AccountId: 011433970860
ContactId: 93517946-505a-4565-9ed9-b3dc6fc78f50
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 540000 ms
Total Talk Time (AGENT): 244549 ms
Total Talk Time (CUSTOMER): 178502 ms
Interruptions: 4
Overall Sentiment: AGENT=0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/07/93517946-505a-4565-9ed9-b3dc6fc78f50_20250107T23:12_UTC.wav
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[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I wanted to see what was I missing on my end.
[CUSTOMER][NEUTRAL] On my claim, I think they told me with my, it was the explanation of benefits, but I wanted to reconfirm.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Yes I can help you with with your claim and what you need can I please get your name and your call back number just in case our call is disconnected?
[CUSTOMER][NEUTRAL] Really.
[CUSTOMER][NEUTRAL] [PII] and my call back number is.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and your first name was [PII], you said?
[CUSTOMER][NEUTRAL] Yes, I.
[AGENT][NEUTRAL] OK, [PII], what is your policy number, please, sir?
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] 243 557 8.
[AGENT][NEUTRAL] OK, let me look that up.
[AGENT][NEUTRAL] OK, [PII], can you verify your date of birth for me, sir?
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][NEUTRAL] Thank you. And then I'm also going to need for you to verify your address, phone number, and email address that we have on the policy for you.
[CUSTOMER][NEUTRAL] My address is [PII]. Phone number is [PII].
[CUSTOMER][NEUTRAL] Uh, my email address is [PII].
[AGENT][NEUTRAL] OK, thank you. I appreciate you verifying that information. OK, so I do see a claim that was reported on [PII], is that the one you're checking about?
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let me look at that one for you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yes, sorry, thank you.
[AGENT][NEUTRAL] Do you have the claim number?
[CUSTOMER][NEUTRAL] Um, yes, I do. Well, it's, yeah, I do have it. 354.
[AGENT][NEUTRAL] OK, what is that please?
[CUSTOMER][NEUTRAL] 773 6.
[AGENT][NEUTRAL] OK, that claim number.
[AGENT][NEUTRAL] Is saying that this was a duplicate claim looking at it, it says that um.
[AGENT][NEUTRAL] The above reference claim appears to be a duplicate of a previous submitted expenses so let me look and see if I can find the original for you.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Oh, I think I, I have another one here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, it's, uh, where that I see here 354-0546.
[AGENT][NEUTRAL] OK, let me look.
[CUSTOMER][NEUTRAL] Well, it's because they had asked me for something else and they told me to update it like that, that's why.
[AGENT][NEUTRAL] Oh, OK, alright, so let's look and see 354.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 0546.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Come
[AGENT][NEUTRAL] OK, so part of this claim was paid, but then we have remarks that say, please provide a diagnosis code for this state of service. This information can be obtained from the physician's office or the hospital.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Wait.
[CUSTOMER][NEUTRAL] Front of
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Oh, for the actual play, not the, it's not, but it's not the it's not the explanation of benefits, right?
[AGENT][NEUTRAL] Right. It is the diagnosis code.
[AGENT][NEUTRAL] For the data service.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then it also says um part of the claim was denied because the policy does not provide a benefit for prescription drugs.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Yes sir, but then, um, looking at it, let me go back to it and let me let you know that for um.
[CUSTOMER][NEUTRAL] Please
[AGENT][NEUTRAL] The urgent care part of it, the express urgent care, $55 was paid on that part.
[CUSTOMER][NEUTRAL] Yeah, the IP
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] Yeah, yeah, I paid that.
[AGENT][NEUTRAL] So the rest of it, OK. So the rest of it are the two codes that I mentioned to you that we need the diagnosis code and then the prescription drugs aren't covered.
[CUSTOMER][NEUTRAL] Mo
[CUSTOMER][NEUTRAL] Well, the prescription one, I won't worry about that. It wasn't that much.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, let me try to get the diagnosis code. I mean, yeah, the diagnosis code.
[AGENT][NEUTRAL] Yes sir, OK, you can go ahead and get that and then send it in and then um allow uh 5 to 10 business days for them to review the claim again and process it, OK?
[CUSTOMER][NEUTRAL] OK, I have another question. I went to um, um.
[CUSTOMER][NEUTRAL] I went to another doctor for
[CUSTOMER][NEUTRAL] For something else.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] He was like a surgeon specialist, but I'm not sure if you guys cover that as well.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so, um, let me look at your policy real quick.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that was outpatient or inpatient?
[CUSTOMER][NEUTRAL] Uh, that was inpatient.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] On your policy.
[CUSTOMER][NEUTRAL] She she should
[AGENT][NEUTRAL] You have an inpatient and this is just to give you your coverage and it's not a guarantee of payment. You have an inpatient calendar year benefit of $3500 per year um to help you with your deductible, your co-pay, or your co-insurance. So if you were in the hospital for more than 18 hours,
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] And um you could file the claim.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] But I'm not sure if you guys would accept it because it's uh.
[CUSTOMER][NEUTRAL] It was for, it was for a healthcare specialist.
[AGENT][NEUTRAL] But you were in the hospital for more than 18 hours?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, in order for that inpatient benefit to kick in, you'll have to be in the hospital more than 18 hours.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But it was like a regular doctor visit though.
[AGENT][NEUTRAL] Oh, so then that would be, let's look at this.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You have outpatient benefits $750 per calendar year to be used in an ER urgent care center, MRI imaging center or an ambulatory center, but I do not see that you have office visits.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, I'll send it in if anything and I'll see what you guys take a look at it.
[AGENT][NEUTRAL] OK. All right. Was there anything else [PII], I can help you with?
[CUSTOMER][NEUTRAL] No, that's it for now. I'm gonna try to get this uh.
[CUSTOMER][NEUTRAL] The diagnosis for.
[AGENT][POSITIVE] OK. All right. Well, you have a good rest of your night, [PII], and we thank you for calling APL.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] You too. Thank you.
[AGENT][POSITIVE] You're so welcome. Bye-bye, [PII].
[CUSTOMER][NEUTRAL] Bye bye.