AccountId: 011433970860
ContactId: 5d8fd95d-8b82-4d96-87b5-a637fadc99c6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 727539 ms
Total Talk Time (AGENT): 214932 ms
Total Talk Time (CUSTOMER): 212303 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/06/5d8fd95d-8b82-4d96-87b5-a637fadc99c6_20250106T15:47_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I'm the plan administrator for Shepard, and I have an uh employee, um, that wants to go over why her benefits were not paid.
[AGENT][NEUTRAL] OK. And what is the, um, your group number, please?
[CUSTOMER][NEUTRAL] Uh, the group number for let me see, um, 17273.
[AGENT][NEUTRAL] OK, let me look that up real quick.
[CUSTOMER][POSITIVE] Thanks.
[AGENT][POSITIVE] You're very welcome.
[AGENT][NEUTRAL] OK, and what is your name, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, Ms. [PII], what is the um insured's name?
[CUSTOMER][NEUTRAL] Yeah, I'll, I'll give her her information, um.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and do you have her, uh, policy number?
[CUSTOMER][NEUTRAL] Well, our policy numbers all the same. We don't have policy numbers for APL. We're we're all the same number.
[AGENT][NEUTRAL] OK. You don't have her individual policy number for her coverage?
[CUSTOMER][NEUTRAL] We don't have individual policy numbers for that. We don't have individual policy numbers for APL.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, alright. And then um one quick verification, Ms. [PII], can you verify the physical address for your group?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Thank you I appreciate you doing that.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Let me look real quick and.
[CUSTOMER][NEUTRAL] I mean, I, I have a bill. She's right in front of me, so she had received a bill. She had something done Gastrohealth, and it was done on let me see what day was this data of service.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Data service. Let me see data service. Oh, here [PII] go by the data service. Oh yeah, [PII].
[AGENT][NEUTRAL] OK, thank you. And then, uh.
[CUSTOMER][NEUTRAL] And it was with the, yeah, go ahead.
[AGENT][NEUTRAL] Do you see a um claim number on that paperwork that you received?
[CUSTOMER][NEUTRAL] I have an account
[CUSTOMER][NEUTRAL] I have an account number.
[CUSTOMER][NEUTRAL] Will that help?
[AGENT][NEUTRAL] Um, I've got her policy pulled up. Let me see, uh, do you know?
[CUSTOMER][NEUTRAL] Account number.
[AGENT][NEUTRAL] Yes, ma'am. Go ahead.
[CUSTOMER][NEUTRAL] And I see a claim number here.
[AGENT][NEUTRAL] A claim reference number?
[CUSTOMER][NEUTRAL] It says gastrointestinal procedure 43251.
[AGENT][NEUTRAL] OK, and what's the charge amount? Does it have an amount on there? You said the data service was 116 of 24.
[CUSTOMER][NEUTRAL] Yeah,
[CUSTOMER][NEUTRAL] Yeah, it just says.
[AGENT][NEUTRAL] What is the
[CUSTOMER][NEUTRAL] It says the amount you owe is 246.76. The subtotal billed was $2,813 and the insurance covered 2,566.24.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] OK, alright, let me see if I can't find that claim real quick for you so we can see the remarks on it and get some answers for her. Oh, you're very welcome.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] OK. Thank you.
[AGENT][NEUTRAL] OK, I'm gonna put you on a brief hold because there's several different um procedure codes that I need to add up to to match that total that you gave me so it's gonna be a brief hold. Thank you, ma'am.
[CUSTOMER][NEUTRAL] Yeah, it's fine.
[CUSTOMER][NEUTRAL] Sure, sure.
[CUSTOMER][NEUTRAL] Sure, yeah.
[CUSTOMER][NEGATIVE] That you are on hold.
[AGENT][NEUTRAL] 43254.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 5
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 42
[AGENT][NEUTRAL] Hello, this is [PII] back with you again, Ms. [PII].
[AGENT][NEUTRAL] I did find the claim. The claim number is 342-722-0.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And the reason why it wasn't paid was because the maximum benefit payable for that date of service had been met, so she had maxed out her benefits for the day.
[CUSTOMER][NEUTRAL] And what was the what
[CUSTOMER][NEUTRAL] Well, for the day?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Or is it, isn't it for the year?
[AGENT][NEUTRAL] For the day.
[CUSTOMER][NEUTRAL] I thought I, I thought our our plan was for the year. It was in $1000 is it $1500?
[CUSTOMER][NEUTRAL] A year
[AGENT][NEUTRAL] Let me look and see for outpatient what it is.
[AGENT][NEUTRAL] For outpatient she has the $500 per calendar day.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Calendar day
[CUSTOMER][NEUTRAL] But she, how did she use it for that day?
[AGENT][NEUTRAL] She had many charges on that day that were for outpatient. I can if you would like I can go ahead and transfer you on over to a claims examiner and they can break down exactly what was paid for for the day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so, but what was that's what I'm understanding. Hold on, hold on. Let me ask, OK, OK, so, so the, where is it?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] This doesn't say it, hold on.
[CUSTOMER][NEUTRAL] All right, I have, I have here, hold on.
[CUSTOMER][NEUTRAL] Not sure. Hold on.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] I want to explain this to her because I have to explain it to her and
[CUSTOMER][NEUTRAL] I know you're gonna help me with this that hold on.
[CUSTOMER][NEUTRAL] Where do I put it? I can see how.
[CUSTOMER][NEUTRAL] Hold on.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] No, the LTB.
[CUSTOMER][NEUTRAL] Just had it. Hold on uh.
[AGENT][POSITIVE] Yes ma'am, go ahead and take your time.
[CUSTOMER][NEUTRAL] Thank you. Just have the document in front of me and I'm like.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] I'm free.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] OK, I have here right that we have outpatient. It was an outpatient, so this is an outpatient service, correct?
[AGENT][NEUTRAL] Yes, it was filed under outpatient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so it's $500 per person per calendar day. What does that mean per calendar day? For every day that you're there they only meet up to $500?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] That's, so why is it when she received her bills?
[CUSTOMER][NEUTRAL] And it doesn't say it says APL 0.
[AGENT][NEUTRAL] Um, that is something that we'll have to ask a claims examiner. There's only so much that I'm allowed to see on my screen, but we can get you on over to the claims examiner and they can help you further, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright, thank you, thank you.
[AGENT][POSITIVE] You're so welcome, Ms. [PII]. You have a blessed day and thanks for calling APL.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right. Thank you, bye bye.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] Referring.
[CUSTOMER][POSITIVE] Thank you for calling American Public Life. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], this is [PII], uh, in the care team. I've got Miss [PII], she's a broker on the phone with the insured, um, Edith Morales. Let me give you the policy number.
[CUSTOMER][NEUTRAL] OK, hold one moment, I'm sorry, you said her name is [PII]?
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] Yeah, [PII] is the is the um contact person for the group, yes ma'am.
[CUSTOMER][NEUTRAL] Broker.
[CUSTOMER][NEUTRAL] OK, and what is the policy number?
[AGENT][NEUTRAL] It's 2217.
[AGENT][NEUTRAL] 5442.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And they are calling about claim number 342-7220.
[AGENT][NEUTRAL] I read the remarks to them that they had maxed their benefits for the day and explained that was $500 500 dollars per calendar day, but she still has further questions about.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Why we didn't pay.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I'm transferring her on over to you guys so you can explain it to her further.
[CUSTOMER][NEUTRAL] OK, you can send her over.
[AGENT][POSITIVE] OK, thank you. Bye bye.
[CUSTOMER][NEUTRAL] Bye.