AccountId: 011433970860
ContactId: 9376dd47-f9ca-4e59-a45c-13a39d9f2322
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 773119 ms
Total Talk Time (AGENT): 387139 ms
Total Talk Time (CUSTOMER): 308279 ms
Interruptions: 14
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/22/9376dd47-f9ca-4e59-a45c-13a39d9f2322_20250422T19:51_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, ma'am. I wanted to check on a claim that I had filed.
[AGENT][NEUTRAL] OK, so you're the insured to check claims staff for yourself, is that correct?
[CUSTOMER][NEUTRAL] Yeah, well, it's actually for my husband.
[AGENT][POSITIVE] Yes, ma'am. I can help you with that. And what is, who am I speaking?
[CUSTOMER][NEUTRAL] Yeah, I think I
[AGENT][NEUTRAL] Ma'am.
[CUSTOMER][NEUTRAL] This is [PII].
[AGENT][POSITIVE] Thank you, Ms. [PII], what is a good callback number for you?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, and your policy number, please?
[CUSTOMER][NEUTRAL] 02
[CUSTOMER][NEUTRAL] 088763
[AGENT][NEUTRAL] OK, Ms. [PII], thank you. Give me a moment please to get all of your information pulled up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And Ms. [PII], I will have to verify with you first for security purposes and also any information that is provided would be a verification of benefits and not a guarantee of payment.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] So first off, if you would please verify your date and your husband's name and his date of birth.
[CUSTOMER][NEUTRAL] Uh, [PII] 9351.
[CUSTOMER][NEUTRAL] And [PII], 63053.
[AGENT][POSITIVE] OK, thank you. Also the home mailing address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. The phone number that we have on file for you is the same as the one that you provided for me, so that is the best contact number that we should have, is that correct? OK, and lastly your email address please.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so I do see that there is a claim that is to go through our nightly processing tonight, uh, Ms. [PII] for him.
[AGENT][POSITIVE] And this shows that the benefit.
[AGENT][NEUTRAL] To be paid is $100.
[CUSTOMER][NEUTRAL] On which part?
[AGENT][NEUTRAL] This would be on preventative. Let's see, it shows that there are 2.
[AGENT][NEUTRAL] To, uh, different dates of service for preventative.
[AGENT][NEUTRAL] At $50 each.
[CUSTOMER][NEUTRAL] OK, what is that
[CUSTOMER][NEUTRAL] He had 2 ambulance calls.
[AGENT][NEUTRAL] Yes ma'am, let me look.
[CUSTOMER][NEUTRAL] Is that what you're looking at?
[AGENT][NEUTRAL] I'm looking, there's a lot of things on here. Those are the two that we paid on.
[CUSTOMER][NEUTRAL] Right, well,
[CUSTOMER][NEUTRAL] Well, I, what I did was I sent the backup for the ambulance calls and then I sent the backup for the intensive care.
[CUSTOMER][NEUTRAL] Um, for the intensive care.
[CUSTOMER][NEUTRAL] Oh, so I'm not sure exactly.
[CUSTOMER][NEUTRAL] Um, maybe they were looking at some of the ELBs or something.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] But that didn't pay on, that wasn't like for the ambulance or the intensive care. That was for something else.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] No, yes, and this, this is for data service [PII].
[AGENT][NEUTRAL] And on [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] There's an ICU for [PII].
[CUSTOMER][NEUTRAL] Yeah, those were both ambulance calls.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so let me look at the remark on these um.
[AGENT][NEUTRAL] These two then give me just one moment and tomorrow you should tomorrow afternoon you'll be able to see it should.
[AGENT][NEUTRAL] To be by tomorrow afternoon, Miss [PII]. Your explanation portal so that you could look at.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] At all the remark codes.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, because it's a bunch of them for the.
[AGENT][NEUTRAL] [PII], that shows ambulance ground, so let me look at that remark.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so for the ambulance, the denial code on here states in order to give consideration to this state of service, we will need a fully itemized hospital slash facility billing with all charges fully identified.
[CUSTOMER][NEUTRAL] Even for the hospital, I mean even for the ambulance ride to the hospital?
[AGENT][NEUTRAL] Yes, ma'am. That is what this is showing. There's another
[CUSTOMER][NEUTRAL] I mean, I sent the ELB but they're saying that's not gonna I mean it.
[AGENT][NEUTRAL] Remark for ambulance ground on the same date.
[AGENT][NEUTRAL] Correct. That's not enough. It's what we're needing more information.
[CUSTOMER][NEUTRAL] Well, no, I had one in November.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, I had one in November and then one in January and
[AGENT][NEUTRAL] Mhm. And they say the exact same thing.
[CUSTOMER][NEUTRAL] So, uh,
[AGENT][NEUTRAL] Mhm. It's
[CUSTOMER][NEUTRAL] So what did they pay $60 on? I mean, was that on something else?
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] It was $100. It was two preventative charges.
[CUSTOMER][NEUTRAL] OK, that was something else on the ELB I guess.
[AGENT][NEUTRAL] Like she had for wellness. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK, OK, so they really haven't paid anything on those.
[AGENT][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] That maybe supposedly that last time. So I, I know I've been waiting on a detailed list from the hospital and it's taken like, oh, it's taken a long time to get that. Um, I called a couple of weeks ago. OK. So basically, they haven't paid or denied anything on the ambulance or the intensive care stays.
[AGENT][NEUTRAL] Right, sure.
[CUSTOMER][NEUTRAL] Is that correct?
[AGENT][NEUTRAL] You, yes ma'am, let me look because I see for [PII] and I see you and that is, that is the same remark code in order to give consideration to this data service we will need a fully itemized hospital slash excuse me, facility billing with all charges fully identified.
[CUSTOMER][NEUTRAL] OK, OK, so I'm, I'm thinking they're just denying it because.
[CUSTOMER][NEUTRAL] I know you have to be, you have to check into a hospital whenever you ride, you know, go in the ambulance to get the $200 or whatever. But they're saying they need more proof than the ELB saying he was in the hospital for a week, but that doesn't count.
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] Well, that's part of the information that you have to.
[CUSTOMER][NEUTRAL] OK. So really that's not.
[CUSTOMER][NEUTRAL] Right. OK. So, um, so that may be the only thing lacking.
[AGENT][NEUTRAL] Yes, we do have to have your. Yes, ma'am. We, we do have to have the explanation of benefits, but on any of these types of claims, we always have to have an itemized bill.
[AGENT][NEUTRAL] From the providers, um, showing diagnosis, charges, you know, the procedure codes, um, when reviewing these types of claims. So there's not a
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, because I know that.
[CUSTOMER][NEUTRAL] Oh, I'm sorry, go ahead.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] No, ma'am. No, go ahead.
[CUSTOMER][NEUTRAL] Oh, because I know.
[AGENT][NEUTRAL] Go ahead. What's your question, Ms. [PII]?
[CUSTOMER][NEUTRAL] They had said he had a heart. That's OK. They also said he, you know, had a heart attack and they said for me not to file that claim till I got the medical detail list. But um
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEGATIVE] I guess probably I shouldn't have filed any of it until then because they're not they're just denying it until I get the other information correct.
[AGENT][NEUTRAL] Right. Yes, ma'am. Now, there was one charge on here for
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEGATIVE] [PII], it was a lab. He had some testing done. Now, that was denied because lab tests are not covered under this policy. That's not a covered benefit under this policy. Um,
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] But yes, ma'am. All these other ones are just that we are in need of, you know, more information to complete the review of the claim.
[CUSTOMER][NEUTRAL] OK. I mean, I'm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK, because it said completed on the website and that that threw me off because I thought.
[AGENT][NEUTRAL] Right, yeah.
[CUSTOMER][NEUTRAL] They're saying they're paying nothing but so will I have to do a, a refile it or how will that work?
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] When I get the other information.
[AGENT][NEUTRAL] What, all you will need to do is.
[AGENT][NEUTRAL] Yes, ma'am. You will just need to submit, you can upload um the documentation directly into your portal like you did, I think you did that this time, yes, you did. So there's not a way um Miss [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Some people get confused on this, so this I'm gonna explain it to you. You log into your portal to submit this other information once you get it.
[AGENT][NEUTRAL] You will just, it's gonna somewhat appear like you're filing a new claim.
[CUSTOMER][NEUTRAL] Mhm. Yes, ma'am.
[AGENT][NEUTRAL] OK, it's you'll follow those same.
[CUSTOMER][NEUTRAL] I'm sorry, it, it will be like I'm filing a new one.
[AGENT][NEUTRAL] Right, but you're just gonna upload the information that we were needing. Our system will know that that is information we were missing on this other claim. You won't be able to select the claim number that's been assigned to this information and like attach the other documents too. Does that make sense?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I won't be able to do that. I'm just gonna go in there, upload what I have and it's gonna create another claim number. OK. OK. Well, maybe after I finally get that, uh, yeah, OK.
[AGENT][NEUTRAL] You're just gonna
[AGENT][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] Yes, exactly.
[AGENT][NEUTRAL] Correct. But we will review.
[AGENT][NEUTRAL] That information.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You know, looking at those dates of service when we get the information and.
[AGENT][NEUTRAL] We'll be able to say, OK, well, this was what we were needing for this claim right? that you and I have gone over today.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK. OK. I just, when I saw it said.
[CUSTOMER][NEUTRAL] Completed. I thought, oh well, they never asked me if they needed anything else, you know, so that kind of threw me off. So, OK, well, I will hopefully get that here shortly. It seems they told me it would take a while, but
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] I guess they just normally don't send that type of information out, although it's always, I mean, it'd be good to have all that information to actually see what they charged you for, you know.
[AGENT][NEUTRAL] I don't.
[AGENT][NEUTRAL] Yeah, they don't.
[CUSTOMER][NEUTRAL] No, they don't. OK, well, that's.
[AGENT][NEUTRAL] But yes, ma'am, that is something you have to specifically request from them. So just as soon as you get it, you don't have to worry about a timeline on this because we do not have a timely filing. So just whenever you receive it, then you can upload that and then we'll review that.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you for your help so much. I will do that as soon as I get it.
[AGENT][NEUTRAL] Well, yes, ma'am.
[AGENT][POSITIVE] You're very welcome, Miss [PII]. And is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Uh, no, ma'am.
[AGENT][POSITIVE] OK, well then, thank you again for calling APL and I hope you have a very nice evening.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.