AccountId: 011433970860
ContactId: 6661d8e3-06e2-42db-a9d0-9e3fa9e3ea20
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1426859 ms
Total Talk Time (AGENT): 320661 ms
Total Talk Time (CUSTOMER): 596690 ms
Interruptions: 1
Overall Sentiment: AGENT=0, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/02/6661d8e3-06e2-42db-a9d0-9e3fa9e3ea20_20250402T15:08_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah, hi [PII], um, I had just called, um, because my wife or my family got denied for a claim for an ER visit, um, on [PII], and the representative had, yeah, the representative had me call benefits and card.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEGATIVE] And I called them and they said based off the coverage I have that we should be covered for that. So I don't know if you can I have the claim number and everything. I have two claim numbers actually from the same day. They're from the same visit that were denied.
[CUSTOMER][NEUTRAL] And the representative that I talked to with you guys told me that we were that she was not seeing that we were covered for this and then when I called benefits in a card they said that we are they said if we need to that you can call them while we're on the phone and they can tell you.
[AGENT][NEUTRAL] Uh, what's the claim number that you have?
[CUSTOMER][NEUTRAL] The first one I have is 3,581,690.
[AGENT][NEUTRAL] OK, give me just a moment here.
[AGENT][NEUTRAL] All right. And then if I could verify please your first and last name and date of birth.
[CUSTOMER][NEUTRAL] Uh, my first and last name is [PII]. My date of birth is, uh, [PII].
[AGENT][NEUTRAL] Thank you, [PII]. And then I need to verify for security reasons your uh physical address and email address, please.
[CUSTOMER][NEUTRAL] Uh, the physical address is [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I don't know if you have my I have my wife's which would be [PII]. That's her email. I don't think mine would be in there but.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK, so I see the first claim, the 3,581,690. What's the second one that you have?
[CUSTOMER][NEUTRAL] 3579417.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me
[AGENT][NEUTRAL] So I'm looking at the policy itself because it's saying, please refer to section 5 of the policy. So I was pulling that up to take a look at it.
[CUSTOMER][POSITIVE] Well we purchased the most that they offer, which was the enhanced. He actually sent me what I had actually looked at when we were buying when you know signing up for everything, um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] The original it says not included and then when we went to our other one then it is included which is what we paid for we paid for the enhanced which is um.
[CUSTOMER][NEUTRAL] It goes further and it says additional insurance.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It says $250 and then you can go to like it says 11.
[CUSTOMER][NEUTRAL] I don't know if it qualifies as urgent care, but in the urgent care facility it says 100%.
[CUSTOMER][NEGATIVE] Minus the $60 copay.
[CUSTOMER][NEUTRAL] It says urgent care visits 100% after $60 co-payment, not, you know.
[CUSTOMER][NEUTRAL] That, you know, I, like I said, we just, we went to the doctor for this and then he referred us to the ER in the hospital there so we went to that one it was AdventHealth.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] But it also says it covers medical imaging and that's in the enhanced and then she was saying that we don't get it was just an X-ray that was taken, not MRI I mean that was the last call I had with one of your representatives and I was just trying to figure out that didn't make sense, but what I have here it, it does say medical imaging, it doesn't really specifically break down anything.
[CUSTOMER][NEUTRAL] Medical imaging $100.
[CUSTOMER][NEUTRAL] I don't know if you wanna call them because she was saying what it showed we can call I have the number that was given to me and I talked to he said we can ask for him again.
[CUSTOMER][NEUTRAL] I don't know if your system is showing that we're because she was saying to call and get more coverage I said well I have the most that they offered.
[CUSTOMER][NEUTRAL] And that's when she we kind of started this and she said well maybe you need to call them because we're not showing you weren't showing that in your system.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] So, was there any sort of admission to the hospital for 18 hours or longer?
[CUSTOMER][NEUTRAL] Hello? OK.
[CUSTOMER][NEUTRAL] No, but that that's what the last person was trying to say, but what I'm trying to say is that you might have the wrong information. We should be covered for an emergency room.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Says hospital emergency room $250. I'm looking at what he sent me over.
[CUSTOMER][NEUTRAL] The, the admission is a different section.
[AGENT][NEUTRAL] OK, what is the, so.
[CUSTOMER][NEUTRAL] Like that's the that's the that's the basic, that's what I'm looking at there, um, it talks about at at hospital admission benefit or something like that, but then you can buy an enhanced part and we were paying for that.
[CUSTOMER][POSITIVE] It actually has additional hospital benefit of $1000 for max of one day, um, plus it has emergency room visits.
[CUSTOMER][NEUTRAL] And medical imaging test if you were in there for $100 a day max 2 days.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And then it has hospital emergency room 250 physician's office 50 emergency dental work 50, hospital admission 250, so it's like an additional 250 I'm assuming daily hospital confinement intensive care unit, it just kind of keeps going on and on and it says ambulance ground and air 250.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Then it says medical imaging $100.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh no, it says AD and
[CUSTOMER][NEUTRAL] So that was like the additional coverage that's what we were paying for we're paying for the most that they would allow.
[CUSTOMER][NEUTRAL] As far as medical goes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I see what you, OK.
[CUSTOMER][NEUTRAL] The the last they need to like you could get with them and they.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That additional.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And OK, so.
[AGENT][NEUTRAL] I was wondering if maybe it was under one of the different policies, because like you have an accident policy.
[AGENT][NEUTRAL] There's hospital indemnity in the accident and cause I'm scrolling through.
[CUSTOMER][NEUTRAL] Yeah, I think the
[CUSTOMER][NEUTRAL] The accident is part of the enhanced too, I think because I'm looking at this paper here.
[CUSTOMER][NEUTRAL] There's like the basic policy and then there's like an enhanced that's how they sold it to us anyways.
[CUSTOMER][NEUTRAL] But you could have paid for just basic and it would have been I don't know.
[CUSTOMER][NEUTRAL] Like half
[AGENT][NEUTRAL] Because I see intensive, I see like intensive care.
[CUSTOMER][NEUTRAL] It's like 50
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] That's in the too, but then there's also right at the bottom. I mean I can send it. I'm looking right at it and it says.
[CUSTOMER][NEUTRAL] Emergency room.
[CUSTOMER][NEUTRAL] I don't know if it's the same thing we're looking at, but.
[AGENT][NEUTRAL] Well that's yeah I'm trying to see what.
[AGENT][NEUTRAL] I see hospital emergency room, initial treatment within 72 hours, benefit of 250 on the accident.
[CUSTOMER][NEUTRAL] That's what that is. That's that's what it shows me is 250.
[AGENT][NEUTRAL] OK, so,
[CUSTOMER][NEUTRAL] And then medical imaging.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] The claim that was denied wasn't filed under this policy under where that coverage is. It was filed under the other one.
[AGENT][NEUTRAL] Because
[CUSTOMER][NEUTRAL] Well, I, I only only have one card.
[CUSTOMER][NEUTRAL] You know what I mean? I don't know. We provided the, the hospital the card, so we only have one card. It says the same thing and it and it shows on there MC coverage, no deductible out of policy then MEC enhanced coverage adds to and it gives some other stuff in there and it shows the employee ID number and the group number and there's nothing separate here. I'm looking at it as pharmacy and vision.
[AGENT][NEUTRAL] Yeah, you've been
[CUSTOMER][NEUTRAL] It says INN UC $60 which I'm assuming that's uh you know it means urgent care, but.
[AGENT][NEUTRAL] Yeah, I just the claim was filed.
[AGENT][NEUTRAL] So.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] So, for the accident policy, you would not get a card. It's not something that um the employer or us issue cards for. So the claim is going to need to be resubmitted under the accident policy because that is where it appears that those benefits are.
[AGENT][NEUTRAL] Not under this policy, the hospital indemnity one that you have a card for.
[AGENT][NEUTRAL] So to reprocess the
[CUSTOMER][NEUTRAL] I mean, I
[CUSTOMER][NEUTRAL] Go about doing that that's what I'm trying to say like we only have one card like you go to the place and you hand them the card, it's all we have. I don't have any information. I thought, you know, that was basically.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Is that something benefits of the choir can do or what? Like you follow what I mean like.
[AGENT][NEUTRAL] So as far as filing the claim, like how that can be done, you can um I can send you the information on how to do it. They can be submitted online, they can be sent to us in the mail or faxed. You just need the claim form and then you would need the itemized bills from the provider being the emergency room and the doctor.
[CUSTOMER][NEUTRAL] I don't have any of that.
[CUSTOMER][NEGATIVE] They haven't sent me anything. I don't have any of it.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Like, uh, why wouldn't they both be together like as far as like the enhanced and what we have and just kind of show that it's a rider over top of the original coverage.
[CUSTOMER][NEUTRAL] Like who would know that it's a separate thing if I only have the one card.
[CUSTOMER][NEUTRAL] The card actually said it on there MEC enhanced coverage.
[CUSTOMER][NEUTRAL] Add INN and then it gives you like I don't know some other things there.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The only other thing that I can do at this point, you know, I can reach out to a claims examiner, [PII], have them call you.
[AGENT][NEUTRAL] I don't know if they can take the information already submitted and reprocess it under a different policy. Um, I'm not a claims examiner, but I'm happy to have somebody give you a call back if you would like to do that.
[AGENT][NEUTRAL] Um, I just know that
[AGENT][NEUTRAL] From what I can see on this policy, the reason why it denied, it looks like all the benefit riders are on the other policy, so.
[CUSTOMER][NEUTRAL] Yeah, but as far as I'm concerned, I only have one policy.
[CUSTOMER][NEUTRAL] Because I only have one card like it wasn't given to me and said OK this card used here and this card is for this.
[AGENT][NEUTRAL] I understand this accident policy isn't going to issue a card. So if you would like, I can send you a copy of the policy to your email, physical mail. I can give you the policy number, but it's not something that is going to have a card issued for it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I understand that, that, that may work in your world, but in the real world, that doesn't really work cause like the way this went down is we went to the doctor first. He had something going on with his knee. He was refusing to walk.
[CUSTOMER][NEUTRAL] And then the doctor referred us to the ER.
[CUSTOMER][NEUTRAL] So having a card that I keep in my wallet.
[CUSTOMER][NEUTRAL] It's kind of what most people do, so I understand you don't issue a card that's fine. What I'm saying is at some point.
[CUSTOMER][NEUTRAL] On the back end, both policies should merge and show.
[CUSTOMER][NEUTRAL] The overriding coverage on to the original.
[CUSTOMER][NEUTRAL] Policy.
[CUSTOMER][NEUTRAL] You understand? so that this doesn't happen again where it a claim gets submitted and they go OK we're denying it, but we actually had coverage for that stuff.
[AGENT][NEUTRAL] No, I, I definitely see what you're saying. Um, unfortunately, it, you know, they're they're separate. There's just not a way to make them one.
[CUSTOMER][NEUTRAL] I mean in the from so gotta go I gotta go back to my house and get a printed piece of paper to go run to the ER with and, and at the time I didn't know we were going to the ER, you know what I mean? I was just going to, I set up a doctor's appointment for him to look at the knee. He hadn't really had it, you know, we didn't know what had happened.
[CUSTOMER][NEUTRAL] He's [PII] old, so.
[AGENT][NEUTRAL] Right. Yeah.
[CUSTOMER][NEUTRAL] Um, so anyway, I get put in touch for a claims person to call me. I can give you my number.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And I, I, I think the easiest is to try to reprocess it under the, the, the policy because I, I don't have any of the paperwork from the hospital that has any of that what they were billing and all that stuff.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Um, I'm assuming at some point they were gonna send me a bill, but like, because now you've denied, so they're gonna send me whatever without whatever you didn't cover, but.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So does the rider policy cover an X-ray or $100 towards the imaging I'm assuming is.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Um, let me pull that back up. I exited out. I'm sorry. Give me just a second.
[CUSTOMER][NEUTRAL] Because I, I see the medical imaging, which to me that would include X-ray. It doesn't specify that it's excluded.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. So,
[AGENT][NEUTRAL] Medical imaging is an MRI, a CT scan, a CAT scan, a PET scan.
[AGENT][NEGATIVE] Does not list X-ray.
[CUSTOMER][NEUTRAL] I understand
[CUSTOMER][NEUTRAL] That's for the original policy.
[CUSTOMER][NEUTRAL] But I have an additional.
[CUSTOMER][NEUTRAL] You know what I mean? The enhanced coverage.
[CUSTOMER][NEUTRAL] Because the other lady told me the same thing, but she didn't even know that we had the enhanced coverage. I told her we had it. She didn't see that additional policy that you saw, so I'm talking about the additional policy.
[AGENT][NEUTRAL] Right. And I'm, I'm, I'm reading the definition of what they say a medical imaging is.
[CUSTOMER][NEUTRAL] The accident whatever.
[AGENT][NEUTRAL] From the policy. So this is what the policy states a medical imaging benefit would be paid for is those things, and that's on the other policy.
[CUSTOMER][NEUTRAL] So where, what's defined as an urgent care then?
[CUSTOMER][NEUTRAL] Like when it says urgent care visits, $50 co-payment, 100%.
[CUSTOMER][NEUTRAL] I mean I define that as an urgent care visit.
[AGENT][NEUTRAL] Yeah, I mean, it would be an urgent care facility.
[CUSTOMER][NEUTRAL] It doesn't say that it just says urgent care visit.
[CUSTOMER][NEUTRAL] No other services are covered under this benefit. Also office visits related to mental disorders or substance abuse are not covered under this benefit.
[CUSTOMER][NEUTRAL] I guess just have a claims person call me and I'll discuss with them where we go with this because it's kind of like what we were presented with.
[CUSTOMER][NEGATIVE] It seems to be not what we're getting.
[AGENT][NEUTRAL] OK, what's a good callback number for you, [PII]?
[CUSTOMER][NEUTRAL] But, but
[CUSTOMER][NEUTRAL] Yeah, uh, [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, just to confirm, [PII], correct?
[CUSTOMER][NEUTRAL] Yeah, that's my cell phone number, yeah.
[AGENT][NEUTRAL] OK. So I will put in the request right after right now and um I will put in both of the claim numbers and I will just put in detail kind of what we've discussed and your concerns. I will include both of the policy numbers, the one for the hospital and also the one for the accident, and uh just let them know that you're wanting a call back to go over these and um just allow 24 hours for a callback from claims, OK?
[CUSTOMER][POSITIVE] OK. All right, thank you.
[AGENT][POSITIVE] You're welcome, [PII]. Have a good rest of your day.
[CUSTOMER][POSITIVE] All right thanks bye bye.
[AGENT][NEUTRAL] Um, bye-bye.