AccountId: 011433970860
ContactId: 89547ea3-579a-40de-bd15-c2dab510dfc3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 321119 ms
Total Talk Time (AGENT): 128067 ms
Total Talk Time (CUSTOMER): 114030 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/26/89547ea3-579a-40de-bd15-c2dab510dfc3_20250226T16:34_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Um, I am calling because so we got denied for a claim that was sent in and I'm trying to send in my appeal.
[CUSTOMER][NEUTRAL] Um, is there a way to submit this online or do I need to actually mail this to you guys?
[AGENT][NEUTRAL] OK. Are you the provider or the insured?
[CUSTOMER][NEUTRAL] The insured
[AGENT][NEUTRAL] OK, may I have your name?
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] And [PII], may I please have a callback number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] May I have your policy number?
[CUSTOMER][NEUTRAL] 02352915
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And is this claim for you or for the spouse?
[CUSTOMER][NEUTRAL] The, um, so my husband [PII] is the insured. I'm the spouse and the claims for me.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And could you verify your date of birth for me please, [PII]?
[CUSTOMER][NEUTRAL] Uh, mine is [PII].
[AGENT][NEUTRAL] And then I also need to verify the mailing address listed on file.
[CUSTOMER][NEUTRAL] Um, it should be our new one which is [PII].
[AGENT][NEUTRAL] OK, and thank you so much [PII], for verifying the policy and you stated that a claim had been denied. Do you have that date of service?
[CUSTOMER][NEUTRAL] Uh, there were quite a few dates of service, um.
[CUSTOMER][NEUTRAL] I don't. And I left the paperwork at uh my husband's um at home. Um.
[AGENT][NEUTRAL] May I have one of them?
[CUSTOMER][NEUTRAL] Uh, what's the last one that was done.
[CUSTOMER][NEUTRAL] Was [PII].
[CUSTOMER][NEUTRAL] I had a series of 7 different
[CUSTOMER][NEUTRAL] Procedures done for.
[CUSTOMER][NEUTRAL] My legs.
[AGENT][NEUTRAL] OK, so I did pull that claim up.
[AGENT][NEUTRAL] And so what it's denying for is that you don't have the office visit benefit writer or the office procedure writer. So that's the reason why those claims denied.
[CUSTOMER][NEUTRAL] So I, I just, I don't understand that. I mean.
[AGENT][NEUTRAL] OK, so anything that is rendered within an office setting this policy does not have those benefit riders.
[CUSTOMER][NEUTRAL] OK, even though it is a clinic where he, this is where all their work is done.
[AGENT][NEUTRAL] Yes, anything that's billed.
[CUSTOMER][NEUTRAL] So you're saying I can only get stuff done in a hospital?
[AGENT][NEUTRAL] Yes, the way that this policy is looking.
[CUSTOMER][NEUTRAL] Alright
[AGENT][NEUTRAL] It shows that you do, you just don't have anything that is rendered within an office setting period. So that is the reason why those claims and the other claims denied.
[CUSTOMER][NEUTRAL] OK, and there's no way of disputing this?
[AGENT][NEUTRAL] No, it would either once we, if we receive it again it would deny either as a duplicate of the previous submitted claim due to that it's just not covered under this policy. Now, if there, if you're needing to add additional benefits, then the, your spouse or your husband, he will have to speak with his HR department to see if that can be updated. But as of right now, that benefit is not listed on here.
[CUSTOMER][NEUTRAL] Is that something, even though the procedures have already been done, if we added that on now, can we get that covered?
[AGENT][NEUTRAL] The only way is if they had backdated it to the effective date, but I doubt that they would do that. They normally would just start it at the beginning.
[AGENT][NEUTRAL] Or when they request for that update, so the ones that has already been submitted in it's a possibility that those will not be reprocessed and paid.
[AGENT][NEUTRAL] But he would just have to discuss that with his HR department.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right. Well, thank you.
[AGENT][POSITIVE] And is there anything else I can, you're welcome. Anything else I can assist you with today, [PII]?
[CUSTOMER][POSITIVE] That's it. Thanks.
[AGENT][POSITIVE] Thank you for calling American Public Life. Have a great day.