AccountId: 011433970860
ContactId: 86f106c2-c54e-496d-944f-8944ca1a20e2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 681010 ms
Total Talk Time (AGENT): 147766 ms
Total Talk Time (CUSTOMER): 311946 ms
Interruptions: 5
Overall Sentiment: AGENT=0.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/15/86f106c2-c54e-496d-944f-8944ca1a20e2_20250515T13:22_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Good morning, [PII]. This is [PII] over in customer care. How are you?
[AGENT][NEUTRAL] Fine, how are you?
[CUSTOMER][NEUTRAL] I'm good. Um, I have an insured on the line. Her name's [PII], and she's wanting to speak to somebody on a denied claim. I was hoping you could help with.
[AGENT][NEUTRAL] What's the policy number?
[CUSTOMER][NEUTRAL] 736958
[AGENT][NEUTRAL] And which claim is it on?
[CUSTOMER][NEUTRAL] It's 360-1282.
[CUSTOMER][NEUTRAL] And her question on the denial is really the hospice not covered.
[CUSTOMER][NEUTRAL] Um, she said that he was in a like hospice facility, um, and so she's just questioning why that was denied.
[AGENT][NEUTRAL] Oh, OK, so this is on part 2. I was under part 1. Let me see.
[CUSTOMER][NEUTRAL] Oh yes, I'm sorry, yeah, it's for [PII].
[AGENT][NEUTRAL] See what we got here.
[CUSTOMER][NEUTRAL] I looked at what she submitted, but.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] So you said it was in regards to the hospice care, you said?
[CUSTOMER][NEUTRAL] Yeah, so that was really her biggest concern, um, she said that.
[CUSTOMER][NEUTRAL] She understood the ambulance, um.
[CUSTOMER][NEUTRAL] Even though she said he was admitted, she's like, I guess it was an ambulance ride to the hospital admitted and then back home, but really the biggest one she was worried about was the hospice. She didn't understand why it wasn't being paid when it's a cancer policy.
[AGENT][NEUTRAL] Mm, let me see what did she send us here.
[CUSTOMER][NEUTRAL] She said, I see the EOB. I see.
[AGENT][NEUTRAL] I see.
[AGENT][NEUTRAL] Give me a second, let me pull up the certificate to see.
[CUSTOMER][POSITIVE] No worries.
[AGENT][NEUTRAL] What the policy says about it.
[CUSTOMER][NEUTRAL] I see it says hospice care center. I'm wondering now in my brain like, did she, did, did he just get hospice at home? I didn't ask that, but now I'm wondering if maybe that was the case.
[AGENT][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] In a hospice care center, yeah, it has to be benefits for each day is received in a hospice care center.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So, what we got was
[AGENT][NEUTRAL] Just some EOB so they say the name of the.
[CUSTOMER][NEUTRAL] Uh, I saw hospice, but let me see if I can find anything.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] I'm looking at here.
[AGENT][NEUTRAL] Mm, it looks like it could, it says, it says the name which is Northeast Georgia Medical Center, but it's
[AGENT][NEUTRAL] Return home.
[AGENT][NEUTRAL] So, I'm not sure if this was at home with the home healthcare.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] For the hospice care, I guess we'll have, I have to clarify that from her.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And this is, um, Ms. [PII] on the line?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, we're speaking with Ms. [PII], and I have a callback number for that's different than the one she's calling from if you want it.
[AGENT][NEUTRAL] OK, what is that number?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] Yeah, no worries, [PII]. I appreciate you.
[AGENT][POSITIVE] Mhm. You're welcome.
[CUSTOMER][NEUTRAL] Alright, here she comes.
[AGENT][POSITIVE] Thanks.
[AGENT][NEUTRAL] Claims department this is [PII].
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII].
[AGENT][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] Um, do you have my story or should I start all over?
[AGENT][NEUTRAL] Yeah, she had the, [PII] had told me that you were calling, you had questions in regards to the hospice that was denied, the hospice services.
[CUSTOMER][NEUTRAL] Yeah. Yeah.
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Um, it's kind of a little contradicting, but I'm sure there's a lot of reasons. Um, I understand the part that says he must be coming from a hospital in the hospice, so he was in hospice care for 5 days, and he had to be transported only by, of course, ambulance there and then the ambulance actually brought him home 5 days later, so we could, you know, kind of.
[CUSTOMER][NEUTRAL] Help him pass um.
[CUSTOMER][NEUTRAL] So I I just didn't know if that had been considered in this claim, um.
[CUSTOMER][NEUTRAL] He was impatient and he stayed there for 5 days. It was an actual
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It looked like a little hospital, you know.
[CUSTOMER][NEUTRAL] Anyway,
[CUSTOMER][NEUTRAL] I just want to make sure that had been considered before I just said OK they didn't pay nothing.
[CUSTOMER][NEUTRAL] Initially I've had this policy for so long.
[AGENT][NEUTRAL] OK, so he was initially confined.
[AGENT][NEUTRAL] And then went into the hospice care.
[CUSTOMER][NEUTRAL] I initially, well, we had many hospital, we had many hospital visits, but this particular before, no, he, he, he, he was, he was at home and we were doing the best we could, but we had to break um.
[CUSTOMER][NEUTRAL] He was trying to do too many things and so we had to get him into a hospital setting where they could mon where they could create.
[CUSTOMER][NEUTRAL] of medicine pattern that we could live with and that he could understand because the cancer had hit his brain. So we had to actually put him into hospice care for 5 days to get him kind of stabilized with treatment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, and then, of course, you know, things went down and anyway, so we brought him home to pass. I didn't want him passing there, so, um.
[CUSTOMER][NEUTRAL] I just, I just wanted to make sure my story had
[CUSTOMER][NEUTRAL] Being considered with the fact that.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] OK. So, Ms. [PII], so he was at the hospice facility for some [PII]e and then he went home on the hospice care?
[CUSTOMER][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Yes, well, he was in, he was in hospice when he went to the facility for 5 days.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me take a look at the claim. Give me one moment, I'm gonna put you on a brief hold.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thanks for holding, Ms. [PII]. OK, so I do show that the, the hospice benefits were denied saying that the policy does not cover hospice services. However, I do show that the policy does have a hospice care center benefit. So I will send, have this claim further reviewed um and give you a call back regarding that. And can you verify your callback number for me?
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] That would be perfect. Yeah, that'd be perfect.
[CUSTOMER][NEUTRAL] Sure, [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. I will give you a call back regarding this claim. Is there anything else I can assist you with today, Ms. [PII]?
[CUSTOMER][MIXED] No, I just wanted to kind of add to that. I know we've had this policy forever and so grateful. Oh my gosh, so grateful that it's just, it's been amazing to help thank you but uh so I reached out to the hospice in the beginning and I said I need an itemized statement. Well, in order to get that I got to take time off work. They want a $25 filing fee.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] To go get the copies, it's so much per copy and I was like.
[CUSTOMER][NEUTRAL] You know, if, if I need to do that, if it's gonna pay enough, but it's anyway, so when I got the Medicare statement, I thought, well this verifies it, so hopefully that'll work if, if they need copies and I don't know, I just have to make that decision I guess but.
[AGENT][NEUTRAL] OK, if we need any other information I'll I'll let you know but I'm gonna have the claim looked at a little further and give you a call back.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much. I do appreciate it.
[AGENT][POSITIVE] You're welcome. Thank you for calling APL. You have a good day.
[CUSTOMER][NEUTRAL] Uh huh you too bye bye.
[AGENT][NEUTRAL] Bye.