AccountId: 011433970860
ContactId: 727aba55-cb55-42f1-afe6-fe7d867ae7e7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 825979 ms
Total Talk Time (AGENT): 249573 ms
Total Talk Time (CUSTOMER): 373690 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/26/727aba55-cb55-42f1-afe6-fe7d867ae7e7_20250326T14:14_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah, hi, I just wanted to kind of verify that the last claim that I submitted I just got like a text message saying that it was completed, so I just wanted to see I don't see really on my end what the result is like for if there was any payout or anything.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, can I get your name?
[CUSTOMER][NEUTRAL] First name is [PII]. Last name is [PII].
[AGENT][NEUTRAL] Mhm, what's your policy number?
[CUSTOMER][NEUTRAL] Uh, you know what, I don't have that in front of me. Hold on one second.
[CUSTOMER][NEUTRAL] Wash hands really, really quickly, OK?
[AGENT][NEUTRAL] Oh sure.
[CUSTOMER][NEUTRAL] Sorry, hold on, I'm
[AGENT][POSITIVE] No worries.
[CUSTOMER][NEGATIVE] Sting in my stomach. Um, oh shit, I just had it.
[CUSTOMER][NEUTRAL] 214501-1
[AGENT][NEUTRAL] And what's a good phone number, [PII] in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] I've been trying.
[CUSTOMER][NEUTRAL] Hi [PII]. No, we're not sitting in the sink.
[CUSTOMER][NEGATIVE] Oh sorry
[CUSTOMER][NEUTRAL] Sorry for the noise.
[AGENT][NEUTRAL] It's OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hey [PII] do not lift him up.
[AGENT][NEUTRAL] And what's your
[AGENT][NEUTRAL] What's your date of birth, [PII]?
[CUSTOMER][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, it's a claim for you?
[CUSTOMER][NEUTRAL] Uh, the claims for me, yeah, it's my husband's policy.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so this is for a data service of [PII] looks like it's an office visit and you may have had an X-ray, OK, and so the check amount is for 2, the check amount is for 275.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, is there anything in addition to that?
[CUSTOMER][NEUTRAL] For like the.
[AGENT][NEUTRAL] Yeah, this is the benefit for each of the services performed so that's the amount of this check.
[CUSTOMER][NEUTRAL] 275 total.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] There's something else that is in there for some is it for a different claim?
[AGENT][NEUTRAL] OK, what, what did you submit?
[AGENT][NEUTRAL] This is processed under your accident claim?
[CUSTOMER][NEUTRAL] Like there were 2.
[CUSTOMER][NEUTRAL] There's 2 separate accident claims. There was one for the office visit and then the one was one for the hospital.
[AGENT][NEUTRAL] Was it for the same date? The same accident or two different exits?
[CUSTOMER][NEUTRAL] Do you see if there was
[CUSTOMER][NEUTRAL] No, it was.
[CUSTOMER][NEUTRAL] Two different.
[CUSTOMER][NEUTRAL] Let me see what the dates.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] I can't see the date of service but it's.
[CUSTOMER][NEUTRAL] Claim, do you need a claim number?
[AGENT][NEUTRAL] If you haven't.
[CUSTOMER][NEUTRAL] 358-037-9
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Shut
[AGENT][NEUTRAL] OK, so that was processed yesterday as well, um, the notification that you received, did it have that claim number on the notification?
[CUSTOMER][NEUTRAL] He
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It didn't. Oh wait, I'm trying to look.
[CUSTOMER][NEUTRAL] Yes, I had 2 of them.
[AGENT][NEUTRAL] OK, that's something new that's why I was asking. Did you get a text message letting you know that the claim had been completed?
[CUSTOMER][POSITIVE] Oh great.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and then it listed the two claim numbers. OK, so this one is for date of service [PII], this check is for 600.
[CUSTOMER][NEUTRAL] And this is the emergency department 29.
[AGENT][NEUTRAL] Uh-huh. Mhm.
[CUSTOMER][NEUTRAL] Oh, OK. And what was that, that, um.
[CUSTOMER][NEUTRAL] What was that including? Like it was that including the imaging and the the emergency room bill or the emergency room, uh, is it?
[AGENT][NEUTRAL] It's the
[AGENT][NEUTRAL] Facility charge, the provider that treated you while you were there. And then did you have an X-ray done?
[CUSTOMER][NEUTRAL] I had 2 CTs and an X-ray.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And then I haven't gotten the ambulance bill yet to submit.
[CUSTOMER][NEUTRAL] So I'm just.
[AGENT][NEUTRAL] OK, so we
[CUSTOMER][NEUTRAL] I'm obviously gonna do that when that happens, but.
[AGENT][NEUTRAL] Mhm. So regarding the X-ray, if, if, if more than one major diagnostic exam or X-ray um is submitted, we'll pay um the highest applicable benefit and I think we paid the X-ray on the other claim that I went over.
[CUSTOMER][NEUTRAL] I just didn't know what.
[AGENT][NEUTRAL] The first one
[CUSTOMER][NEUTRAL] Yeah, that was a that was a separate um claimer injury.
[CUSTOMER][NEUTRAL] The hospital, the hospital one was completely different, like,
[CUSTOMER][NEUTRAL] Weeks later.
[AGENT][NEUTRAL] Let me look at your policy wording.
[AGENT][NEUTRAL] It take me a few minutes to look at your policy. Give me a second.
[CUSTOMER][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] He
[CUSTOMER][NEUTRAL] He's Oh, I don't have that baby. I wanna do OK.
[CUSTOMER][POSITIVE] As soon as we're done, I'm done on the phone, we'll try to, we can play a game.
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] So where did you put it?
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Still looking.
[AGENT][NEUTRAL] OK, so in your policy wording it says that the X-ray, uh, must occur within 365 days after the covered accident. That's a check. Uh, this benefit is payable once per covered accident and up to 5 days per plan year. So you've had 2 in a plan year. It's, it's.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It's OK.
[AGENT][NEUTRAL] It says if more than one major diagnostic exam or X-ray occurs on the same day, which this wasn't the same day.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Only the single highest applicable benefit is payable, so this is a different day, so I'm gonna have this looked at.
[AGENT][NEUTRAL] The 2nd X-ray that we didn't pay.
[CUSTOMER][NEUTRAL] OK, so just to
[AGENT][NEUTRAL] For the for the February date of service.
[CUSTOMER][NEUTRAL] Say that again.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The, the, the, the, yeah, the X-ray that you had done on the [PII], we denied it, but in reading the policy wording, it says that if more than 1.
[CUSTOMER][NEUTRAL] No, say that, say what you said again?
[AGENT][NEUTRAL] Major diagnostic exam or X-ray occurs on the same day, which these are two different days.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Only the single highest applicable benefit is payable. OK, so I'm gonna check that because it's two different days, but then the paragraph before that says the X-ray must occur within 360365 days after the covered accident occurs, a check on that one. this benefit is payable once.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Hello
[CUSTOMER][NEUTRAL] As a
[AGENT][NEUTRAL] He covered accident.
[AGENT][NEUTRAL] So you're saying this is a totally different accident.
[CUSTOMER][NEUTRAL] So, so this is.
[AGENT][NEUTRAL] Is it a totally different accident?
[CUSTOMER][NEUTRAL] Yes, the one the claim that I went to the immediate care which was I, I can't remember the date of service. I think it was like.
[CUSTOMER][NEUTRAL] February or January?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It was January, the immediate care. I had just got like X-rays done during that immediate care visit.
[AGENT][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Then Super Bowl Sunday, so [PII] or something like that or whatever date that was.
[CUSTOMER][NEGATIVE] I fell at home and like synopized and hit my head and hit my hip, was transported to the emergency department because I like was unresponsive for a couple of seconds and my husband called an ambulance and while I was at the hospital, they did a CT of my brain and then they did an X-ray of my hip.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Because I had hip pain and the, the X-ray of my hip was like inconclusive from like calcification or something along those lines where they couldn't determine if there was like a fracture. So they CTed my hip.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So that was completely different. That was like February and the other one was completely different. So I had an X-ray in January and an X-ray and two CTs in February.
[AGENT][NEUTRAL] So what was the accident in January?
[CUSTOMER][NEUTRAL] Two different accidents.
[CUSTOMER][NEUTRAL] I fell and slipped in my driveway on ice, and I took myself to the immediate care because I had neck and back pain, and they diagnosed me with cervical radiculopathy because I had numbness and tingling throughout my arms, like bilateral arms.
[CUSTOMER][NEUTRAL] From the fall that I had in January.
[CUSTOMER][NEUTRAL] So that was just an X-ray in January. So that seems like that claim is accurate. I just was curious on what the $600 was covering, like the emergency room and then like one major diagnostic. Is that what that's my understanding?
[AGENT][NEUTRAL] Yeah, so 300 was for the ER treatment, so that would be for the emergency room treatment and then the other one was for.
[CUSTOMER][NEUTRAL] Yes, yes.
[CUSTOMER][NEUTRAL] And then would it be 300 for the major diagnostic?
[AGENT][NEUTRAL] And the other one you had a CT scan?
[CUSTOMER][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] Yeah, so we paid a $300 benefit on that. So that's diagnostic.
[CUSTOMER][NEUTRAL] So,
[AGENT][NEUTRAL] That was on [PII].
[CUSTOMER][NEUTRAL] That would be accurate then.
[AGENT][NEUTRAL] Mhm. Mhm.
[CUSTOMER][NEUTRAL] So that's what I was curious about what the $600 was for and then the.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You said that the
[CUSTOMER][POSITIVE] Immediate care was just for.
[CUSTOMER][NEUTRAL] But um in immediate care and.
[AGENT][NEUTRAL] The claim in the claim in January, the claim in January.
[CUSTOMER][NEUTRAL] Yes, it was just the X-ray, which was I think $75.
[AGENT][NEUTRAL] Yeah,
[AGENT][NEUTRAL] And then did you report to like an urgent care?
[CUSTOMER][POSITIVE] Correct.
[AGENT][POSITIVE] Yeah, there was a $200 200 dollars benefit for that.
[CUSTOMER][NEUTRAL] And then the 75 for the X-ray.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, then it seems accurate to me. I just was curious to make sure that it was that that was what you were seeing, OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It is.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah, it is, it is.
[CUSTOMER][POSITIVE] Makes sense now. OK, alright, I appreciate it. And then do you know how quick of a turnaround it's for like getting the money deposited?
[AGENT][NEUTRAL] Oh, OK.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Yeah, so it was, so they were processed on yesterday. The, the checks were released this morning and so allow 3 to 4 business days from today's date to see them in your account.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you very much. I appreciate it.
[AGENT][POSITIVE] Oh, you're welcome. Did you have any other questions I can assist with today, [PII]?
[CUSTOMER][POSITIVE] No, that's it. Thank you.
[AGENT][POSITIVE] Alright, thanks for calling APL have a good day.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Bye bye.