AccountId: 011433970860
ContactId: 7619337b-4335-4f49-af0a-74b2e1d0ad43
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 318279 ms
Total Talk Time (AGENT): 139945 ms
Total Talk Time (CUSTOMER): 101700 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=-1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/24/7619337b-4335-4f49-af0a-74b2e1d0ad43_20250224T19:13_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, yes, good afternoon, [PII]. This is [PII] and I'm calling to check on a claim.
[CUSTOMER][NEUTRAL] I was on the phone earlier with somebody and.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] They, it got cut off and they never call me back.
[AGENT][NEUTRAL] OK, let's see, can I go ahead and get a good callback number from you?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. I need to check on a claim. Do you have your policy number?
[CUSTOMER][POSITIVE] Uh, yes, let me get that for you.
[CUSTOMER][NEUTRAL] It is 211-0350.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK, I think that was me we were talking to yeah it just disconnected um I tried calling back but I don't know it might have been a problem on my end. I apologize for that.
[AGENT][NEUTRAL] Let's see. OK, I'm gonna verify that information again if you don't mind. Can I get uh your date of birth, please?
[CUSTOMER][NEUTRAL] Or [PII]?
[AGENT][POSITIVE] Thank you and then uh your mailing address please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Got it. OK, thank you for verifying that. Alrighty, yes, so I have that information pulled up. Give me just a moment, [PII]. I'm gonna put you on a brief hold, um, and then I'm going to reach out to our claim specialist regarding this, um, again this was for the, um.
[AGENT][NEUTRAL] It was an inpatient um hospital visit, but we declined it as outpatient, right?
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, yes. Give me just a moment, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Sing.
[CUSTOMER][NEUTRAL] Afternoon, thanks for calling APL. This is [PII]. How may I help you?
[AGENT][NEUTRAL] Hey [PII], this is [PII] over on the care team. How are you?
[CUSTOMER][NEUTRAL] Fine, how are you?
[AGENT][NEUTRAL] Doing all right, thank you. I have a member on the line wanting to talk to y'all. Um, she submitted a claim for her HI policy. It denied as not covering of outpatient surgery. She said that it is inpatient. Um, she did say that, you know, the, she submitted the correct information and all that, that shows that it was over 18 hours. Um, I have that information whenever you're ready.
[CUSTOMER][NEUTRAL] Sure, what's the policy number?
[AGENT][NEUTRAL] 2,110,350.
[AGENT][NEUTRAL] And it's for a part two, that's who we're speaking with.
[CUSTOMER][NEUTRAL] No it's 211-0351?
[AGENT][NEUTRAL] 50.
[CUSTOMER][NEUTRAL] And which claim is it in regards to?
[AGENT][NEUTRAL] So I think she submitted it quite a few times, but I believe the original was uh 356-336-1.
[CUSTOMER][NEUTRAL] OK, let me glance and see what we got.
[AGENT][NEUTRAL] I tried looking. I don't see anything with times, but she did say that she submitted that. Um, I don't know, there does seem to be some confusion with this because at first she said it was, she was there for 32 hours.
[AGENT][NEUTRAL] But then she said that it was from the [PII], so at the most that would have been 24, but.
[CUSTOMER][NEUTRAL] Let's see, on this first document, she only sent the surgeons.
[CUSTOMER][NEUTRAL] Information, let me see on this most recent claim.
[CUSTOMER][NEUTRAL] That was processed on the [PII].
[CUSTOMER][NEUTRAL] OK, OK, so we have the UV, so let me take a look and see what we have here on here if it had any.
[CUSTOMER][NEGATIVE] Yeah, that's why I was denied. Even on the EOB it's outpatient. It doesn't have any observation hours or room and board.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] So in order for us to consider it under inpatient, we need either the admin discharge summary that provides us what time they were admitted on the [PII] and what time they were discharged on the [PII] cause the UV doesn't even show that they had a room or any observation hours. So that's why I was denied again as um.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, and I told her that, um.
[AGENT][NEGATIVE] I told her that and she said that was what she had originally sent. That's why I tried looking at this first claim, but even there I couldn't see anything.
[CUSTOMER][NEGATIVE] It doesn't. That's just the surgeon's, that's just the surgeon's information. It doesn't provide us with the time she was admitted or discharged on the [PII] and that's what we're needing.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right. OK. Would you mind explaining that to her?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][POSITIVE] I appreciate it. Are you ready for her now?
[CUSTOMER][NEUTRAL] Yeah, you can send it to me.
[AGENT][POSITIVE] All right, thank you, bye bye.