AccountId: 011433970860
ContactId: 86d65048-f240-40ca-918f-ee9e16569ee3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 994059 ms
Total Talk Time (AGENT): 632475 ms
Total Talk Time (CUSTOMER): 306969 ms
Interruptions: 4
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/17/86d65048-f240-40ca-918f-ee9e16569ee3_20250317T20:38_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], how are you? This is [PII].
[AGENT][POSITIVE] I'm good how are you sir?
[CUSTOMER][NEUTRAL] I'm good. I'm good, thank you. I have a question. Uh, are you, um, is the claim support also handling right now the HI and the accident, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, good. Alright. I have a member on the line with an HI and uh she submitted a claim and it looks like she's saying that it's not fully paid that um we pay only 3 physical therapies and it's supposed to be 5.
[CUSTOMER][NEUTRAL] And yeah, I told her I can send her a request to have it reprocessed and she said she wants somebody in the claims department to assist her.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, can I get that policy number?
[CUSTOMER][NEUTRAL] Yes, 2590118.
[AGENT][NEUTRAL] OK, so 21.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK, we pay up to 5 at $15.
[AGENT][NEUTRAL] Each $15 per visit.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Max is 5, OK.
[AGENT][NEUTRAL] Sorry, I'm just trying to get my thoughts together.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, I did check on it too just to make sure, but yeah, I only found 3 as well, so I'm like, OK.
[AGENT][NEUTRAL] OK, did, did you happen to notice when you were looking if there were 5 dates that could be paid?
[CUSTOMER][NEGATIVE] Um, yeah, we denied, um, I think we denied two of them, saying that she used the maximum, which that will not be true if we only paid 3.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, OK, so PT we paid 17 of 25, 113.
[AGENT][NEUTRAL] And 1:15.
[AGENT][NEUTRAL] And then we did not, 120.
[CUSTOMER][NEUTRAL] The 120. Mhm. So just one more, I guess, yeah, I was just checking.
[AGENT][NEUTRAL] And 220 I guess.
[CUSTOMER][NEUTRAL] Mhm. Oh yeah. Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah and it doesn't look like we've paid anything prior to this, nor did she have a policy prior to this, so.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I mean I'll talk to her but it looks like this needs to be sent back for review.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, that's the, yeah, and I told her that that's what probably we need to do, but she still wanted to ask, talk to you, so let me go ahead and transfer her, OK? All right, thank you. Here she comes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, that's fine sure.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Thank you for holding and being patient for me Ms. [PII]. I got Miss [PII] on the line. She's in the claims department and she's gonna assist you from here.
[CUSTOMER][POSITIVE] OK, thank you so much. You're welcome have a good afternoon.
[CUSTOMER][POSITIVE] Oh, you too. Thank you.
[AGENT][NEUTRAL] Hey, Miss [PII], this is [PII]. How are you?
[CUSTOMER][POSITIVE] How you doing, [PII]? I'm doing well.
[CUSTOMER][NEUTRAL] Um, I had, OK, she probably explained it to you.
[AGENT][NEUTRAL] Um, go ahead.
[AGENT][NEUTRAL] She did, she did.
[AGENT][NEUTRAL] Um, and what I'm looking at, um, I can see what you're talking about. Your policy does indicate a max of 5. it looks like we only paid 3 dates and we denied the other ones as the maximum for the benefit had been exhausted, um, so what I will have to do is, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Send this back to the examiner that processed it and have them um review and reprocess this claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so, um.
[CUSTOMER][NEUTRAL] 123 that would be 4. I know I have physical therapy tomorrow, so that would be my last one tomorrow, correct?
[AGENT][NEUTRAL] Um, so it looks like, let me, let me find the dates where we paid because it looks like we denied 120 and 220 which would equal your 5.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But I'm gonna double check those things.
[CUSTOMER][NEUTRAL] You did not one? OK, OK.
[AGENT][NEUTRAL] Yeah, just because I'm not, I, I haven't looked through every single document, so let me find those dates. OK, let's see, general visit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, PT, OK, so it looks like we paid 17, 113, and 115, and then we denied 120 through 220, which would be.
[AGENT][NEUTRAL] 123456789, 10 additional PT visits that were denied.
[CUSTOMER][NEUTRAL] Well, I, you know what, I, I, you know what I did, and I, my, that was my bad cause I sent all the dates, but I see what you're, OK, go ahead.
[AGENT][NEUTRAL] Yeah, yeah, all the dates were sent in, um, on, on that one on that one document and so we denied all like a date span for all of those dates. So what it'll be is that they'll have to go back and pull out two more dates from the state span and pay the additional 2.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes, OK, that's what I was um inquiring, that's all.
[AGENT][NEUTRAL] Yes ma'am, yes ma'am, and I will get this sent back over to them to get that reviewed. It usually doesn't take when it's coming from a call, um, from our insured or from a provider like that. It usually doesn't take more than 24 to 48 hours to get those reviewed and reprocessed, um, so I would say by Wednesday we should have that reviewed and reprocessed for you.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] You're very welcome. Is there anything else I can do for you?
[CUSTOMER][NEUTRAL] No, I just want to make sure what I have and what you guys think, cause see I wrote all this down ahead of time as well, so that's why the question what happened.
[AGENT][NEUTRAL] Yeah, yeah, of course, no that I mean that is perfectly amongst your rights to question it and and it looks like we have all of the information we need to get you maxed out. It looks like it could have just been done a little early, um, so like I said, I'm gonna have them go back and review this and indicate that there are additional dates and that your, your benefits do state that your maximum is 5,
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then I think let's see, the only, uh usually, and I'm gonna confirm, usually the only time that these can't be paid is when like something like a doctor's visit is on the same day. But um I would have to go back and read your language, but if that's the case, you have like 15 dates here to choose from, so, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, well, I'll let you guys choose from that.
[AGENT][NEUTRAL] OK
[AGENT][POSITIVE] OK, I'll have them go back and look at this and we'll get it all sorted for sure, OK?
[CUSTOMER][NEUTRAL] OK, one more question. So that means I can't solve anything else, if anything happens to me?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] So this your policy is per accident if I'm not mistaken it's not per year. Let me confirm because I don't wanna tell you that and then I'm wrong, um, let's see, physical therapy.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it states, let's see.
[AGENT][NEGATIVE] Per calendar year it doesn't say let me see if I can get your like actual policy pulled up because this is not pulling up.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] The screen that we have benefits on sometimes just does not provide all of that information.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So let me get over there and see if I can get that.
[CUSTOMER][NEUTRAL] You.
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Let's see
[AGENT][NEUTRAL] And you have.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Plan 2, so let's see if we can get that.
[CUSTOMER][NEUTRAL] Wait a minute. Wait a minute. Mommy's busy, OK, wait a moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] My little dog wants to play.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK OK.
[CUSTOMER][NEUTRAL] I of the ball.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] I think this is nope that's plan.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Uh, there's plan 2.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's look at these benefits.
[AGENT][NEUTRAL] See what we have here.
[AGENT][POSITIVE] Because sometimes that language, it'll be something for one benefit and something completely different for another.
[CUSTOMER][NEUTRAL] Tell me about it. Some, some small print.
[AGENT][NEUTRAL] I know it. I know it. OK. Um, per day when treatment due to an injury, sickness, the school or speech therapy, OK, so that.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Doesn't indicate limitations so let's go to your schedule and see what your schedule is.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] So it is 5 per calendar year on this so um it is gonna be per calendar year so any additional physical therapy related to an accident.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Um, for [PII], once this has been reviewed and processed, it will match you for the year. Now that does not mean that you don't have any additional benefits available. Um, let's see, because like your, your hospital stuff is gonna be per accident.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So that's going, God forbid you have to be in the hospital, but should you find yourself needing the hospital, that is per accident. So I wouldn't worry about that. Um, your office visits, like the physician's office visits, you get up to 3 of those. It looks like we've only paid for 2, so you have an additional office visit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Oh, I do.
[AGENT][NEUTRAL] Um, yes, you have an additional office visit because it looks like we've only paid for 2 because those are at $50 and um per day and we've only paid $100 so far. So we've only paid for 2 of those, you have one physician's office left. You have all of your urgent care visits left, which is $3 per year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] April.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you have all of your emergency room visits left, which is 2 per year.
[CUSTOMER][NEUTRAL] OK. What was the other one before that?
[AGENT][NEUTRAL] Um, urgent care.
[CUSTOMER][NEUTRAL] Oh, OK. It's like a little small hospital area?
[AGENT][NEUTRAL] Yeah, it's, it's basically like a um
[AGENT][NEUTRAL] Uh, like a minute clinic or something like that where you can, yeah, where you can go and not you're not quite seeing an ER facility but you're not going to a general practitioner either it's more emergent than that but less emergent than an actual emergency room so it's kind of one of those in between, but yeah, it's like a minute clinic or an urgent care facility or something like that, um, you get 3 of those.
[CUSTOMER][NEUTRAL] Yeah, uh-huh.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The nurse home
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And how many visits for that? 3, and the emergency room visits, 3 of those as well? Or was it 2?
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] You get 2 of those.
[CUSTOMER][NEUTRAL] 2. OK. God forbid, but, OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I know, I know we're not gonna speak that out there, but.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] No, but I want to get a um with I know I saw something that you don't cover like um.
[CUSTOMER][NEUTRAL] Serious mental illness. What is that?
[AGENT][NEUTRAL] Let's see, so that's probably in your exclusions, but.
[AGENT][NEUTRAL] Let's see, OK, so.
[AGENT][NEUTRAL] So we don't cover like intentionally self-inflicted injuries or sickness. Um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We don't cover.
[AGENT][NEUTRAL] Like if you're intoxicated or experimental treatments. Um, so it's a serious mental illness without demonstrable demonstrable organic disease. So, essentially, let me kind of
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So serious mental illness is defined.
[AGENT][NEUTRAL] By your policy as bipolar disorder, depression in childhood or adolescence, um, major depressive disorders, obsessive compulsive disorder, paranoid and other psychotic disorders or schizoaffective disorders.
[AGENT][NEUTRAL] Um, so those are the illnesses that are, are defined as serious mental illness in the policy and schizophrenia. Um, that's another one. I did, that was on the next page. So what it means by demonstrable, um, organic disease is that this is something that you have been diagnosed with. It's not like drug or alcohol-induced.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. What about just talking to a mental health counselor just to get out stuff.
[AGENT][NEUTRAL] Um, so like, uh, like therapy basically.
[CUSTOMER][NEUTRAL] Is that
[CUSTOMER][NEUTRAL] Yeah, that's what I, I do. I take therapy.
[AGENT][NEUTRAL] OK, so, um, it's going to that truthfully, the diagnosis may be covered, but that's going to fall under your like office visits and stuff because they are typically, if I'm not mistaken, they bill and are considered a physician's office because they are treating you, you know, therapy is treatment. So they are treating you for that disorder, whatever that may be, anxiety, depression, whatever that may be.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, and so,
[CUSTOMER][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] You know, you are limited to those number of physicians' office visits.
[CUSTOMER][NEUTRAL] OK, so there's just like the uh the one that I have. So I have one left so I can use that on that if I choose to.
[AGENT][NEUTRAL] So that would be your limitation there.
[AGENT][POSITIVE] Yes ma'am, you could.
[CUSTOMER][NEUTRAL] OK. No, I might as well, cause I have a, no, OK. So I have 1 physician's office visit, 2 emergency, and 3 emergency care visits if I have to go there.
[AGENT][NEUTRAL] Mhm. The, yeah, the urgent care. Mhm.
[CUSTOMER][NEUTRAL] OK. Uh, no, that's all. I just want to make sure, yeah.
[AGENT][NEUTRAL] OK. Uh yes, ma'am.
[CUSTOMER][NEUTRAL] Sorry about all the questions, but I just want to make sure that this is, this is totally different to me, this insurance.
[AGENT][NEUTRAL] No, that's OK.
[AGENT][NEUTRAL] Yeah, it's, it's new, um, uh, it's, it can be confusing because it's not like your major medical where you know we pick up or we or we pay a certain amount after you've met a deductible, you know, it's more, it's a little, I mean it is more limited than a regular major medical insurance because, you know, it only pays so many times per year or whatever so um.
[CUSTOMER][POSITIVE] But I appreciate you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yeah, not everybody has had this type of insurance before it can be confusing, but that's why we're here. We're, we're happy to answer any questions or concerns that you may have and try to help you understand your insurance a little bit better.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you. You did, you did a big help with that as well. Thank you so much.
[AGENT][POSITIVE] No problem.
[AGENT][POSITIVE] Oh well great you're so welcome if you need anything else or have any more questions, you give us a call OK?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] OK. Thank you so much, Ms. [PII]. All right. Bye-bye. Bye-bye. You too. Bye.
[AGENT][POSITIVE] OK. You're welcome. Have a great day. Bye-bye.