AccountId: 011433970860
ContactId: 7701a42c-fd03-4265-8b4b-74ea688846fa
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 892119 ms
Total Talk Time (AGENT): 380195 ms
Total Talk Time (CUSTOMER): 395667 ms
Interruptions: 4
Overall Sentiment: AGENT=1.2, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/25/7701a42c-fd03-4265-8b4b-74ea688846fa_20250325T16:25_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, yes, um, did you want my name or the certificate number or group number?
[AGENT][NEUTRAL] What's your policy number?
[CUSTOMER][NEUTRAL] Um, 02319989.
[AGENT][POSITIVE] Thank you. And what is your name, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] And what is a good callback number, Ms. [PII], in case we get disconnected, I can get right back to you.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And do you mind verifying your date of birth and current mailing address, please, ma'am?
[CUSTOMER][NEUTRAL] Sure, it's uh [PII].
[CUSTOMER][NEUTRAL] And my mailing address is [PII].
[AGENT][NEUTRAL] All right, thank you. And what about your email address? Let's just verify that while I got you on the line.
[CUSTOMER][NEUTRAL] Uh, my work or personal?
[AGENT][NEUTRAL] Looks like we have a Gmail address on file.
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[AGENT][POSITIVE] All right, thank you. Ms. [PII]. I've got your policy pulled up. How can I help you today?
[CUSTOMER][NEUTRAL] I was calling to check um.
[CUSTOMER][NEUTRAL] I had surgery um [PII] of last year.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And um I know UMR my medical um insurance flagged it as um an accident.
[CUSTOMER][NEUTRAL] And um
[CUSTOMER][NEUTRAL] So there was some difficulty processing that, but I, I called them actually back in February um so they are reprocessing it and um I think I had a letter from you guys saying that you guys didn't, it was an overnight um.
[CUSTOMER][NEUTRAL] Hospital stay with the surgery?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I know that that has um that'll.
[CUSTOMER][POSITIVE] Like extends um my coverage right because there's only like.
[CUSTOMER][NEUTRAL] $2700 or something for the.
[CUSTOMER][NEUTRAL] You know, like MRIs and CTs and whatever, but if you're.
[CUSTOMER][NEUTRAL] If you have an overnight hospital stay or longer that covers a little bit more, I think the, the balance goes up to like up to 5000 or something. I don't know, but anyways, can you check on that to see if um anything was paid out and if not why and if we can.
[AGENT][NEUTRAL] Mhm
[AGENT][POSITIVE] Absolutely. Yes, it would be my pleasure to check on that for you. And what was that data service again, if you don't mind?
[CUSTOMER][NEUTRAL] Relook at that.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] It was [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, let's see if we have any claims on file for that data service.
[AGENT][NEUTRAL] Now for [PII] I don't have a claim on file.
[AGENT][NEUTRAL] For a hospital visit.
[CUSTOMER][NEUTRAL] December would.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] In [PII], no claim on file. I do have one for Saint Thomas Medical Partners for [PII], but it is for an office visit.
[CUSTOMER][NEUTRAL] Yeah, that's when I was released, yeah.
[CUSTOMER][NEUTRAL] Oh that's weird. I didn't go into the office.
[CUSTOMER][NEUTRAL] Oh, they must have missed.
[AGENT][NEUTRAL] Hang on just a second, yeah.
[CUSTOMER][NEUTRAL] You know, the little medical codes that they have.
[AGENT][NEUTRAL] Let me check this for you real quick. Hang on just a second.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] I'll look at that claim real quick for you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] My pleasure.
[AGENT][NEUTRAL] It's taking a minute for it to come up. Bear with me just one second.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] I understand.
[AGENT][NEUTRAL] Now, are you receiving a bill from the hospital?
[CUSTOMER][NEUTRAL] Um, not from the hospital, but from me, um.
[CUSTOMER][NEUTRAL] Uh, the doctor.
[CUSTOMER][NEUTRAL] Because like I said, the um my UMR um.
[CUSTOMER][NEUTRAL] I think flagged it as an accident and so they denied it and I called in February I think February, excuse me, um, [PII], and the guy sent me a confirmation email and everything and I just called, um, I think on Friday and for some reason he didn't update it correctly because it never went through so I talked to another lady she said she was putting it through.
[CUSTOMER][NEGATIVE] Um, to be reevaluated, um, and of course you know I was upset because this is.
[CUSTOMER][NEUTRAL] Yeah, 4 months later.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Going on 5 months.
[CUSTOMER][NEUTRAL] And I have a.
[CUSTOMER][NEUTRAL] Another visit with my surgeon on the [PII], so I mean I kind of.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So this was
[CUSTOMER][NEUTRAL] Like to be able to because last time I told them.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That it was gonna be paid, you know.
[AGENT][NEUTRAL] So this is from a doctor [PII] Does that name sound familiar?
[CUSTOMER][NEUTRAL] No, I mean unless it was.
[AGENT][NEUTRAL] Sounds like it might have been a
[CUSTOMER][NEUTRAL] Uh, my, my surgeon was [PII], so it could have been one of his like assistant, medical assistants or a hospitalist.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] That might have seen you in the, I mean, in the hospital.
[CUSTOMER][NEUTRAL] The the
[CUSTOMER][NEUTRAL] Physical therapy? Yeah, yeah, because I definitely didn't. I went from the hospital home, so I didn't see anybody on the [PII].
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Except for in the hospital.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Yeah, so we do not have a hospital claim on file.
[AGENT][NEUTRAL] The only thing that we have on file is for this uh [PII], Doctor [PII].
[AGENT][NEUTRAL] And he is with the Saint Thomas Medical Partners.
[AGENT][NEUTRAL] So that is probably one of the physicians that saw you in the hospital.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] During your time there.
[AGENT][NEUTRAL] So I would contact the hospital and make sure that they have our APL information on file.
[AGENT][NEUTRAL] And see if they will file a claim with us.
[AGENT][NEUTRAL] Was it for a surgical procedure?
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And you can also.
[CUSTOMER][NEUTRAL] But it's, I'm more worried about surgeon. I don't think I have.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] anything from the hospital, maybe it is the hospital that.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Maybe I'm confused. Maybe it's no, because it was the surgeon's office when I went there.
[AGENT][NEUTRAL] I don't have a claim from the surgeon's office either.
[CUSTOMER][NEUTRAL] But you don't have either, the surgeon's office or the hospital.
[AGENT][POSITIVE] That's right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I will contact them and make sure and I'm sorry, I should probably write this down because it the um if it was a hospitalist or.
[AGENT][POSITIVE] You're fine. You take your time.
[CUSTOMER][NEUTRAL] Because I didn't actually see him, you know, um, and you said it's [PII].
[CUSTOMER][NEUTRAL] Could you spell his last name?
[AGENT][NEUTRAL] Sure. It's [PII], Dealer, yeah.
[AGENT][NEUTRAL] [PII] Dealer MD.
[CUSTOMER][NEUTRAL] From the extension Saint Thomas Partners.
[AGENT][NEUTRAL] Mhm and that was for data service 12-624.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah, that was probably the hospitalist, just to make sure that I could.
[CUSTOMER][NEUTRAL] Go home.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Alright, I will
[CUSTOMER][NEUTRAL] Give them a call and make sure they submit that then and have your information.
[AGENT][POSITIVE] Absolutely.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And OK, and then I guess I will um.
[CUSTOMER][NEUTRAL] Since you don't have the surgeon or the hospital, make sure that they send you what they have.
[CUSTOMER][NEUTRAL] And get this taken care of I guess, but I, I am correct and assuming there's for a surgery and overnight stay that does.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Extend what you guys will pay past the normal outpatient.
[AGENT][NEUTRAL] Right, so, and I can go over this benefits with you know, benefits given over the phone is a verification of coverage and not a guarantee of payment.
[CUSTOMER][NEUTRAL] Procedure stuff correct?
[AGENT][NEUTRAL] For your
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Outpatient benefits, you do have coverage up to $2400 per calendar year.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Now there is a $100 deductible that has to be met before that $2400 is paid on claims.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And for your outpatient services, that is when you're in the hospital, less than 18 hours.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And that does include emergency room, outpatient.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Surgery.
[AGENT][NEUTRAL] Diagnostic testing.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Physical therapy, you have the benefits for treatments in a doctor's office, independent lab facility, durable medical equipment, um, you also have a home health care writer, as well as a cancer outpatient treatment writer.
[AGENT][NEUTRAL] Now that is under your outpatient benefit and if you're in the hospital less than 18 hours, that is under your outpatient.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] For your inpatient hospital, that is anything over 18 hours.
[AGENT][NEUTRAL] That benefit amount is $4000 per calendar year that we can pay towards your hospital stay.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Over 18 hours.
[CUSTOMER][POSITIVE] Perfect.
[AGENT][NEUTRAL] And we do have a portal. If you're ever interested, you can create an account on our portal at secured.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And you can view your, click on your policy number and view your policy benefits. You can also view claims.
[AGENT][NEUTRAL] And click on claim numbers to see what the claims decisions were. Now of course those will always be mailed to you as well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But you can look at that online.
[AGENT][NEUTRAL] Also, and if you need to print additional cards, you can do that.
[CUSTOMER][NEUTRAL] OK, yeah, I have to create a log in.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][POSITIVE] Perfect, I will have to look at that.
[AGENT][POSITIVE] Absolutely.
[CUSTOMER][POSITIVE] All right, well thank you for your help.
[AGENT][POSITIVE] Well, it has been such a pleasure to assist. yeah, go ahead. I'm ready for you.
[CUSTOMER][NEUTRAL] Um,
[AGENT][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] Um, I'm just.
[CUSTOMER][NEUTRAL] Think oh what was I probably have the email um.
[CUSTOMER][NEUTRAL] No, that would have been if it was last year.
[CUSTOMER][NEUTRAL] What can you search by like um.
[CUSTOMER][NEUTRAL] You know, just any current claims for this year.
[AGENT][NEUTRAL] Mhm, I sure can. Let me check and see if we have any claims for this year.
[AGENT][NEUTRAL] And we do, let me check that for you.
[AGENT][NEUTRAL] West Tennessee Healthcare Henry for Data Service 2 1225.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And we paid them $140.
[CUSTOMER][NEUTRAL] Let me
[CUSTOMER][NEUTRAL] I'm just looking for any, you know, problems that like wasn't paid that I need to.
[AGENT][NEUTRAL] There was also.
[CUSTOMER][NEUTRAL] You don't give any more information.
[AGENT][NEUTRAL] Yeah, there was also a West Henry Healthcare, a West Tennessee Healthcare Henry um for Data Service 210, and we paid $350.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And for data service [PII], we paid 180. That's all to West Tennessee Healthcare Henry.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now there was a claim.
[AGENT][NEUTRAL] For
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] For WT Medical Associates, they billed for an office visit, and of course your office visit is not covered for the co-pay.
[AGENT][NEUTRAL] And that's on [PII].
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEGATIVE] So it's denied.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Perfect well good it seems like.
[CUSTOMER][NEUTRAL] At least I'm caught up with that. I just have to get the.
[CUSTOMER][NEUTRAL] Hospital and or the surgeon for the surgery last year.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] Um, all right, I appreciate all your help.
[AGENT][POSITIVE] Well, it has been a pleasure to assist you with that information and claim information, Ms. [PII], and don't forget to set up that account online. I think that will be useful for you to be able to see what claims we processed and received. But if you have any questions along the way or need further assistance, never hesitate to give us a call. We're here for you.
[CUSTOMER][POSITIVE] Absolutely.
[CUSTOMER][POSITIVE] All right, thank you so much have a good day.
[AGENT][POSITIVE] It's been such a pleasure. Thank you for calling APL. You have a wonderful day as well and take care.
[CUSTOMER][POSITIVE] Thank you bye bye.
[AGENT][POSITIVE] Thank you. Bye-bye.