AccountId: 011433970860
ContactId: 642208d7-dc61-4820-86e9-7f3e17a6cc7e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 739669 ms
Total Talk Time (AGENT): 355072 ms
Total Talk Time (CUSTOMER): 133468 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=-1.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/642208d7-dc61-4820-86e9-7f3e17a6cc7e_20250109T14:09_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Um, yes, my name is [PII], and I have a question about a claim that I filed.
[AGENT][NEUTRAL] OK, well, I can help you with your claim and Ms. [PII], may I have a good contact number in case we're disconnected and your policy number?
[CUSTOMER][NEUTRAL] Um, contact number is [PII].
[CUSTOMER][NEUTRAL] Uh, policy number is 2296636.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And Ms. [PII], can you verify your date of birth, your mailing and email address on file?
[CUSTOMER][NEUTRAL] Sure. Date of birth is [PII]. Um, mailing address is [PII]. And email is [PII].
[AGENT][NEUTRAL] Alrighty, and thank you so much for verifying your information. All the information provided is a verification of benefits, not a guarantee of payment. And um do you have the claim number or the date of service I can look up for the claim?
[CUSTOMER][NEUTRAL] Uh, the claim number is 354-8960.
[AGENT][NEUTRAL] So this is for your husband?
[CUSTOMER][NEUTRAL] Husband. Yeah, [PII].
[AGENT][NEUTRAL] OK, let me go to him. Hold on one second.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 960.
[AGENT][NEUTRAL] OK, so I see the claim here, and then what questions did you have?
[CUSTOMER][NEUTRAL] I am just curious as to why only $55 was covered because it was
[CUSTOMER][NEUTRAL] Um, a claim for 3 separate days.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] They, because when I looked at the claim here, it shows that they basically only paid the $55 for, I think it was [PII]. I'm just trying to bring it back up.
[AGENT][NEUTRAL] Oh, I see what's happening. OK, hold on one moment. What's the.
[AGENT][NEUTRAL] So the 55 was paid towards [PII].
[CUSTOMER][NEUTRAL] [PII], yeah.
[AGENT][NEUTRAL] OK, I will.
[CUSTOMER][NEUTRAL] And I submitted it for 3 total, 3 different days. I think it was the [PII], and [PII], if I remember correctly at the top of my head.
[AGENT][NEUTRAL] OK, so it's supposed to be [PII], 3 days, [PII], [PII], and [PII], [PII]. OK. Do you mind if I place you on just a brief hold to look through these claims?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Alright, [PII]. Well, first of all, she wants to know why.
[AGENT][NEUTRAL] Hold on, let me pull up 12345680 wait, I did that wrong.
[AGENT][NEUTRAL] Did I? Oh no, I did it right, did I?
[AGENT][NEUTRAL] 012345678. There we go.
[AGENT][NEUTRAL] So do you pick, oh wait a minute.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Well, actually, hold on.
[AGENT][NEUTRAL] That's all I need to do. I don't need to look at the claim. I mean, I don't need to look at the dates. I need to see what came in. Do do do.
[AGENT][NEUTRAL] Oh, I did it, I did it because I don't see anything for.
[AGENT][NEGATIVE] Well, it don't matter cause once the thing comes up, it's gonna tell me what was sent so we don't even have to go back there.
[AGENT][NEUTRAL] Claim.
[AGENT][NEUTRAL] Oh Lord.
[AGENT][POSITIVE] And I like the 3rd page.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Referral. What do you need a referral for?
[AGENT][NEUTRAL] Oh, to show the diagnosis code?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Just anything? OK.
[AGENT][NEUTRAL] The [PII].
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] The [PII].
[AGENT][NEUTRAL] I'll do CLHQ and then do [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] I have no idea.
[AGENT][NEUTRAL] Because she has a $350 per calendar day.
[AGENT][NEUTRAL] See, that's why we need to be able to call claims. She has a $350 per calendar day max.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] We only pay 55 and this is the only claim for that day. What?
[AGENT][NEUTRAL] Oh my [PII].
[AGENT][NEUTRAL] I know what the, what is the year we say?
[AGENT][NEGATIVE] Uh, I see the [PII] on the docks, but I don't see anything on the [PII] on the claims. They processing claims the way they read that policy. We're in trouble.
[AGENT][NEUTRAL] Oh, see, they didn't even acknowledge the [PII], OK.
[AGENT][NEUTRAL] Wait, did they say we can call claims now or no?
[AGENT][NEUTRAL] Where is the.
[AGENT][NEUTRAL] I don't know where.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] You know what, I'm gonna send the, the this hub because that's what the last thing was. I don't know if it didn't changed again.
[AGENT][NEUTRAL] Hello, Ms. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. So, I was looking through the documents that was received and the way the claim paid out. So if you don't mind, I'm going to send this back to claims for them to research. The reason I say that um
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] When I pulled up your, the documents from, you know, the things that you sent in, I saw [PII] on there, but I don't see any mention of that. I just see [PII] on the claim, and then you have a $350 like per calendar day that you can use for outpatient.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And this was the only claim that was for, well, there was no claim on file for the [PII] because I was thinking maybe they did it separately, but then when I went to the [PII], this was the only claim, so I'm not sure why the
[AGENT][NEUTRAL] Um, at least the full, because it looks like the total bill is 215, but if this was the only claim for the day and the max is 350, I'm not sure why that wasn't paid out. So I'm gonna send that back to claims for them to research and if they need to reprocess, reprocess, I'm gonna have them give you a call um by tomorrow at the latest to give you an update because it, it just doesn't.
[AGENT][NEGATIVE] I don't understand.
[CUSTOMER][NEUTRAL] So you don't, you don't, you only see the [PII], you don't see the [PII] or the [PII], the dates on there on the explanation of benefits from the insurance company?
[AGENT][NEUTRAL] No, no, no, on the, I'm talking about on our explanation of benefits, it was only bill or paid out for the [PII], but when I pulled up like what you sent in, I saw this, I didn't see anything for the [PII], but I did see the [PII].
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, so I have [PII], [PII], and then the [PII] on what I sent what I'm looking at.
[AGENT][NEUTRAL] But I also, let me pull up the um
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one second.
[AGENT][NEUTRAL] You said the the the [PII] shows on the explanation of benefits from
[CUSTOMER][NEGATIVE] No, no, on what I sent over from Aetna, my insurance company's Aetna's explanation of benefits saying what was covered, what's not covered.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Yeah, I, I didn't see anything about the [PII], but I can go through it again and, and when they reprocess it, they will too. But let me go back just while we're on the phone.
[CUSTOMER][NEUTRAL] Yeah, I just wanna make sure that.
[CUSTOMER][NEUTRAL] You guys have all the pages.
[AGENT][NEUTRAL] OK, so that top part is like crossed out and then under it shows the [PII], this is on the [PII].
[CUSTOMER][NEUTRAL] Which is
[CUSTOMER][NEUTRAL] Yup. And then there's the [PII].
[AGENT][NEUTRAL] This is the [PII].
[CUSTOMER][NEUTRAL] And then there's a [PII] because it goes on to the next page.
[AGENT][NEUTRAL] Oh, I see, it's upside down. I see it. I see the [PII].
[AGENT][NEUTRAL] That one came in like, it looks like it's just like verbiage, but then when it's upside down, so when I scroll more and turn it, I can see the [PII]. So yes, I do see those three.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I'm gonna send this back to them. Yes, ma'am, and I'm gonna have them, I'm requesting for them to give you an update call within 24 hours. So by tomorrow um morning at the latest, of course, it could be today too. I just don't want to say today and it doesn't happen.
[CUSTOMER][NEUTRAL] OK, so you'll resubmit it, OK.
[CUSTOMER][NEUTRAL] OK, that's fine.
[AGENT][NEUTRAL] OK. Well, I'm definitely sorry for the confusion, but once they take a look at it and let us know if it was processed correctly or they're gonna call you with an explanation. I just
[AGENT][NEUTRAL] I, I don't understand it. All right, well, was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Nope, that's it.
[AGENT][POSITIVE] All right. Well, thank you so much for calling APO Ms. [PII]. I hope you have a great day and [PII].
[CUSTOMER][POSITIVE] Yes, thank you. You too.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] All right bye.