AccountId: 011433970860
ContactId: 66be63a2-fd6c-4fef-9ba1-0f383f6803d7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 505480 ms
Total Talk Time (AGENT): 134589 ms
Total Talk Time (CUSTOMER): 252815 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=-2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/03/66be63a2-fd6c-4fef-9ba1-0f383f6803d7_20250603T12:19_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Good morning, [PII]. This is [PII]. How are you?
[AGENT][NEUTRAL] Good morning. I'm fine. How about you?
[CUSTOMER][NEUTRAL] Good. It's too early. I need more coffee.
[CUSTOMER][NEUTRAL] Um, alright, I have an insured on the line. She's like all upset about this claim. Do you want her policy number to start with?
[AGENT][NEUTRAL] Yes, what's the policy number?
[CUSTOMER][NEUTRAL] 025472227.
[AGENT][NEUTRAL] And that was 025472227?
[CUSTOMER][NEUTRAL] It should be
[CUSTOMER][NEUTRAL] Yep, for [PII].
[AGENT][NEUTRAL] For [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what claim is it in regards to?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] It's claim ending in 1309. I didn't check to see how many she has. It's 358.
[CUSTOMER][NEUTRAL] 1309.
[AGENT][NEUTRAL] OK. Let me take a look.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So, you know, she's upset about the two denial lines where we're asking for an itemized statement with diagnosis codes.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] She says that she sent that, you know, I pulled up what was sent and I don't see that she did send us like 42 pages, but I haven't found anything as of yet.
[CUSTOMER][NEUTRAL] And then she's going on about, well, you know, I don't even know why you guys need that it's just an office visit like an office visit is an office visit, like, you know, why do you need a diagnosis code? It's nothing else, you know, and I'm like, OK, and, and she's like, it's none of your business going on and on and I just like, OK, you know, so anyhow, that's kind of where we're at.
[CUSTOMER][NEGATIVE] I told her we needed it to continue processing it, but she doesn't wanna really give it to us so.
[AGENT][NEUTRAL] OK, let me see what we got. Yeah, it is 42 pages. Let's see real quick.
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] Like I said, I was like I, my, my coffee is not quite moving in all directions. Yeah, goodness gracious.
[AGENT][NEUTRAL] And that's the only date that she's questioning? Is that one that we're asking for the.
[CUSTOMER][NEUTRAL] It's just, yeah, those two office visits for [PII]. She's like.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Yeah, and honestly she's one of those BWA people where she got it through Business Workers of America and she didn't really understand what an HI plan was that's why it's not it's not even active anymore she canceled it because it wasn't what she thought it was.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You know.
[AGENT][NEUTRAL] Yeah, so far, I'm definitely not seeing no diagnosis information.
[AGENT][NEUTRAL] Just only the CPT code.
[AGENT][NEUTRAL] Nope. You are right. I don't see any diagnosis code.
[AGENT][NEUTRAL] I don't, we don't have a diagnosis code for either of these um office visits.
[CUSTOMER][NEUTRAL] Yeah um
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah. I can tell her the same thing. You can send it to me and I can tell her again that in order to consider those dates, we need the diagnosis code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I'd appreciate you if you could just retell her that.
[AGENT][POSITIVE] Yeah, I don't have no problem doing it.
[CUSTOMER][NEUTRAL] OK, um, do you want her callback number or it's the one she's calling from.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You can send her to me.
[CUSTOMER][NEUTRAL] Alright, I'm gonna let her know. Alright, let me just let her know I'm gonna transfer one second.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Claims department, this is [PII].
[CUSTOMER][NEUTRAL] Hi, I'm not sure if she told you why I was calling um I just wanted to see if you guys could push my claims through.
[AGENT][NEUTRAL] Yes, Ms. [PII], she had advised me that you had some questions in regards to the office visits. We had requested, requested the itemized billing with the diagnosis code for the [PII] and [PII]. And looking at the documents received, I don't show that we have that information. We need that in order to consider benefits. It looks like under your office.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Physician office benefit, it only covers due to accidents. So in order for us to consider benefits under the policy, we need the diagnosis information in order to consider benefits.
[CUSTOMER][NEGATIVE] None of them. I wanna, I wanna a breakdown of this policy because every time I call y'all tell me something different. It's like now it's like I don't qualify. Like I paid a lot of money into this to not get any reimbursement. It was pointless. I should have just kept been self pay. I would have been charged less too.
[AGENT][NEUTRAL] This is a limited hospital indemnity plan. It's not a major medical plan, so it does cover limited benefits.
[CUSTOMER][NEGATIVE] Yeah, I was not, I was, I was misled on that. I was told that this would cover office visits and my copay would be $25 and all this crap.
[CUSTOMER][NEGATIVE] So now you're telling me my policy only covers injuries.
[AGENT][NEUTRAL] This
[AGENT][NEUTRAL] As far as outpatient, under the outpatient accident treatment benefit, it pays a limited benefit in a physician's office of $50 per day, you get a max of 3 days per calendar year. And I just must advise that this is just a verification of coverage and benefits. It does not guarantee payment.
[CUSTOMER][NEUTRAL] OK, I'm gonna
[CUSTOMER][NEGATIVE] That's fine. I'm gonna, I think I'm just gonna get on to the Better Business Bureau and notify, like put a a thing out there because this is definitely something that should have been brought to my attention and not misled that this was some type of insurance policy. Um, it's pointless to have this. It's 100% pointless.
[CUSTOMER][NEGATIVE] If you're not gonna be able to use the the policy or you guys aren't gonna are gonna help in any way, I mean I would have probably gotten a cheaper rate as self pay. I get a better discount than I did being under your plan. I, I was charged $170 some dollars a month for nothing, literally nothing.
[CUSTOMER][NEGATIVE] So I'm gonna get on, I'm gonna get on your page too and, and make sure I know that like put a, put a comment out there. I mean you you guys are charging people for this and they're being misled thinking this is an insurance policy, you know, I went through heck, I lost my job. I didn't have any money, so I um.
[CUSTOMER][NEGATIVE] Got this plan after talking to a million people because this guy told me that this is what this was and I was completely misled so I'm just gonna, I'm gonna go on your website.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEGATIVE] I can see how that would be frustrating that you were not explaining exactly what the policy covers.
[AGENT][NEUTRAL] Is there anything else that I can assist you with today, Ms. [PII]?
[CUSTOMER][NEUTRAL] Yeah, I don't have them. I didn't.
[CUSTOMER][NEUTRAL] Nope.
[AGENT][NEUTRAL] OK,