AccountId: 011433970860
ContactId: 66ff3d8f-d0f7-473b-9935-3e47d92fb299
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 861099 ms
Total Talk Time (AGENT): 332198 ms
Total Talk Time (CUSTOMER): 227668 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/14/66ff3d8f-d0f7-473b-9935-3e47d92fb299_20250214T21:58_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] I, I, I submitted a claim about 2 months ago, I think, and I wanted to know if the.
[CUSTOMER][NEUTRAL] I, I didn't receive any information, yeah.
[AGENT][NEUTRAL] The status.
[AGENT][NEUTRAL] Sure, I can assist you with the status of the claim and may I have your name and a callback number just in case we get disconnected?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah, I, I, I'm not sure what mine, I, because I changed my last name, but I'll give you my old last name. I think that's what's on it. It's uh [PII]
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then [PII]
[CUSTOMER][NEUTRAL] [PII]. And if it's not working, I'll give you the other name.
[AGENT][NEUTRAL] OK, let me have a callback number just in case we get disconnected.
[CUSTOMER][NEUTRAL] OK. [PII].
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and may I have your date of birth, um, mailing address and email address for verification.
[CUSTOMER][NEUTRAL] Uh, [PII]. Mailing address is [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And then what, what else did you say?
[AGENT][NEUTRAL] Email address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect, thank you.
[AGENT][NEUTRAL] OK, let me check the claim. OK, let me pull the details of the claim. Um, do you mind holding for me?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Yeah, of course, thank you.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for me, Miss. OK, you're welcome. It looks like the um EOB was returned to us, um, and you said that [PII] is correct.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mm, yeah, I'm not sure why, but it was returned to us. That's why you didn't get it. um, but we did send out um the information.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So some street.
[CUSTOMER][NEUTRAL] And there is an [PII].
[AGENT][NEUTRAL] I don't think we have the apartment number. Let me see. Let me go back to it.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Yep, we're missing that [PII]. OK, so let me add that and send in uh the copy of the EOB again um or I can send it by email if you want. I can send it by email, but um.
[CUSTOMER][NEUTRAL] What do you
[AGENT][NEUTRAL] Yes, I can, um, but the claim was denied. Um, the reason for the denial on this claim is because, um, when we received the documents, it says that it was a, um, practitioner. It is not a, um, physician.
[AGENT][NEUTRAL] And we need um for the service to be performed by it.
[CUSTOMER][NEUTRAL] I that.
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] It's mental health. It's.
[CUSTOMER][NEUTRAL] It's a mental health claim.
[CUSTOMER][NEUTRAL] It's a therapist.
[AGENT][NEUTRAL] We do not cover therapists. It has to be a physician and licensed doctor for sickness or injury.
[CUSTOMER][NEUTRAL] You know, before I saw her I called and confirmed.
[CUSTOMER][NEUTRAL] And they told me that they will cover it.
[AGENT][NEUTRAL] Mm, as long as it's a licensed doctor, it will, but um he's not a licensed doctor. Let me check here.
[CUSTOMER][NEUTRAL] Deduct
[CUSTOMER][NEUTRAL] I asked when I, when I first, before I went to my therapist, because it's mental health and it's not a doctor, and I called and I verified and I'm sure there is a recording.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Do you remember when did you call?
[CUSTOMER][NEUTRAL] And they
[CUSTOMER][NEUTRAL] When, uh, probably September.
[CUSTOMER][NEUTRAL] Or October, I can't remember, I mean.
[CUSTOMER][NEUTRAL] I called the insurance company.
[AGENT][NEUTRAL] OK, I don't see.
[AGENT][NEUTRAL] I don't see any notes. The only note I got here is the provider requesting venison.
[AGENT][NEUTRAL] for the policy sir and um then a request for the policy certificate to be sent out to you.
[CUSTOMER][NEUTRAL] Mhm. So maybe a call before that?
[AGENT][NEUTRAL] I don't see any, any notes before that. I'm not saying that you did not, but I don't see the notes. Um, but what I can.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah,
[AGENT][NEUTRAL] OK, what I can do is send you the explanation of benefits and send you the policy limitations of the policy and if um if you want, you can always submit an appeal. You have 180 days to submit an appeal.
[CUSTOMER][NEUTRAL] OK, and I have another question. um I also the bill.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For my mammogram, and that was also discussed before I
[CUSTOMER][POSITIVE] started my insurance and they said that it will, they cover.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] The yearly exam was not covered and then they also asked for an ultrasound because it's a part of my routine checkups since I have family history, and that was not covered as well, and I also got a bill for that.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me check if we cover that part. OK, one moment. I don't see coverage for that one either.
[CUSTOMER][NEUTRAL] And I also
[CUSTOMER][NEUTRAL] And also
[CUSTOMER][NEUTRAL] Also have uh an MRI also once here and I also asked and I didn't have it yet, but I'm going to have and I, I really need a confirmation if I'm gonna get covered or not.
[AGENT][NEUTRAL] And you said you called this line or you called or you spoke to somebody in another um company.
[CUSTOMER][NEUTRAL] It's also
[CUSTOMER][NEUTRAL] Um, oh, I don't, it was not this line that, that's the one that's for, right?
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] No, it's, uh, we, we have only one line for everything, claims, um, benefits, um, everything goes through the same line.
[CUSTOMER][NEUTRAL] Oh, yeah, probably.
[CUSTOMER][NEUTRAL] Yeah, so probably that line.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Could be that it was, you know, uh, in the beginning, I spoke with the Covered California.
[CUSTOMER][NEUTRAL] Because I did it through them.
[AGENT][NEGATIVE] And they don't have this information, um, because, um, there is no wellness coverage under this one. There's no preventative, no wellness. There's no coverage if it's not a licensed doctor, so, um.
[AGENT][NEUTRAL] I may not sure who you spoke to, but those are not covered under this policy. And again, I can send you the paperwork of the policy so you can look into it, but yeah, there's no coverage.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So I'm not covered for a yearly mammogram?
[AGENT][NEGATIVE] No, this one doesn't cover that.
[CUSTOMER][NEUTRAL] So what am I covered for?
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Cause I went to the doctor.
[CUSTOMER][NEGATIVE] For the doctor, like, I don't get it.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mhm. OK, let me give you the benefits on your policy, and this is not a guarantee of payment, just a verification of coverage, and that's just a disclaimer. Um, so you have one of our hospital indemnity plans. Um, with this one you have hospital admission benefit which is $750 per day and that's one day for covered person per calendar year if you're admitted into the hospital. Um, you also have hospital confinement benefit.
[AGENT][NEUTRAL] And that's at $200 per day for 30 days, and that's if you're hospitalized and you stay in the hospital, so every day it's $200.
[CUSTOMER][NEUTRAL] But tell me.
[AGENT][NEUTRAL] Sorry?
[CUSTOMER][NEUTRAL] Not in the hospital? Like, can you tell me what's my benefits, not in the hospital? Like, yearly checkup, like routine things.
[CUSTOMER][NEUTRAL] That people have insurance for.
[AGENT][NEUTRAL] OK. Um, yeah, this is definitely not a major medical, so let me give you uh the rest of the benefits, um, but it is gonna be a different, it's not the same as the major medical. OK. Um, so for outpatients, um, accident treatment benefits, you have emergency room which is $200 per day, 2 days, urgent care, $50 per day, maximum of 3 days.
[AGENT][NEUTRAL] Um, physician's office, $50 per day, 3 days.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, physical speech or
[CUSTOMER][NEUTRAL] Physician's office, so if I, if I go to a doctor.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Just to see a doctor.
[AGENT][NEUTRAL] Mhm. Yes.
[CUSTOMER][NEUTRAL] Then how much do I take?
[AGENT][NEUTRAL] OK, so it's going to be.
[AGENT][NEUTRAL] And then the physician's office is going to be $50 per day.
[AGENT][NEUTRAL] Maximum of 3 days.
[CUSTOMER][NEUTRAL] What do you mean
[CUSTOMER][NEUTRAL] I go to see the doctor.
[CUSTOMER][NEUTRAL] I go to see a doctor because I have a throat ache.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Do I pay $50?
[AGENT][NEUTRAL] No, we pay $50.
[AGENT][NEUTRAL] So if the visit is 100, we pay 50, you pay 50 this is 150, we pay 50, you pay 100.
[CUSTOMER][POSITIVE] Oh wow, wow.
[AGENT][NEUTRAL] Yeah, it's a limited policy. This is a limited policy. So, um, I'm not really sure um where, where you got the benefits the first time, but this is a really limited policy. Mhm.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEGATIVE] OK, I didn't know the, the, you know, the, the person who sold it to me on Coverage [PII] um misinformed me and all of those things. He really sold it to me differently. I, I'm gonna call them and I'll make them go back to the recording and listen to all the stuff he promised.
[CUSTOMER][POSITIVE] Uh, but thank you. If you can send me about this, uh, benefits, that would be great.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Mm.
[CUSTOMER][NEUTRAL] I know so much.
[AGENT][NEUTRAL] OK, and I'll go ahead and send that explanation of benefits as well, OK? Um, is there anything else I may help you with today?
[CUSTOMER][POSITIVE] Thank you have a good week.
[CUSTOMER][POSITIVE] No, that's it. Thank you.
[AGENT][POSITIVE] You're welcome and thank you for calling ATL. Have a good day.
[CUSTOMER][NEUTRAL] Bye bye.