AccountId: 011433970860
ContactId: 6785ed3f-ce62-40a7-bb7d-7b782095ddba
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1040989 ms
Total Talk Time (AGENT): 633959 ms
Total Talk Time (CUSTOMER): 368656 ms
Interruptions: 3
Overall Sentiment: AGENT=0.3, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/06/6785ed3f-ce62-40a7-bb7d-7b782095ddba_20250106T19:26_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII] speaking. How may I help you?
[CUSTOMER][NEUTRAL] Yes, um, I, I have submitted a couple of claims for one for an accident and one for hospital indemnity, and I just needed to get some information on those. I just got a reply in the mail, so I just need to verify exactly what's needed.
[AGENT][POSITIVE] Certainly I'd be happy to help you with that information. Can I have your name please?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] And Miss [PII], can I please have a callback number in case we should get disconnected and I can call you back please?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] Thank you and do you have your policy number handy or you need me to look it up?
[CUSTOMER][NEUTRAL] Uh, no, I've got it. It's uh 244-506-7.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you and just give me one moment please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And may I please have you verify your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you and your mailing address please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and that last piece of verification, your email address please.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I probably have my work, um, as [PII].
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, thank you for verifying that information.
[AGENT][NEUTRAL] And let me just see, so that first, uh, policy num or I'm sorry, that policy number you provided me is the hospital indemnity, so let me just take a look at that real quick and see what's going on.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] So it looks like some of the um copies that I sent were blurry and maybe not able to be read.
[AGENT][NEUTRAL] OK
[CUSTOMER][POSITIVE] Um, I do have them. I did pull up the copies that I have on my desktop, and they do look pretty blurry. Um, I was able to download them directly to my desktop and they look better, so I can resend those.
[CUSTOMER][NEUTRAL] Um, that says the admission and discharge dates and times. Um, the only thing I can find that shows like an admission, well, it doesn't show an admission time, but it shows what time he, like a time that he was in the hospital, one of the first things that was done is the uh pre-anesthesia report.
[CUSTOMER][NEUTRAL] It shows that that was the uh service date and time. It shows the [PII] at [PII]
[CUSTOMER][NEUTRAL] That's the only thing I can find with like a.
[CUSTOMER][NEUTRAL] A date on it as far as what time he was in the hospital. I believe he was there earlier than that, but this is the earliest.
[AGENT][NEUTRAL] OK, and this was for uh.
[CUSTOMER][NEUTRAL] For [PII].
[AGENT][NEUTRAL] Yeah for your dependent, OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yes, uh-huh.
[AGENT][NEUTRAL] Yeah, it does appear they're a little.
[AGENT][NEGATIVE] Blurry and hard to read um so let me see if.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me take a look at the other.
[AGENT][NEUTRAL] So usually what
[CUSTOMER][NEUTRAL] Uh, this anesthesia.
[AGENT][NEUTRAL] Yeah, go ahead.
[CUSTOMER][NEUTRAL] Oh, go ahead.
[AGENT][NEUTRAL] Uh, and that's what I'm looking at now is the, so usually what we request is.
[AGENT][NEUTRAL] That proof of loss being that itemized bill and then it needs a procedure and diagnosis codes. Now, when it's an observation status, so normally under that hospital indemnity, it has that um if you, if there was an admission to the hospital, um it uh does require that room and board charge. Now, we can consider observation um as an inpatient, but it has to meet that, uh.
[AGENT][NEUTRAL] Definition and just bear with me for one moment.
[AGENT][NEUTRAL] So in other words it has to meet that definition of inpatient being that if it's in an observation unit, it has to be 18 hours or more so that's why it's requesting that date and time now um just bear with me for one moment because I see.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, this looks a little bit clearer.
[AGENT][NEUTRAL] This is under the accident.
[CUSTOMER][NEUTRAL] Yeah, so he, he went to a, a different hospital for the accident. Um, we went to the, the nearest hospital. Uh, they told us that they were unable to, like they were able to just dress it and keep it.
[CUSTOMER][NEUTRAL] So, you know, clean, um, and referred us to the other hospital. He needed a hand specialist and they said they didn't have anyone on staff.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That could handle that. So the accident was at like the hospital was different for the accident one. And he was only there for, I don't know, maybe 5 or 6 hours with that one. But then the next day is when we went to the other hospital, they admitted him in the morning. I believe that we were there pretty early.
[CUSTOMER][NEUTRAL] Um, the earliest time I can find is [PII] that was on the pre-anesthesia report, and then he was discharged the next day at like [PII]
[CUSTOMER][NEUTRAL] So I don't know if this uh the pre-anesthesia records would be verification enough for what time he was actually there.
[AGENT][NEUTRAL] Usually, um, the facility where he was kept in the in the observation, they should be able to provide you that uh itemization showing that, um, at least if not the time, um, most of the time though, they can provide that information for you as well and you just kind of.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] You know let them know what's needed if you're able to speak with someone sometimes that's not possible. a lot of times you have to go through that, you know, a portal um but basically if you're able to what we, what we could use is um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, possibly, uh, a hit like a hit admit discharge summary, um, or like I said if they can provide you, there's a form called a UBO4.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's kind of like a universal billing, yup, U like umbrella, B like boy.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 04
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now what that is is um can I ask, do you have a primary uh uh major medical insurance in addition to this plan?
[CUSTOMER][NEUTRAL] Uh, yes. Yeah, and they're, we actually, so my husband's on Medicare, and then he's also covered under my insurance. And there is an issue between the two of them right now. They're trying to decide who is primary and who is secondary. Yeah, and so nothing's been paid on this yet because they're going back and forth trying to figure out those details.
[AGENT][NEUTRAL] OK, so what.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Who primary
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so if um because you do have that major medical.
[AGENT][NEUTRAL] Excuse me, insurance in place that UBO4 form, it's a universal billing form, and what it does is the, the hospitals and, and, uh, facilities they use that form to bill to insurance companies, so it will give us all of that information. It will give us the patient's name, the admit, uh, admit and discharge time and date diagnosis and then usually they'll have that charge on there for observation.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so they'll give you, if it's not the exact time, it will give us at least the unit so like I said, it does need to be 18 hours or longer in order for it to be uh considered inpatient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So with that um like I said if we're able to obtain that UBO4 form that should help us and kind of guide us to, you know, that admit date and discharge date and then that time like I said they'll they'll bill it in units usually so it it it will have that number of how however long he was there and you said he was admit admitted on which date?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] On, uh, the accident was the [PII]. He was admitted to the hospital on the [PII] in the morning. Um, I believe it was, I don't remember what time we had to be there, but I remember it was pretty early, and then he was discharged on the [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so like I said if we can.
[CUSTOMER][NEUTRAL] So he was there for just over 24 hours.
[AGENT][NEUTRAL] Right, that's what I was just gonna say. So it sounds like it was at least that 24 hours, so it would meet that 18 hours, um, of course it, you know, if those units show that it's more than the 18 hours, then we would consider it as inpatient. Now like I said, if possible, if you're unable to obtain that UBO4 form.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] My suggestion would be to get like an admit and discharge summary because that will also, you know, give us that information. Usually they'll list when the um admission and then, you know, what transpired for treatment and then how he was discharged to, you know, go home and where, where he should follow up. Usually it's a specialist or PCP you know, your, your primary care physician. So, um, either one of those would be helpful.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and, and should provide us that information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I do have a discharge summary. I just don't have an admission summary for some reason. I'm just, I'm in his portal for the uh for the hospital that um we went to.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And they have, they, I don't know why they don't have the admit one in there, um, but maybe I'll just call them and tell them that I need that if I get the UBO4 form, does that also um uh because on here it says, uh, we need itemized bills with the admission and discharge dates and time and then it also says.
[CUSTOMER][NEUTRAL] Itemized statements of services provided listing the charges diagnosis codes and procedure codes would that form satisfy both of those? OK.
[AGENT][NEUTRAL] Yes, and I was just gonna say that UBO4 will kind of cover all of that um because like I said it will have those dates that we need um the patient information and then like I said it will have that itemization of charges because like I said that's what they use to build your your major medical insurance so um that's what they require so that's kind of why we kind of hold it hand in hand with that, you know, because it's basically all the information encompassed in that one form.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Oh fantastic.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] OK, OK, fantastic. I will give them a call uh right now and see if we can get a copy of that.
[AGENT][NEUTRAL] OK, did you have any other questions, Ms. [PII]?
[CUSTOMER][NEUTRAL] OK, and then on the.
[CUSTOMER][NEUTRAL] Um, I guess the accident one, does that have a different policy number for that one?
[AGENT][NEUTRAL] Um, let me take a look here.
[AGENT][NEUTRAL] Yes, and I'm just gonna look at that real quick, bear with me for a moment.
[CUSTOMER][NEUTRAL] OK, yeah, if I could see if there's anything else that's needed for that one too.
[AGENT][NEUTRAL] Now, um
[AGENT][NEUTRAL] It looks like.
[AGENT][NEUTRAL] It looks like we did um process that um.
[AGENT][NEUTRAL] Under the accident policy and we did pay some of the benefits, but we are asking for that same information as far as the admission, um, the admission to the hospital and the um daily hospital benefit because under your accident policy there is a benefit payable for the admission to the hospital and then that daily confinement benefit.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, now that claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I don't show that um I, I showed that it was finalized on [PII] so a check, a paper check was mailed out um to your address on file. I don't see any direct deposit set up so you could be expecting a check, um, you'll be expecting a check for that. um, now let me just take a look here.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And you said only a portion of that was paid because it's missing the same information?
[AGENT][NEUTRAL] Right, it looks like we paid a benefit of $325 on that initial so that paid the um the benefits were paid for initial emergency room, the X-ray, and then like I said, the hospital admission and discharge, we were um requesting that same information for the um admit and discharge information.
[AGENT][NEUTRAL] And then it looks like um we paid a benefit for that fracture on his finger as well and so the total uh the total amount for the check under that accident policy is gonna be $325.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then like I said, we'll need that admit and discharge so we can process those benefits um that might be payable under that policy as well.
[CUSTOMER][NEUTRAL] OK. Um,
[CUSTOMER][NEUTRAL] OK, OK, so when I, uh, fax this information over, should I include the page with the requested information and then let them know that this is needed for the accident and the hospital portion of the claim?
[AGENT][NEUTRAL] Um, you don't necessarily need, so what happens when you resubmit that information, it will, it will open up a new claim number but it's still the same claim. So what we'll do is, um, we usually reconcile what's on file and, and in this case like I said we, we did process some of the benefits under the accent policy but we did request additional information so I can give you that claim number if you'd like and you can reference that claim number and um on the submission if you'd like.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Oh yeah perfect.
[AGENT][NEUTRAL] Um, that makes it a little bit easier, um, so under that, under the accident policy that claim, uh, claim number is gonna be 35.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] 4
[AGENT][NEUTRAL] 7681.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And again that's the admit and discharge information and like I said I'm gonna indicate in the notes that uh I I uh asked you to request that UBO4 form or like I said the admit and discharge summary so that's under the accident policy and then under the um hospital indemnity that claim number.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 35.
[AGENT][NEUTRAL] 45.
[AGENT][NEUTRAL] 953.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, just to, to let you know, it looks like um I'm not sure how it happened. It's possible because the pages were blurry and not uh not legible. Normally, we would uh
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] We would look under that additional policy for you, but it looks like so just and I'm telling you this just so in case you do get extra paperwork you won't um you won't be surprised by it. So what happens is it looks like when we first received the claim it was actually processed under you, but the notes do indicate that it should have been for uh part two which is for [PII], so it's probably gonna get reprocessed again under the correct uh under the correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, patient, so, um, you may receive duplicate information because we did send an explanation of benefits out to you and I think that's what you received and it's for that claim, the 354-595-3, is that what you received? Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, yes, that's what I thought, yes, OK.
[AGENT][NEUTRAL] OK, and it probably has your information on there and you may not have even noticed that it was processed under you.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] It should
[CUSTOMER][NEUTRAL] Oh well it says claimant [PII], so that should be my husband [PII]. OK, got you. Oh yeah, because I see insured is me at the top and the claimant should have been him. Yes, yep, I see that.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] That's correct, yeah, so.
[AGENT][NEUTRAL] Yes, so I see that it was um it was corrected and put under [PII], but that has not been, um, that second information has not been processed yet and, um, just like I said I just kind of wanted to give you a heads up so you weren't too confused when you got an additional request for the same information so I just wanted to let you know that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, perfect. OK, I appreciate that. OK, well thank you very much. You've been very helpful. I will contact the hospital right now and see if I can get those records and get those sent out as soon as possible.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, and like I said, even if they have a conflict of how they're billing, they should still have that UBO4 on file and like I said, what you'll just do is let them know that you have a supplemental, um, a supplemental policy and you're trying to uh submit that claim to us, but we're requesting that UBO4 form if it's available.
[CUSTOMER][POSITIVE] OK. OK, perfect. OK, thank you so much. You've been very helpful.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you Ms. [PII]. Thank you for calling APL. I hope your husband's feeling better and on the mend.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Oh thank you, yeah, thank you. I appreciate it.
[AGENT][POSITIVE] Have a great day and thank you for calling APL.
[CUSTOMER][POSITIVE] Thank you. Uh-huh, bye-bye.
[AGENT][NEUTRAL] Mm bye bye.