AccountId: 011433970860
ContactId: 9b6e82e6-9a8a-4cbe-9728-4ffe7d2f226f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 861739 ms
Total Talk Time (AGENT): 370240 ms
Total Talk Time (CUSTOMER): 260976 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/25/9b6e82e6-9a8a-4cbe-9728-4ffe7d2f226f_20250225T18:51_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] T
[CUSTOMER][NEUTRAL] Hi, I'm calling about policy number 764299. My name is [PII].
[AGENT][NEUTRAL] OK, Ms. [PII], and what is your callback number for you please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you. And how can I help you today, Ms. [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Uh, they submitted, OK, I sent in two different claims. I sent in one for Emry with you all, and they paid that one, and I sent in the medical records with the diagnostic codes from Grady, and they're saying that it is a duplicate.
[CUSTOMER][NEUTRAL] Uh, claim from the one, but it's two different hospitals. I was in Grady from [PII].
[CUSTOMER][NEUTRAL] I had a TIA then, and then I turned around and had another 1 [PII], which put me in Emory Hospital.
[CUSTOMER][NEGATIVE] And they haven't paid for the hospital days that I had at Grady's.
[AGENT][NEUTRAL] OK, so, so you're needing to check on the claim status for the Grady claim, is that correct? And that was the initial one?
[CUSTOMER][NEUTRAL] Mhm, the one from [PII].
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] OK, yes, so I can help you with this. First off, Miss [PII], I'll have to verify several things with you. For security and any information that I do provide will be a verification of benefits and not a guarantee of payment. So first off, if you could please verify the primary policy holder's name and date of birth and then your date of birth.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII], Lord have [PII], [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And your date of birth?
[CUSTOMER][NEUTRAL] I had it. Oh, [PII]. I'm sorry, I had a stroke and my mind is not.
[AGENT][POSITIVE] That's OK, you're doing excellent. No worries, Ms. [PII]. And then your home mailing address?
[CUSTOMER][NEUTRAL] I know it's a [PII] in [PII].
[CUSTOMER][NEUTRAL] I don't know the box number but I live in [PII] most of the time.
[CUSTOMER][NEUTRAL] So he comes up here.
[AGENT][NEUTRAL] OK, so what I need to, I'm gonna have to verify some things with you though for security, Ms. [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Is there a way that you can verify what that at PO box is?
[CUSTOMER][NEUTRAL] Hold on one second, I'm sorry.
[AGENT][NEUTRAL] OK, that's OK.
[CUSTOMER][NEUTRAL] I have to call him or put him on the call.
[CUSTOMER][NEUTRAL] Um, it's [PII].
[AGENT][NEUTRAL] OK, thank you. And the phone number that we would have on file for Mr. [PII]?
[CUSTOMER][NEUTRAL] OK, hold on. I don't know. Nobody know by heart.
[AGENT][NEUTRAL] I understand that too. Mm.
[CUSTOMER][NEUTRAL] It is
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you. All right. And so all of these, these are all for you, correct?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] The claims that you're wanting to check on, OK.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Cause he told me to call.
[AGENT][NEUTRAL] All right.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Alright, and you said that the stay at Grady was started on [PII].
[AGENT][NEUTRAL] 4 or [PII]. What year?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And that was with Brady Hospital.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I got out on [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And they have not paid for the hospital days.
[AGENT][NEUTRAL] And bear with
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so give me just a moment to look at some things. OK, so I see that that is for [PII].
[AGENT][NEUTRAL] Hey, we did just recently review a claim and yes ma'am it was showing that it was denied as a duplicate of previously submitted expenses.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So give me just, and that is for [PII]. So give me just a moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][POSITIVE] It's good
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Fairly steak.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, cause the first time they denied that it didn't have the diagnosis code on it that I sent in the medical records.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] OK, so I see on the initial.
[AGENT][NEUTRAL] Document that we or the initial claims information that we received Ms. [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For beginning on the [PII] data service.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That claim was reviewed and the review on here.
[AGENT][NEUTRAL] There was a benefit paid to you or to Mr. [PII] in the amount of $75.
[CUSTOMER][NEGATIVE] They didn't pay for the hospitalization.
[AGENT][NEUTRAL] This is for Grady.
[AGENT][NEUTRAL] Correct. So on here I'm looking at the
[CUSTOMER][NEUTRAL] I, I was in there.
[AGENT][NEUTRAL] Right, so I'm looking at the remarks on here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] This states the maximum total benefit of 180 days for any one period of confinement has been met.
[AGENT][NEUTRAL] Period of confinement means continuous confinement in a hospital. Periods of confinement for the same or a related cause.
[AGENT][NEUTRAL] Which are separated by less than 90 days will be considered the same period of confinement. That is one of the remarks.
[AGENT][NEUTRAL] Another remark on this claim that was processed states the calendar year maximum on diagnostic services has been met.
[AGENT][NEGATIVE] And the final remark states the calendar maximum for this benefit has been exhausted. There are no additional benefits payable for this calendar year.
[AGENT][NEUTRAL] That was your hospital admission benefit.
[CUSTOMER][MIXED] OK, but I had the same thing happened back in [PII] and they didn't do that. They paid for.
[CUSTOMER][NEUTRAL] Cause I had two different strokes.
[AGENT][NEUTRAL] Now what I can do is I can connect you with one of the examiners to look at the documentation that was received.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But according to this, OK, so had you been hospitalized?
[AGENT][NEUTRAL] Related to the stroke.
[AGENT][NEUTRAL] Prior to your admission in January?
[CUSTOMER][NEGATIVE] Um, the last time I had one, it was back in [PII] or [PII], but it was way past 180 days.
[AGENT][NEUTRAL] OK, let me look.
[AGENT][NEUTRAL] Give me just a moment.
[CUSTOMER][NEUTRAL] I had a TIA at Grady.
[CUSTOMER][NEUTRAL] And the one at Emory this time.
[CUSTOMER][NEUTRAL] was deemed as
[CUSTOMER][NEUTRAL] My arteries being closed going to my.
[CUSTOMER][NEUTRAL] Kidney.
[CUSTOMER][NEUTRAL] That's totally different.
[CUSTOMER][NEUTRAL] Even though I had the drooping of the face, but the diagnosis was different and also in the one for Emory, I had the flu too.
[AGENT][NEUTRAL] Sounds like you've been through quite a lot, Ms. [PII].
[CUSTOMER][NEUTRAL] Yes, I have lupus and oh my God, it's just.
[CUSTOMER][NEUTRAL] One thing after another.
[AGENT][POSITIVE] Oh my goodness. Sorry.
[CUSTOMER][NEUTRAL] Thinking I've had it for 47 years.
[AGENT][NEUTRAL] Oh, really? That's a long time.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, cause most people expire after 20 years.
[AGENT][NEUTRAL] That's a very long time to have lupus.
[AGENT][NEUTRAL] OK, so your hus OK.
[AGENT][NEUTRAL] Just bear with me while I'm looking at several pieces of information because you have a, you know, a lot here to.
[CUSTOMER][NEUTRAL] Yeah, cause I sent the medical records.
[CUSTOMER][NEGATIVE] Cause when you ask for a beer here in [PII] with the diagnosis code, they never give you the right bill.
[AGENT][NEUTRAL] OK, so see, it looks like that.
[AGENT][NEUTRAL] When you were hospitalized last year?
[AGENT][NEUTRAL] It looks like the daily hospital benefit was maxed out because there was a total benefit out of excuse me, $12,000 paid.
[AGENT][NEUTRAL] I believe that is where the 180 day remark is coming from, but again, I will be happy to connect you with someone that can actually verify that.
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] On this hospital stay.
[CUSTOMER][MIXED] OK, but then it wouldn't.
[CUSTOMER][NEUTRAL] OK, I was in the hospital last year around this time, so that that would be past 180 days, right?
[AGENT][NEUTRAL] Well, the maximum total benefit is 180 days that we would pay for any one period of confinement.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So a period of confinement means continuous confinement in a hospital.
[AGENT][NEUTRAL] And periods of confinement for the same or a related calls, which are separated by less than 90 days are considered the same period of confinement.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I get what you're saying now.
[AGENT][NEUTRAL] OK. So that's where that remark came from.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But I can see that he is set up in the portal, Ms. [PII], so you all can log in.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, and see this explanation of benefits with those remarks on it, the claim number if you would like to write it down that this was reviewed under.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, I can pull it up on the uh thing, but I was trying to figure out why if they only pay $75.
[AGENT][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] But that
[AGENT][NEUTRAL] Because that is why you, um, the calendar, your maximum, you had already met that on your diagnostic services.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the other reason was the calendar maximum for the benefit of your hospital admission benefit had been exhausted.
[AGENT][NEUTRAL] And then the other remark is related to the, you know, the 180 days maximum benefit that we could pay.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Well, is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEGATIVE] Uh, no. So if I end up going back in the hospital for something similar to that, they're not gonna pay, right?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] If it is related, as it states, and your policy is also, you can look at your policy information, Ms. [PII], that's in the portal. There's a full copy of your policy, but yes, any confinement that it's related to.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] This are the same.
[AGENT][NEUTRAL] Unless it is separated by 90 days is considered one period of confinement.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] For a max of 180 days.
[CUSTOMER][NEUTRAL] OK, got you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, thank you.
[AGENT][POSITIVE] Well, you are certainly so welcome. And if that's all then that I can help you with, thank you again for calling APL Ms. [PII], and I hope you have a very nice afternoon and I hope you continue to do very well.
[CUSTOMER][NEUTRAL] You too.
[CUSTOMER][POSITIVE] All right thank you so much bye bye.
[AGENT][POSITIVE] Yes ma'am, you're welcome. Bye bye.
[CUSTOMER][NEUTRAL] Hi