AccountId: 011433970860
ContactId: aaccd296-5a3b-4563-9fa3-5f6df881d4d6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 546599 ms
Total Talk Time (AGENT): 283737 ms
Total Talk Time (CUSTOMER): 184226 ms
Interruptions: 2
Overall Sentiment: AGENT=0.9, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/28/aaccd296-5a3b-4563-9fa3-5f6df881d4d6_20250128T14:49_UTC.wav
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[CUSTOMER][NEUTRAL] But it was coded as.
[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Yes, ma'am, um, we received an EOB from you guys in the mail on
[CUSTOMER][NEGATIVE] And nothing was paid on one of my son's visits, so I was just gonna see, I guess what the office coded it as, um, to see, cause it was just a sick visit, so I just wasn't sure why nothing got paid on it.
[AGENT][NEUTRAL] OK, yeah, um, let me take a look at that for you. And do you mind if I have your name and the policy number?
[CUSTOMER][NEUTRAL] Um, the policy number is 02439606.
[CUSTOMER][NEUTRAL] And this is [PII].
[AGENT][POSITIVE] Alrighty. And one second, Ms. [PII] while I get all that pulled up for you.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] All right, and Ms. [PII], would you be able to verify for me, please, your date of birth?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Perfect and I'm just gonna verify additional information with you if you could verify for me please, um, your mailing address on file.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Wonderful and then just one last thing is that email address on file if you can.
[CUSTOMER][NEUTRAL] Oh shoot, I've got 2. I'm not, I don't remember which one it is. Um, there's [PII]
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That was it.
[CUSTOMER][NEUTRAL] That one's it. OK.
[AGENT][NEUTRAL] And you said it was recently for your son, [PII], is that correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] All right. Um, would it be from Children's Medical Center?
[AGENT][NEUTRAL] From January.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, January was a recheck. He
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] The [PII].
[CUSTOMER][NEUTRAL] He of December, somewhere around that time frame, he had, he was, had an ear infection.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I do see that, so it looks like it came in, yes, [PII].
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] All right, so I'm showing here probably the same thing you're seeing is that um.
[AGENT][NEUTRAL] It's saying that the benefits are only available in a physician's office or in out let me read that again hold on um.
[AGENT][NEUTRAL] In an outpatient surgery in an outpatient hospital or physician's office, therefore, no benefits are payable, um.
[AGENT][NEUTRAL] As far as what it was coded, if you don't mind, Ms. [PII], I can absolutely put you on a brief hold and see if I have any examiners available. I can either have an examiner research it and call you back, um, or if I have one available, I can also, uh, see if I have somebody available to talk to you now about it.
[CUSTOMER][NEUTRAL] OK, cause that's why I just didn't understand cause all it was was an ear infection and he got tested for like strep RSV and whatever, so that's why I just.
[CUSTOMER][NEUTRAL] I was, I just didn't understand what any of that meant.
[AGENT][POSITIVE] Yeah, absolutely, um, and let me, let me take a look at your benefits real quick. Um,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Cause this is his 3rd 1, I think in like 6 months, 2nd or 3rd in section. So we haven't had any problems with the previous visits. Um
[CUSTOMER][NEUTRAL] I didn't know if maybe it's because they tested them for the RSV strep and flu or what.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] It looks like you're only outpatient benefits, so I'm looking at your benefits here and you have like a hospital admission benefit and a confinement benefit and then you also have benefits for like diagnostic imaging and follow up tests.
[AGENT][NEUTRAL] Uh, but then the only outpatient benefits here are an outpatient and sickness surgery, um, and then accident and sickness, uh, that's it, surgery in a physician's office or in a, um, surgical facility, so I'm not showing any.
[CUSTOMER][NEUTRAL] So do you
[CUSTOMER][NEUTRAL] Well, do you know how it was coded as an outpatient because that, that's just his physician's office. It wasn't an outpatient uh.
[AGENT][NEUTRAL] OK, so physicians, outpatients considered anything that you're not confined to a hospital. So inpatient is when you're confined to a hospital and everything else, urgent care, outpatient ER all of those doctors' offices are fall under outpatient.
[CUSTOMER][NEUTRAL] Put any, any.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Even just a regular um physician's office, like his primary care physician.
[AGENT][NEUTRAL] Yep, that's an outpatient physician office and it's just because you're not confined as inpatient, which is the difference, which is when you're defined for more than 18 hours in a hospital setting.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, so you don't have any benefits on this policy for outpatient visits outside of your outpatient, um, surgical benefit.
[CUSTOMER][NEUTRAL] So if it, I, I guess I'm, I'm sorry that you're having to explain this to me like a [PII]. But, um, every other time then that he's, either of the three kids have been sick, it's been covered. So I don't understand why it's a different.
[AGENT][POSITIVE] No, you're right.
[CUSTOMER][NEUTRAL] Is it just the testing like the um
[CUSTOMER][NEUTRAL] The swabs and stuff that are considered the outpatient and not just the actual physicians visit itself.
[CUSTOMER][NEUTRAL] Because, um, every other physician visit I've had with all three of the kids, even with [PII] and his previous ear infections have been covered.
[AGENT][NEUTRAL] So I'm looking here on Aria. She has two claims, but neither of them have been paid. Um, [PII] has one claim, but it was also not paid, and [PII] has one claim that was paid back in April, and it did fall under the accents and surgical benefits.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And that.
[AGENT][NEUTRAL] And it looks like the date of service was from [PII]. I don't know if what had happened there.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] But that one was paid and it did fall under that benefit so you might also have benefits with 90 degree benefits which is not with us at APL, um, and they take care of some wellness benefits, um, but I wouldn't be able to look.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, so maybe.
[AGENT][NEUTRAL] So it might have been that.
[CUSTOMER][NEUTRAL] OK, so I guess.
[CUSTOMER][NEUTRAL] How does that get filed? Like, does it go from you guys to 90 degrees or how does, or does the office have to file that with the 90 degrees?
[AGENT][NEUTRAL] So what happens is you're um the providers send all of those um claims to a company called IMA and IMA sorts them if they fall under the wellness benefits and all of that they send them to 90 degree benefits if you have that and then if it doesn't fall under that they send them to us.
[CUSTOMER][NEUTRAL] OK, so then I should check with maybe 90 degrees then or um.
[AGENT][NEUTRAL] You might, yeah, you might reach out to 90 Degree Benefits, and I have their phone number. It's a little tricky when you call, it's gonna ask like for medical benefit information, press 2, but that actually just brings you right back to APL and you just press 1 to speak.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, but 90 degree benefits might be able to provide you more information. I just can't see it because I, I don't have access to their systems.
[CUSTOMER][NEUTRAL] OK, that's fine.
[AGENT][NEUTRAL] Um, do you have their contact number that for you, my friend?
[CUSTOMER][POSITIVE] Um, I'm ready whenever you are.
[CUSTOMER][NEGATIVE] No, it maybe on the insurance card, but that insurance card is so confusing to me that I don't ever know what, what.
[AGENT][NEUTRAL] You're OK. I have it on a quick file and I can just read it to you.
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] Yeah, it's gonna be [PII].
[CUSTOMER][NEUTRAL] And you said just press one.
[AGENT][NEUTRAL] Press 1, yeah, it's gonna make you think you're gonna press 2, but you wanna press 1.
[CUSTOMER][POSITIVE] OK. Thank you so much for your help. You've been so helpful.
[AGENT][POSITIVE] Oh yeah, absolutely, and if there's anything else we can do to take care of you at APL, you just give us a call.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] My pleasure take care.