AccountId: 011433970860
ContactId: 782b3274-5173-486c-a6b6-dfbbc4a173b8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 483799 ms
Total Talk Time (AGENT): 119574 ms
Total Talk Time (CUSTOMER): 204924 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/20/782b3274-5173-486c-a6b6-dfbbc4a173b8_20250320T14:05_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, uh, I'm [PII]. Uh, I have the policy number. Can you pull up, please?
[AGENT][NEUTRAL] Um, yes, ma'am. One moment. Well, first, let me get your name and a good callback number just in case we're disconnected.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Thank you, [PII]. Now, well, I need the policy number.
[CUSTOMER][NEUTRAL] 025485554
[AGENT][NEUTRAL] And please verify your name again and your date of birth.
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK. And please verify your mailing address and your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And please verify your email address.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, but there's a different one.
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] The, the uh [PII].
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] OK. And how can I help you?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, I get the, um, the claim and then since like, uh, you deny again, uh, I have the claim number with me.
[AGENT][NEUTRAL] What's the claim number, please?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] 357 3 times 57.
[AGENT][NEUTRAL] OK. Thank you. One moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] people
[CUSTOMER][NEUTRAL] the.
[AGENT][NEUTRAL] OK. Yes, ma'am. I'm showing that this claim denied because under your policy for outpatient services, we only cover up to 1500 per calendar year and that was maxed out um back on [PII]. So before we received this claim, um your benefit maximum was reached for outpatient services for the calendar year.
[CUSTOMER][NEUTRAL] No, but
[CUSTOMER][NEUTRAL] But the bill coming just now.
[CUSTOMER][NEUTRAL] It's not coming last year.
[CUSTOMER][NEUTRAL] So I, I cannot use this year?
[AGENT][NEUTRAL] Now, we
[AGENT][NEUTRAL] Well, we received the claims and the order, we processed the claims and the order that we received them and we first received this claim, um, let's see, it was for date of service, [PII] for um beautiful for eye surgery.
[CUSTOMER][NEUTRAL] No, the, the, this.
[CUSTOMER][NEUTRAL] No, not that one, not that one. It's like, uh, uh, Doctor, uh Doctor [PII] in uh, uh, regarding the.
[CUSTOMER][NEUTRAL] Regarding the what, uh, regarding the injection in my back.
[AGENT][NEUTRAL] OK. And what was the date of service on that claim?
[CUSTOMER][NEUTRAL] Uh, I, I believe [PII], just a minute. I take a look, just a minute.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then I just get uh the bill right now, you know, just a minute.
[CUSTOMER][NEUTRAL] I have to open that just a minute.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] so.
[CUSTOMER][NEUTRAL] Oh my [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] With the make goodness I.
[CUSTOMER][NEUTRAL] But.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] OK, uh, here.
[CUSTOMER][NEUTRAL] Mm, billing summary.
[CUSTOMER][NEUTRAL] That's it then.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Oh that's there.
[CUSTOMER][NEUTRAL] That's it.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Just a minute because I have the.
[CUSTOMER][NEUTRAL] Stop in my car just a minute.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Oh my God
[CUSTOMER][NEUTRAL] Oh yeah, yeah.
[CUSTOMER][NEUTRAL] I believe.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] The service I believe on December.
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[AGENT][POSITIVE] Yes, ma'am. That's correct. I'm showing that it took place in December.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] And it took that charge took place in December, but your benefit had already maxed out in September. So there were
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] No, the, the thing is they sent the statement for [PII].
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] For [PII] of this year.
[CUSTOMER][NEUTRAL] Well, yeah, for the, for the procedure on December they sent to me um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Listen, um,
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] On, on, yeah, uh, they sent on.
[CUSTOMER][NEUTRAL] February, oh gosh.
[CUSTOMER][POSITIVE] It's pretty.
[CUSTOMER][NEUTRAL] [PII]. So how I know, you know, that I have a charge back then they just sent to me, uh, recently.
[AGENT][NEUTRAL] Well, we processed the claims in the order that we received them, ma'am, and your benefits had maxed out in September. So by the time you received that bill, your benefits had already maxed out for the calendar year. I apologize. But we, for your policy, we only cover up to 1500 per calendar year. And like I said, that benefit was maxed out in September. That's why that claim, um, that, that took place in December. That's why it denied.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] Oh my God, it's ridiculous. uh, thank you.