AccountId: 011433970860
ContactId: ab5de15f-4347-4cab-9dbc-355c48925545
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 537400 ms
Total Talk Time (AGENT): 241919 ms
Total Talk Time (CUSTOMER): 158132 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/25/ab5de15f-4347-4cab-9dbc-355c48925545_20250625T14:23_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], how are you this morning?
[AGENT][POSITIVE] I'm good. How are you?
[CUSTOMER][NEUTRAL] I'm good, thank you very much. Um, I have a question. I submitted a claim and I got a uh a um rejection and I'm just a little confused on the reasons, so I was wondering if maybe you could help me out, to maybe help me understand it.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Let's take a look. Do we have the claim number, policy number?
[CUSTOMER][NEUTRAL] I have a policy number and the reference number.
[AGENT][NEUTRAL] OK, what's the policy number?
[CUSTOMER][NEUTRAL] 02238183
[AGENT][NEUTRAL] OK. And then if I can get your name and date of birth?
[CUSTOMER][NEUTRAL] Sure, [PII], [PII].
[AGENT][NEUTRAL] All right. And what is the address also we should have on file?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And was the claim under your name, [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me just pull up this last one here.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so it looks like reading denied outpatient policy does not provide benefits for outpatient hospital facility.
[CUSTOMER][NEUTRAL] OK, see, and that's my first question is, the surgery was held at, um, Memorial Hospital in [PII] and was in the hospital for 2 nights. So I don't understand. I I'm trying to figure out how it was billed in outpatient when I, the surgery was in the hospital.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then it says not a covered loss under the plan. Benefits payable under the certificate are limited to those outlined on the scheduled benefits. Let's see.
[CUSTOMER][NEGATIVE] Yeah, honestly, I just don't understand any of it. I'm just, and I really don't understand the outpatient one because like I said, I'll be it was done in the hospital.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Yeah, so hospital admission benefit, hospital confinement.
[AGENT][NEUTRAL] How do they?
[AGENT][NEUTRAL] Define that. Let's see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] So, we will pay the hospital admission benefit when a covered person is admitted to the hospital and confined as inpatient due to injury or covered sickness. We will pay the benefit.
[AGENT][NEGATIVE] We will not pay this benefit for outpatient treatment, emergency room treatment, or a stay of less than 18 hours.
[AGENT][NEUTRAL] Consecutive.
[AGENT][NEUTRAL] It's showing a date range from 5:21 to 5:24.
[AGENT][NEUTRAL] That's definitely 18 hours, hmm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah, I send it to you what this is the this is the, uh, the UBO4, right? that you're looking at?
[AGENT][NEUTRAL] Um, well, I'm just reading what I was reading to you was just the policy certificate, kind of what it states on the policy. Um, let me pull up what was submitted and see.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I weird cause like the top has Memorial Hospital, Pembroke, and
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You know, operating room charges, I mean,
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] So like I say, um,
[AGENT][NEUTRAL] Yeah, OK, so what I'm gonna do on this, [PII], is I'm gonna send this back over to claims and have them look at this again, um, and see why it was processed that way.
[AGENT][NEUTRAL] Um, do you have a good number that somebody can call you back at? Because if it was an error, we'll have them reprocess it, um, because I see the [PII] through the 24th that you submitted.
[CUSTOMER][NEUTRAL] Right, right. Um, yeah, I do, um.
[CUSTOMER][NEUTRAL] It's his number is [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, yeah, because that's not really clear to me either, um, when I see the date range, so I'm gonna send it to the examiner, have them relook at this and just explain, you know, it shows the date range. Can you please, uh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Re-examine this and then I will have them give you a call. Um, if it was processed incorrectly, then they'll advise on that. And then if there's something we're missing, they'll definitely explain that in better detail as to why it's, it's not a covered benefit.
[CUSTOMER][NEUTRAL] Right,
[CUSTOMER][NEUTRAL] Right, cause yeah, cause it's funny cause like you said, it's like, well, 3 days in the hospital is not outpatient.
[AGENT][NEUTRAL] Right, right. And I mean, it says in the policy 18 consecutive hours and so it's like, well, OK, that was more than 18 consecutive hours, so what's, what's the issue? So yeah, let me put in that request, have somebody call you back. Did you have any other questions or concerns?
[CUSTOMER][NEUTRAL] Actually, I do. And this is actually a claim that goes further back, but you would have it on your file still, right? Um, I submitted, I, I can't remember, that's why I just want to verify. My husband had surgery and his [PII] and his surgery date was [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] And I have here that it looks like, I have here that I, the claim was, I filed the claim, because on the, on [PII], but I don't recall if I heard anything back or not. If I got something saying it was denied, if it was paid, and I just wonder if you could just like refresh me on that one.
[AGENT][POSITIVE] Yeah, absolutely. So for that, it looks like it was filed 10-11-23. It processed 1017 and paid a $1000 benefit. It looks like it was direct deposit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, perfect. I just, I could not remember to save my life because you know, it's been forever.
[AGENT][NEUTRAL] Mhm, mhm, mhm, yeah, yeah, so no, it looks like that one was paid.
[CUSTOMER][POSITIVE] Perfect, perfect. All right. So I will just, uh, OK, so I'll just wait to hear some, hear about this one to see what, cause that, cause that is the correct form I sent in right? the UBO4.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] Yeah, everything looks correct that I saw [PII], so yeah, I'm not, I'm not clear on that either. So yeah, we'll definitely have somebody give you a call back uh within the next 24 hours.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right. And if they, if I'm not home, they'll leave a message, a contact number and everything.
[AGENT][POSITIVE] Yes ma'am, absolutely.
[CUSTOMER][POSITIVE] OK, perfect. All right, thank you so much, [PII] for all your help.
[AGENT][POSITIVE] You're welcome. I hope you have a good day.
[CUSTOMER][POSITIVE] You too thank you bye bye.
[AGENT][NEUTRAL] Mhm. Bye-bye.