AccountId: 011433970860
ContactId: 71e0e4c0-7b09-422d-9ecb-8cfef34dc136
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 426500 ms
Total Talk Time (AGENT): 193216 ms
Total Talk Time (CUSTOMER): 132893 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/22/71e0e4c0-7b09-422d-9ecb-8cfef34dc136_20250122T21:10_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], I'm not sure if I selected the correct option, but I figured, well, you might be able to help me anyway um I got a text that I could look at a claim online when I log into my account that claim number doesn't exist.
[AGENT][NEUTRAL] Um, let's see here. Can I get your name please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK [PII], um, what is a good call back number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK [PII], do you have your policy number?
[CUSTOMER][NEUTRAL] Uh, I could probably find it pretty quickly.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I did have it pulled up here. Give me a second.
[AGENT][NEUTRAL] If you don't, I can look it up by your social.
[CUSTOMER][POSITIVE] I can give you my social that'll probably be faster.
[CUSTOMER][NEUTRAL] It is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Uh,
[AGENT][POSITIVE] Oh my goodness, give that to me one more time. I put it in incorrectly. I'm so sorry.
[CUSTOMER][NEUTRAL] That's OK. [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, let's see here. What is your, um, mailing address, [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and what about your date of birth and email address?
[CUSTOMER][NEUTRAL] Date of birth is [PII]. The email, I don't know if it's [PII] or [PII].
[AGENT][NEUTRAL] It was the first one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let's see here.
[AGENT][NEUTRAL] OK, did it give you a claim number or?
[CUSTOMER][NEUTRAL] It did, it gave me the number 355.
[CUSTOMER][NEUTRAL] 3666
[AGENT][NEUTRAL] OK. Um,
[AGENT][NEUTRAL] It's probably not showing up yet honestly even though I sent you that text because the claim was just finalized.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes ma'am, it's probably gonna take um just a little bit of time because the claim was just finalized.
[CUSTOMER][NEUTRAL] OK, so which claim is this one for? Because I filed 2.
[AGENT][NEUTRAL] OK, this is gonna be for your hospital indemnity claim. That's the claim I'm looking at now.
[CUSTOMER][NEUTRAL] Oh, OK, OK, well I had sent them some information but didn't know if it was gonna be enough and they still had to have the EOB that I was waiting for from my insurance company.
[AGENT][NEUTRAL] OK, um, I can definitely go over the claim details with you now since I have you on the phone if you would like.
[CUSTOMER][POSITIVE] Oh that would be lovely thank you.
[AGENT][NEUTRAL] OK, you're welcome. OK, so this claim, let's see.
[AGENT][NEUTRAL] Um, so it looks like you sent in.
[AGENT][NEUTRAL] OK, so it looks like you sent in a data service of [PII] through [PII]?
[AGENT][NEGATIVE] Those um got denied because it was prior to the effective date.
[CUSTOMER][NEUTRAL] So the, the hospitalization was [PII].
[AGENT][NEUTRAL] OK, yes ma'am, I do see that um it's just I'm looking at this line right now and those got denied because it was prior to the effective date.
[AGENT][NEUTRAL] Um, and then the [PII], and then the [PII].
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK, so those got denied, um, let me just go over this denial code with you. It states that the policy provides an inpatient indemnity benefit when a covered person is confined as an inpatient to a hospital due to an injury or covered sickness. The benefit is not payable for outpatient treatment, emergency room treatment, or a stay less than 18 hours is in an observation unit.
[AGENT][NEUTRAL] For the purpose of this cert certificate, treatment does not include surgery. Based on the information received, the service was not due, due to an inpatient hospital stay. Therefore, no benefits are payable.
[CUSTOMER][NEGATIVE] So, because I went in for surgery and was there for about a day and a half, it's not covered.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] So it had to be an injury?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] I'd have to look at the policy to understand that better, but my understanding is that it would have been covered for a hospital stay.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Sorry, I'm just rereading this. Give me a second.
[AGENT][NEUTRAL] OK, yes ma'am, um.
[AGENT][NEUTRAL] So it's not covered due to the surgery. Yes, ma'am.
[CUSTOMER][NEUTRAL] And it's just because it's a surgery, not because it was because it was an outpatient, it was a true surgery, so.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, I'll have to look into that a little bit more. I'm sure there's an opportunity to appeal that, but.
[AGENT][NEUTRAL] Yes, ma'am. And since um it was denied on [PII] and it from us, um, it was released at [PII] last night, um, but you always have the option to appeal it since you, if you do not agree with it, so you have 6 months from the denial date to appeal it.
[AGENT][NEUTRAL] So whenever you appeal it um you do have to send in an appeal letter so it does have to come in the form of a letter and it has to be signed and dated.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it, OK.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] Not a problem.
[AGENT][NEUTRAL] Is there any OK is there anything else I can take a look at for you?
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] I can't think of anything right now.
[AGENT][POSITIVE] OK, well if you have any more questions you know definitely give us a call back and we'll help you with anything we can.
[CUSTOMER][POSITIVE] Alrighty thank you.
[AGENT][POSITIVE] Yes ma'am, well have a good day and thanks for calling APL.
[CUSTOMER][NEUTRAL] You too. Bye bye.
[AGENT][NEUTRAL] All right bye bye.