AccountId: 011433970860
ContactId: 637c6d28-25d8-48a0-90ca-4b7104e0c30c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 470100 ms
Total Talk Time (AGENT): 129164 ms
Total Talk Time (CUSTOMER): 114554 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=-1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/20/637c6d28-25d8-48a0-90ca-4b7104e0c30c_20250320T20:48_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] Hi, my name is [PII]. Um, I submitted a claim and I'm just checking on the status because I keep getting a text message that says my claim was completed, but when I go online, I don't see anything, so I'm just checking.
[AGENT][POSITIVE] OK, sure. I can assist you. And may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, may I have the policy number?
[CUSTOMER][NEUTRAL] May you have the what?
[AGENT][NEUTRAL] Policy number?
[CUSTOMER][NEUTRAL] One second please.
[AGENT][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] So I can pull that up.
[CUSTOMER][NEUTRAL] I have a claim number. I don't think I have a policy number.
[AGENT][NEUTRAL] OK, go ahead with the claim number.
[CUSTOMER][NEUTRAL] Claim number is 3,577,820.
[AGENT][NEUTRAL] OK, thank you. One moment. Let me pull that.
[AGENT][NEUTRAL] Coming first.
[AGENT][NEUTRAL] OK. May I have your date of birth, mailing address and email address for verification?
[CUSTOMER][NEUTRAL] Date of birth is [PII], and you said email address?
[AGENT][NEUTRAL] Yes, email address and mailing address.
[CUSTOMER][NEUTRAL] Email address is [PII].
[CUSTOMER][NEUTRAL] And mailing address is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] OK, so it looks like it was denied. um, let me pull the details one moment.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Do you mind holding for me just a minute, I'm just gonna review the claim for a minute.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding. OK, uh Miss uh [PII], um, it looks like, um, we already processed the claim and pay that claim. That's why the most recent one was denied because the maximum benefit has been exhausted. Uh, we send this payment out on [PII].
[CUSTOMER][NEUTRAL] OK, one second. What's the maximum um uh benefits?
[AGENT][NEUTRAL] Maximum benefit is 4000 per calendar year for outpatient service.
[CUSTOMER][NEGATIVE] I don't, I don't understand because my, I have signed up for a plan that covers $7000 deductible and anything that they have to pay. That's the most expensive APL plan that I signed up for with my um employer.
[CUSTOMER][NEUTRAL] So, um, I had a procedure done at an outpatient, um, facility where the deductible was 2 $2500 or some change. So even if that was paid out, I still have, uh, a substantial amount to cover anything else. The doctor did not take your insurance, the APL when I called.
[CUSTOMER][NEGATIVE] The APL to explain to them how I have this bill for 1000 and change that I need to pay and the doctor is not taking it. I explained everything to the lady. The first bill had been processed. She's the one that said, Well, you, if I pay out of pocket, I can file a claim to get reimbursed, which is what I'm doing. So how can the claim be denied? How can I meet my maximum benefit? I don't understand.
[AGENT][NEUTRAL] OK. Um, let me go ahead and give you a breakdown of your benefits, and this is not a guarantee of payment, just a verification of coverage and that's just a disclaimer. So, um, you have two benefits. You have an inpatient benefit if, if you're in the hospital 18 hours or more, either observation or hospitalization. You have 7900 for the inpatient benefit. Um, now, you have uh an additional benefit which is for outpatient.
[AGENT][NEUTRAL] The outpatient benefit is 4000 per calendar year.
[AGENT][NEUTRAL] Um, so the 4000 was already paid out um for the facility, um, and I'm looking at the claim that was recently processed. Um, it looks like they charge the total amount.
[AGENT][NEUTRAL] OK, and this is for Memorial Hospital Minama?
[AGENT][NEUTRAL] Um, they apply a total of 5000.
[AGENT][NEUTRAL] $360.66. This was applied towards the deductible and co-insurance.