AccountId: 011433970860
ContactId: a1ed8f85-b1a3-4fdd-9a5b-c59b78b7aef0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 998500 ms
Total Talk Time (AGENT): 433661 ms
Total Talk Time (CUSTOMER): 224850 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/a1ed8f85-b1a3-4fdd-9a5b-c59b78b7aef0_20250429T13:06_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII]. I'm calling about my claim.
[AGENT][NEUTRAL] OK, [PII], I'm sorry. What was your last name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Hello? OK.
[AGENT][NEUTRAL] And you said you're needing to check claim status, is that correct for yourself?
[CUSTOMER][NEUTRAL] Um, I have questions about my claim because I've spent quite a few $1000 on the surgery and you only give me $100.
[CUSTOMER][NEUTRAL] According to what I'm reading here.
[AGENT][NEUTRAL] I can take a
[AGENT][NEUTRAL] OK, I'll be happy to take a look at your policy and, and look at the claim with you, Mr. [PII]. And what is your callback number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, and your policy number, please?
[CUSTOMER][NEUTRAL] Uh, I'm not sure my policy number, but I have my claim number. Let me see if I put my policy number.
[AGENT][NEUTRAL] OK, on your, if you have your explanation of benefits, your policy number is also on there.
[CUSTOMER][NEUTRAL] Let me see.
[AGENT][NEUTRAL] And if not, I can try and look it up by your full social.
[CUSTOMER][NEUTRAL] Oh, I might just have to do full social because I'm not seeing it right here.
[AGENT][NEUTRAL] And that's the explanation of benefits from APO?
[CUSTOMER][NEUTRAL] I'm just looking at the online site right here. Let me see.
[CUSTOMER][NEUTRAL] let me click on it with this. I can give you my claim number.
[AGENT][NEUTRAL] Yes, sir, but I need to be able to look up your information first. If you're logged into your, are you, are you logged into your portal?
[CUSTOMER][NEUTRAL] OK, can you just use my social?
[AGENT][NEUTRAL] It would have your policy number? OK. Yes, so go ahead and give me your social because on the phone, you may not be able to see everything.
[CUSTOMER][NEUTRAL] Yes, on my phone.
[CUSTOMER][NEUTRAL] OK, it's [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] I'm sorry, did you
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, was that [PII]?
[AGENT][NEUTRAL] [PII] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] OK, thank you, so give me a couple of moments please to locate your information.
[AGENT][NEUTRAL] And which policy is this on?
[CUSTOMER][NEUTRAL] It's not accidental.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I will need to verify several things with you first for security and also any information that is provided would be a verification of benefits and not a guarantee of payment. So first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you. Also your home mailing address, please.
[CUSTOMER][NEUTRAL] It's gonna be [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. The phone number that we have on file for you, Mr. [PII] is the same one as you gave me, so that is your best contact number, is that correct?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK, thank you. And the last thing to verify is going to be your email address, please.
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] OK, thank you. All right, and are you referring to the most recent claim that went through processing on last night?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So I see that um OK, so for data service 2192025 that is the one in which the $100 benefit was paid.
[AGENT][NEUTRAL] Um, and that was for, and of course you should be able to see it's a long, it's a long remark code on there.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Regarding that payment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, that was for.
[AGENT][NEUTRAL] Let's see. Essentially, that was for the physician's office treatment benefit.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The other code for the 327 data service.
[AGENT][NEUTRAL] OK. So this, that was for your
[CUSTOMER][NEUTRAL] That was a surgery. Yeah, like I had a, my entire ACL was reconstructed.
[AGENT][NEUTRAL] OK, so what's the
[AGENT][NEUTRAL] OK, so what this states is we will pay the, excuse me, we will pay the outpatient surgery benefit amount shown in the schedule of benefits for each day a covered person undergoes a surgery for repair while an outpatient in an ambulatory surgical center or as an outpatient at a hospital as a result of a covered accident.
[AGENT][NEUTRAL] This benefit is payable only once per covered accident. Based on the information received, this service does not meet the provision requirements for coverage under this benefit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so how do I get that covered then because
[AGENT][NEUTRAL] Now, you're welcome to
[CUSTOMER][NEUTRAL] I spent $300 on an X-ray. I've spent like 70, 700 MRI.
[CUSTOMER][NEUTRAL] $450 on the surgical center and $1500 on the surgery by itself.
[CUSTOMER][NEGATIVE] And like, I'm just trying to see what's the point of even having this accidental coverage if I'm only getting $100 back for a physician visit.
[AGENT][NEUTRAL] OK. And what, what's this related to an accident?
[CUSTOMER][NEGATIVE] Yeah, like I tore my ACL moving some stuff in my house and had to have surgery because of it.
[AGENT][NEUTRAL] Now, you are welcome to file an appeal, Mr. [PII].
[AGENT][NEUTRAL] Appeals must be filed within 180 days from the date of the decision. And ag[PII], this claim went through processing on yesterday.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the appeal, you can provide, there's not a specific form, but there you can provide any information that you would like considered.
[AGENT][NEUTRAL] Um, it can also be uploaded into your portal like this other information.
[AGENT][NEUTRAL] It can be faxed or email.
[CUSTOMER][NEUTRAL] Yeah, like what other info would I need to give you guys though, because I have like the breakdown of the surgery and everything.
[CUSTOMER][NEUTRAL] You know, it states the surgery was $15,000.
[AGENT][NEUTRAL] Now, again, I'm not one of the examiners as far as I can only see these remarks. Now, I would be happy to try and connect you with someone who can further look at this with you and maybe give you more specific information, but what I read to you is all that I can see. But again, you do have that option to file an appeal within 180 days from the date of the decision.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, well, can you uh contact me with somebody that I can speak to further about it?
[AGENT][POSITIVE] Yes, absolutely. Yes. So before I do that though, is there anything else? Yeah, you're welcome. Is there anything that I could help you with before I do that?
[CUSTOMER][POSITIVE] OK, I appreciate it.
[CUSTOMER][NEUTRAL] No, ma'am.
[AGENT][POSITIVE] OK. Well, Mr. [PII], it was my pleasure in speaking to you today. Thank you for calling APL and I hope that you have a very nice day.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Yes, sir. So one moment, please.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] For calling APL, this is [PII]. How can I help you?
[AGENT][POSITIVE] Well, good morning, [PII], it's [PII]. How are you today?
[CUSTOMER][POSITIVE] Good morning fine, how are you?
[AGENT][POSITIVE] I'm good, thank you. um I have an insured on the line, very nice man, and I've gone over his um claim that he called about.
[AGENT][NEUTRAL] But
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I, I mean, honestly, the um
[AGENT][NEUTRAL] The denial is very vague. I told him about the appeal and everything, but he's just wanting to know what else he needs to submit or exactly what that means. Again, I think it's a vague term, but um the policy number, [PII] is 228.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What's the policy number?
[AGENT][NEUTRAL] 376 9.
[AGENT][NEUTRAL] This is Mr. [PII].
[AGENT][NEUTRAL] And it's on claim 359.
[AGENT][NEUTRAL] 483 5.
[AGENT][NEUTRAL] We just processed it yesterday.
[AGENT][NEGATIVE] We paid him $100 for a visit, but then we denied the surgery. And I when I, I read that entire remark to him.
[CUSTOMER][NEUTRAL] OK, let me take.
[AGENT][NEUTRAL] And he said this was an accident. He had hurt his self, I believe he said moving furniture, but don't quote me on that. It was something in his house, doing, yeah, something in his home.
[CUSTOMER][NEUTRAL] OK, let me see what we, what was sent in.
[CUSTOMER][NEUTRAL] OK, so it looks like he had a surgery for his knee.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, let me see if we got anything that shows that it was due to an accident cause that could be the issue. Let's see.
[AGENT][POSITIVE] Oh wow.
[CUSTOMER][NEUTRAL] Mm, diagnosis code does not say that this is the result of an accident. Let me keep looking.
[CUSTOMER][NEUTRAL] Yeah, the arthroscope.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Trying to see if he sent us something that shows us that it was an accident. So far, what I'm looking at is what we have is not saying it was an accident. So let me keep looking.
[CUSTOMER][NEUTRAL] Those are the surgery charges.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, the surgery was done.
[CUSTOMER][NEUTRAL] In a surgery center.
[CUSTOMER][NEUTRAL] OK, this other [PII] has a er a diagnosis different.
[AGENT][NEUTRAL] Yes, so that's, he's just wanting to know, you know, like what he would need to cement as far as for.
[AGENT][NEUTRAL] You know, an appeal, but he wants to just understand better why, why it was denied.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm let me look at the policy verbiage real quick.
[AGENT][NEUTRAL] So that's
[AGENT][POSITIVE] He's real nice, so.
[AGENT][NEGATIVE] I like, you know, someone that can be very upset about it. He just
[AGENT][NEUTRAL] He just wants to know, understand what he needs to do to.
[AGENT][NEGATIVE] What to get, you know, that, you know, I guess you understand what I'm saying. I feel like I'm falling all over myself this morning, [PII]. He's.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] And I feel, and I've been typing with 10 thumbs today.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Jeez, struggling.
[AGENT][NEGATIVE] The struggle is real over here at my house today in my office area.
[CUSTOMER][NEUTRAL] Just looking real quick at what the policies verbiage says real quick on this procedure on this benefit.
[CUSTOMER][NEUTRAL] This is the outpatient surgical repair.
[CUSTOMER][NEUTRAL] Yeah, I'm gonna have to check a little further on this particular one cause I do see that there's two different diagnosis codes listed here and I, I have to reach out to [PII] to get some clarification regarding the benefit on this one.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So would you like to tell him that you're going to do that and to call him back, or do I need to go through the whole sin in a hub to have this claim researched since
[AGENT][NEUTRAL] I've already talked to you.
[CUSTOMER][NEUTRAL] That's fine however you wanna do it, you can send them to me and I can let him know we uh check into it a little further and give him a call back.
[AGENT][NEUTRAL] OK, that's just entirely up to you instead. I mean, since we've, you know, you've looked at it and you've pulled all this up.
[AGENT][NEUTRAL] For this one, since you're gonna, would you rather just tell him that?
[CUSTOMER][NEUTRAL] That's fine. I can tell him.
[AGENT][NEUTRAL] OK, well, he's fully verified. The phone number in line would be the one to call him back on that's his only contact number.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] OK, [PII], well thank you so much for looking at that. I appreciate your help with this one.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][POSITIVE] All right. Have a great day if I don't talk to you again.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Bye-bye. All right, bye-bye.
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Bye.