AccountId: 011433970860
ContactId: 6118ed6b-8d34-4070-9593-ab2c68451526
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 984700 ms
Total Talk Time (AGENT): 273499 ms
Total Talk Time (CUSTOMER): 347208 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/07/6118ed6b-8d34-4070-9593-ab2c68451526_20250407T14:24_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] I don't want that feedback. Let's see.
[CUSTOMER][NEUTRAL] Can you hear me OK?
[AGENT][POSITIVE] Yes, I can.
[CUSTOMER][NEUTRAL] All right, I filed a claim for some, some procedures I had done and it's showing that.
[CUSTOMER][NEGATIVE] Um, it's not gonna cover anything and before I had these tests done, I called the claims department and I was told that um there was no uh limitation like I didn't have to get preapproval I could go anywhere I wanted to for test and just submit the claim and now I'm getting that benefits don't cover anything, so I'm I'm just a little confused as to why the um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] But
[CUSTOMER][NEUTRAL] The tests that I had done are not covered. I mean, what's the purpose of the insurance is.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You say that it says that I can go anywhere, just file a claim and then um.
[CUSTOMER][NEGATIVE] I paid out of pocket for these tests and nothing is covered. I'm, I'm just a little confused.
[AGENT][NEUTRAL] OK, do you have your policy number and I can check on the claims for you.
[CUSTOMER][NEUTRAL] Yes, the policy number is.
[CUSTOMER][NEUTRAL] 02591638
[AGENT][NEUTRAL] OK, Ms. [PII], I just need to verify a few pieces of information. Um, could you give me your birth date, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And your address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And then lastly, lastly, I just need your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] OK and then what date of service was this for?
[CUSTOMER][NEUTRAL] Um, this started on, um, [PII].
[CUSTOMER][NEUTRAL] I mean, I asked cardiovascular group twice to send me um an itemized bill without the [PII] and [PII] information on there but I was not trying to get any uh I had insurance at that time so those things should need to be on there anyway.
[AGENT][NEUTRAL] And.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let me see.
[AGENT][NEUTRAL] OK, yeah, I see a few dates prior to [PII] when the policy took effect.
[AGENT][NEUTRAL] Um, so let's see.
[AGENT][NEUTRAL] OK, let me pull up your policy.
[CUSTOMER][NEUTRAL] Should be from [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, give me just a moment. I'm pulling up your policy to see what's on the plan.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] OK, so you have a hospital indemnity policy, um.
[AGENT][NEUTRAL] Let me pull that up.
[AGENT][NEUTRAL] OK, it looks like one of these charges you had submitted was for an office visit.
[AGENT][NEUTRAL] Um, it looks like the only thing.
[CUSTOMER][NEUTRAL] Two of them
[AGENT][NEUTRAL] OK, so office visits are not covered under the policy?
[AGENT][NEUTRAL] Um, let me see.
[AGENT][NEUTRAL] I'm also pulling up what you had submitted, so let me get that too.
[AGENT][NEUTRAL] No wait, let's see.
[AGENT][NEUTRAL] OK, actually, let's see, I do see.
[AGENT][NEUTRAL] There's a benefit for 3 office visits per calendar year.
[AGENT][NEUTRAL] Let me see, well, let's see what happened here, um.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Can I place you on a brief hold, Ms. [PII]?
[CUSTOMER][POSITIVE] Yes, that's fine, thank you.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What did this one do? This is DH.
[AGENT][NEUTRAL] 2070.
[AGENT][NEUTRAL] Where is the policy certificate?
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK, I'm so sorry about that um OK so.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It looks like, so the office visits were denied because it has to be due to an accident.
[AGENT][NEUTRAL] So it has to be an accident diagnosis.
[AGENT][NEUTRAL] Um, did you, did you go to the doctor for an accident?
[AGENT][NEUTRAL] Or was it
[CUSTOMER][NEUTRAL] I did. I had a.
[CUSTOMER][NEUTRAL] Um, I was T-boned on [PII].
[CUSTOMER][NEUTRAL] And after that particular accident, um.
[CUSTOMER][NEUTRAL] My blood pressure continued to.
[CUSTOMER][NEUTRAL] To elevate and so the day I went on the [PII] when I went to the doctor.
[CUSTOMER][NEUTRAL] Uh, my blood pressure was 180/110.
[CUSTOMER][NEUTRAL] And so I went to uh
[CUSTOMER][NEUTRAL] Lawrenceville Family Practice and they did an EKG and it was out of whack and that's how I ended up going back to the cardiologist because they were trying to find out what was going on with the blood pressure.
[CUSTOMER][NEGATIVE] Uh, why was it elevating and then why my EKG did not turn out, uh, well, my first stress test, I failed it. So, um, all of this was due to the accident.
[CUSTOMER][NEUTRAL] On the [PII], but at the end of the day, when I called the claims department, I was told you can go anywhere you want to.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEGATIVE] Um, just filed a claim. So if, if I had known that it wasn't gonna pay anything, I mean, why do I have insurance that is not gonna pay on anything and I'm paying the premium and still having to pay out of pocket for for test? I mean, all of this came about due to uh a car accident. I was perfectly fine before that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And so, um, now I don't know, um.
[CUSTOMER][NEUTRAL] I wouldn't know, you know, to, to order these tests to, to check my heart because my heart rate was elevated as well, uh, before.
[CUSTOMER][NEUTRAL] Uh, due to me, uh, after having the, the accident. It was elevated at one point and then it was dropping low. So I mean, like I said, the cardiologist was, is a specialist and the insurance and when I called claims before I committed to any of these tests. Now I went to the, to the doctor. I did not know doctors uh visits were not covered. I didn't know that. And I mean that's.
[CUSTOMER][NEUTRAL] That's probably the smallest amount paid, but one of those tests was $754.
[AGENT][NEUTRAL] OK, well, that's
[CUSTOMER][NEUTRAL] And I just, I guess I just don't understand how if, if it wasn't going to be, you know, covered or paid at some part 80, 20 or 70, I don't know. I mean, I guess I, I don't know what I would have done. I guess maybe I would have tried to just go somewhere else or, but I didn't. I was familiar. This is the cardiologist I've always used.
[CUSTOMER][NEUTRAL] And at the end of the day when I called, I was told, well Miss [PII], you can go wherever you want to go, just do an itemized bill and and send it in to the claims department. So that led me to believe that some of my money would be recouped from these tests.
[AGENT][NEUTRAL] I part of it is let me see what they filed for.
[AGENT][NEUTRAL] OK, so
[AGENT][NEUTRAL] Part of what we need in order to consider these is something that indicates this was related to an accident and that's what we're missing, um, because the diagnosis is that we're on.
[AGENT][NEUTRAL] The claims that were filed didn't indicate anything about an accident. So, if there's some documentation that you could get from your healthcare provider,
[AGENT][NEUTRAL] Um, that mentions that this was related to just what you explained, um, an accident in January, then these could possibly be reconsidered. So that's, that's a big piece, that's a piece of what we're missing is that
[AGENT][NEUTRAL] We don't have any accident diagnosis tied to these claims.
[AGENT][NEUTRAL] So, um, what I would do is I would contact the cardiovascular center that you went to and see if they maybe could provide notes or something like you said because I, I assume if you discuss that uh the accident with them, it should be in your it should be in your documentation somewhere with them.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well, I will, I will call them, um.
[CUSTOMER][NEUTRAL] And then what I need to fax that over is that to anyone in particular?
[AGENT][NEUTRAL] No, that goes directly
[CUSTOMER][NEUTRAL] So that, you know, you know.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It goes directly to our clients.
[CUSTOMER][NEUTRAL] Beg your pardon.
[AGENT][NEUTRAL] It'll go directly to our claims department. I would just reference the claim um this claim number that you have you have the explanation of benefits in front of you, the denial.
[CUSTOMER][NEUTRAL] I do, mhm.
[AGENT][NEUTRAL] OK, yeah, just referenced that claim number that 3581133, but like I said, if we can get documentation that shows that this was related to an accident that this could be reconsidered.
[CUSTOMER][NEUTRAL] Yeah, well, I didn't have any of this going on, you know, before, but I, I understand what you're saying, so I guess.
[CUSTOMER][NEUTRAL] I will call them and uh.
[CUSTOMER][NEUTRAL] And see, I mean, I don't, uh, when you say an explanation, will it be the same as the.
[CUSTOMER][NEUTRAL] The itemized bill thing or you need notes what what um what do you need?
[AGENT][NEUTRAL] Yeah, they should have some type of document or notes from your file that because they have to like when you go to the doctor they'll typically take notes at length about what you know what you're discussing so there should be some type of notes um doctor's notes that show you discussed with them this was due to a motor vehicle accident.
[AGENT][NEUTRAL] Um, and that, you know, that's really what we need or they would just need to refile the claim.
[AGENT][NEUTRAL] Or show that there's an accident diagnosis. So, some type of documentation, again speaking to that, that this would be due to an accident, not just a regular sickness.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, well I will um.
[CUSTOMER][NEGATIVE] I will get in touch with them and try to get that back over just it takes them so long just to even send itemized bills which I don't understand that either.
[AGENT][NEUTRAL] Do you have, did they give you like uh can you get access to like a portal through their system? You might be able to have some luck there like an online system through their facility um because then you can look through like notes and stuff like that because I don't know if they have like a my chart or something like that where you can log into their system and look at um information.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Let me, um, I don't have it with cardiovascular group, but originally I went to uh Lawrenceville Family Practice. That's where they did the first EKG that I failed and then they referred me to um
[CUSTOMER][NEUTRAL] Cardiovascular because that's who I was going to, you know, in the past.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So let me see if I can pull up anything on the portal from there.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh we'll go from there.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, sounds great.
[AGENT][NEUTRAL] OK, is there anything else I
[CUSTOMER][POSITIVE] Alright thank you so much I appreciate your name.
[AGENT][NEUTRAL] Uh, my name is [PII].
[CUSTOMER][NEUTRAL] No, ma'am, I was just asking.
[CUSTOMER][POSITIVE] Thank you, [PII]. I appreciate it.
[AGENT][POSITIVE] Well, thank you, Ms. [PII]. I hope you have a great day.
[CUSTOMER][POSITIVE] Thank you. You too.
[AGENT][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Bye bye.