AccountId: 011433970860
ContactId: 83559506-1783-4bc7-a732-2155d381809f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1029420 ms
Total Talk Time (AGENT): 316133 ms
Total Talk Time (CUSTOMER): 196948 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/04/83559506-1783-4bc7-a732-2155d381809f_20250604T19:31_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, I wanted to see the status of a claim. It's just, uh, the website's not letting me log in.
[AGENT][NEUTRAL] Yes, we are having issues with the website since we launched the new version. I do apologize for the inconvenience, but I'll be more than happy to help you with the claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And may I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, it's uh [PII].
[CUSTOMER][NEUTRAL] Uh, telephone number is [PII].
[AGENT][NEUTRAL] Thank you. And may I have your policy number?
[CUSTOMER][NEUTRAL] Uh, that I don't have. I can give you my social.
[AGENT][NEUTRAL] Oh, that's fine.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] So I'm just waiting for the policies to come up here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, it just pulls up. Hold on one moment.
[AGENT][NEUTRAL] And I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] Uh, date of birth is [PII].
[CUSTOMER][NEUTRAL] Uh, address is [PII].
[CUSTOMER][NEUTRAL] And email isos [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And so this is for your medical policy, right?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah, it's a hospital indemnity.
[AGENT][NEUTRAL] Yes, the reason I'm asking is because I don't see any claims here. Um, like it's literally blank. We haven't received any claims yet.
[CUSTOMER][NEUTRAL] Yeah, there was, uh, I mean.
[AGENT][NEUTRAL] Did
[CUSTOMER][NEUTRAL] I had done it on the old website and then I even right now uh I got a text talking about my updated claim status.
[AGENT][NEUTRAL] OK, let me see.
[CUSTOMER][NEUTRAL] And uh that's that
[CUSTOMER][NEUTRAL] That's the reason I called.
[AGENT][NEUTRAL] Let me see if there's something under the.
[AGENT][NEUTRAL] Accident policy because this screen is completely blank. Hold on one second. Was there anything in reference to an accident or is it is the hospital indemnity?
[CUSTOMER][NEUTRAL] No, it is a hospital indemnity. It was uh something done for my daughter, [PII].
[AGENT][NEUTRAL] Oh, OK, it's not for you. OK. I'm looking at you. I'm sorry. Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Not a problem.
[AGENT][NEUTRAL] Let me go back to the medical. And then as for Olivia.
[AGENT][NEUTRAL] OK, here we go.
[AGENT][NEUTRAL] So I'm just waiting for the claim to come up here. Hold on one moment.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] OK, so we received the claim on [PII] and then [PII], but they're both being denied for the same reason. It's not covered under the member's policy. What, let me open this, hold on one second.
[AGENT][NEUTRAL] Do you mind if I place you on just a brief hold so I can look at these claims and what was submitted and see what's going on?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] No, because they say you gotta pull up the EOB.
[AGENT][NEUTRAL] So let's see 804.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Um, uh, 60 528.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello Mr. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, thank you so much for holding. I apologize for the wait. Um, so I pulled up the document that was received, the, um, your, your, the patient copy of the itemized bill. Um, I'm gonna reach out to a claims examiner and have them go over the claim with you because I, I mean, I see what it says, but I don't.
[AGENT][NEUTRAL] I'm not a claims examiner, so I don't know why this, this was denied, but I also don't know what they're looking for, so I'd rather you speak with claims so they can go over it with you because they're processing it.
[CUSTOMER][POSITIVE] Not a problem.
[AGENT][NEUTRAL] All right, before I get a claims examiner on the line with you, was there anything else I could assist you with today?
[CUSTOMER][NEGATIVE] Uh, no thank you.
[AGENT][POSITIVE] All right, well, thank you so much for calling APL and hold on one moment, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Good, thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], this is [PII] on the care team. How are you doing?
[CUSTOMER][NEUTRAL] Fine, how are you?
[AGENT][NEUTRAL] I'm good. Um, I have an insured on the other line. They want to go over this claim and why it was denied.
[CUSTOMER][NEUTRAL] What's the policy number?
[AGENT][NEUTRAL] Um, 248-801-4.
[CUSTOMER][NEUTRAL] And who was it on?
[AGENT][NEUTRAL] Um, it's for part 3, but the policyholder is on the line.
[CUSTOMER][NEUTRAL] Let me see, for [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, let's see what we got here what we received, give me a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so it looks like this is.
[CUSTOMER][NEUTRAL] For an ER visit.
[CUSTOMER][NEUTRAL] You get though.
[CUSTOMER][NEUTRAL] Coverage here.
[CUSTOMER][NEUTRAL] OK, so all they have is hot inpatient benefits.
[CUSTOMER][NEGATIVE] They don't have outpatient services. That's why nothing was payable. They only have when they're confined in the hospital.
[AGENT][NEUTRAL] Oh, and these are all outpatient, OK.
[CUSTOMER][NEUTRAL] Mhm, it doesn't the policy doesn't cover outpatient services. It only covers inpatient.
[CUSTOMER][NEUTRAL] So that's why they weren't covered.
[AGENT][NEUTRAL] OK, I can
[AGENT][NEUTRAL] OK, I can let him know because he was saying it was a hospital stay and I'm thinking inpatient and um OK.
[CUSTOMER][NEUTRAL] Yeah, it says out out outpatient facility looks like it was in the ER. Um, it looks like this is 421 to 422. So based on what we have, it looks like outpatient is there's no room charges, no observation information on on this information that we have. Looks like this is just the explanation of benefits, not the actual itemized billing.
[AGENT][NEUTRAL] We received, right.
[CUSTOMER][NEUTRAL] So if he was confined at least 18 hours or more, then we definitely would need the itemized billing with diagnosis codes and that information to further review it but what we have now is just indicating ER outpatient visit which is not covered.
[AGENT][NEUTRAL] OK, um, I will still transfer him to you because he's gonna have more questions. I can explain that, but when he goes further.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] I just don't want to get stuck because he's asking a lot of questions, um.
[AGENT][NEUTRAL] I'll go ahead and help him. If I need help, I'll call back.
[CUSTOMER][NEUTRAL] OK, that's fine.
[AGENT][POSITIVE] Alright, thank you.
[CUSTOMER][POSITIVE] OK. You're welcome.
[AGENT][NEUTRAL] Alright bye bye.
[CUSTOMER][NEUTRAL] Mm bye.
[AGENT][NEGATIVE] I'm so tired of this
[AGENT][NEUTRAL] We are the banks, OK.
[AGENT][NEUTRAL] Let me see how I can find this.
[AGENT][NEGATIVE] Right, but if we're not supposed to be doing research, I, I shouldn't even know that. I went above and beyond and she still didn't let me hush because I'm not on mute.
[AGENT][NEUTRAL] Hello Mr. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, thanks again for holding. I do apologize for that wait. I was on hold on the other line, but while I was on hold, let me ask you this. Was this an inpatient? Like was she admitted into the hospital or is this all outpatient, like emergency room or?
[CUSTOMER][NEUTRAL] Uh, I mean,
[CUSTOMER][NEUTRAL] We were just there from uh
[CUSTOMER][NEUTRAL] Uh, for an emergency, and um,
[CUSTOMER][NEUTRAL] Essentially we got there like maybe like at [PII].
[CUSTOMER][NEUTRAL] And then we were literally
[CUSTOMER][NEUTRAL] Let go at [PII] the next day. So, I mean, we're just there for, cause she was having a, a breathing episode.
[CUSTOMER][NEUTRAL] But we were in the hospital.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, but the reason I'm
[CUSTOMER][NEUTRAL] So I'm not sure like what.
[AGENT][NEUTRAL] The reason I'm asking this question is because your policy doesn't have any outpatient benefits, only inpatient, like if you're admitted into the hospital, you go into a room. So that's why I'm asking trying to do if it was like in the emergency room, that's considered outpatient and that's why this claim was denied because it's not a covered service on your policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But if you do have like itemized billing or something from the hospital showing that she was admitted, there's a discharge date, um.
[AGENT][NEUTRAL] Like itemized billing, this is more the explanation of benefits from your insurance company. But if you have like the itemized bill from the hospital or something showing that it was inpatient, she was admitted and, you know, treated, then your this policy benefits can come into place. But if it was like an emergency room, even if it was ours, if it was still in the emergency room and she was never admitted, that's considered outpatient.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] But this policy doesn't have any coverage for outpatients.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Not a problem.
[AGENT][NEUTRAL] But if you do get the billing and you see that it was something like inpatient, definitely submit it so that we'll reprocess it um if we need to.
[CUSTOMER][POSITIVE] OK, not a problem.
[AGENT][NEUTRAL] All right. Was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] Uh, no, thank you.
[AGENT][POSITIVE] All right. Well, thank you so much for calling APL and I do hope you have a good day.
[CUSTOMER][NEUTRAL] Alright you as well.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][POSITIVE] Thank you, bye.