSITIVE] Thank you for holding and being patient for you, Ms. [PII]. I got Ms [PII] on the line. She's in the claims department and she's gonna assist you from here.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] You're welcome. Have a good afternoon.
[CUSTOMER][NEUTRAL] Uh, you too.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Hi Miss [PII], this is [PII]. How are you?
[CUSTOMER][POSITIVE] How you doing, [PII]? I'm doing well.
[CUSTOMER][NEUTRAL] Um, go ahead. OK, she probably explained it to you. She did, she did.
[CUSTOMER][NEUTRAL] Um, and what I'm looking at, um, I can see what you're talking about. Your policy does indicate a max of 5. it looks like we only paid 3 dates and we denied the other ones as the maximum for the benefit had been exhausted, um, so what I will have to do is, um.
[CUSTOMER][NEUTRAL] Send this back to the examiner that processed it and have them um review and reprocess this claim.
[CUSTOMER][NEUTRAL] OK, so, um.
[CUSTOMER][NEUTRAL] 123 that would be 4. I know I have physical therapy tomorrow, so that would be my last one tomorrow, correct?
[CUSTOMER][NEUTRAL] Um, so it looks like, let me, let me find the dates where we paid because it looks like we denied 120 and 220 which would equal your 5.
[CUSTOMER][NEUTRAL] But I'm gonna double check. OK, OK. Yeah, just because I'm not, I, I haven't looked through every single document so let me find those dates. OK, let's see general visit.
[CUSTOMER][NEUTRAL] Uh, PT, OK, so it looks like we paid 17, 113, and 115, and then we denied 120 through 220, which would be.
[CUSTOMER][NEUTRAL] 123456789 10 additional PT business. You know what I I you know what I did my my that was my bad because I sent all the dates, but I see what you're OK. Yeah, yeah, all the dates were sent in um on on that one client on that one document and so we did not.