AccountId: 011433970860
ContactId: ace8a626-d376-4c3b-8fe5-9b9fbe453bd1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 330100 ms
Total Talk Time (AGENT): 154870 ms
Total Talk Time (CUSTOMER): 127087 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=-1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/03/ace8a626-d376-4c3b-8fe5-9b9fbe453bd1_20250603T17:48_UTC.wav
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[AGENT][POSITIVE] Thank you for contacting ATL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, so I have a claim, uh, the claim number is 3545573.
[AGENT][NEUTRAL] Yes, and this is for your policy, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and how may I help you?
[CUSTOMER][NEUTRAL] Well, uh, the Cleveland Clinic told me that it was denied.
[CUSTOMER][NEUTRAL] By
[CUSTOMER][NEUTRAL] By the insurance and I don't understand because that's the reason I have the insurance, you know, when I have two insurance, my primary insurance and this is the secondary insurance. Whatever the first one doesn't pay.
[CUSTOMER][NEUTRAL] Uh, the second has to pay.
[CUSTOMER][NEGATIVE] And it's not, uh, I don't know why it was not paid.
[AGENT][NEUTRAL] OK. If I could just have your, um, if I could just have your name, and date of birth, and a phone number, sir. I'll check your, I will look at the policy. Uh, I will pull it up and we'll see what we have here.
[AGENT][NEUTRAL] So I just need, if you could just.
[CUSTOMER][NEUTRAL] OK, my first name is.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, my name is [PII].
[CUSTOMER][NEUTRAL] My last name is [PII], [PII]
[AGENT][NEUTRAL] And if I could just verify your date of birth and the phone number, please, sir?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] I appreciate that. Thank you.
[CUSTOMER][NEUTRAL] Who's phone number is [PII] um.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you very much, [PII]. I'm just gonna look up and sure we've got here.
[AGENT][NEUTRAL] OK, so
[AGENT][NEUTRAL] What we have is a uh
[AGENT][NEUTRAL] Claim for an office visit. Let me just, let me see if I can pull this up real quickly and see what it is.
[AGENT][NEUTRAL] And thank you for waiting with me, so I'm just waiting for my computer to come up and look at the at the claim that was submitted and we'll see what's going on.
[AGENT][NEUTRAL] I see that we received it back in [PII], so.
[AGENT][NEUTRAL] OK, so Cleveland Clinic, Florida.
[AGENT][NEUTRAL] We show this as uh.
[AGENT][NEUTRAL] And this is for uh [PII]. Is that correct, sir?
[CUSTOMER][NEUTRAL] Yeah, could be, yeah, that was when I went to the hospital.
[AGENT][NEUTRAL] Yes, sir. OK, so what we do, uh, you know, what I have here is that we show that um there is a clinic visit, uh, uh, visit, uh, that a clinic visit is like an, is like an office visit, um.
[AGENT][NEUTRAL] And uh
[AGENT][NEUTRAL] It looks like we have a clinic or an office visit on [PII], uh, and that was for Cleveland Clinic, Florida. Now your policy covers, um, inpatient hospital stays of 18 hours or more or an outpatient hospital stay, uh, but it doesn't cover, uh, a clinic visit.
[AGENT][NEUTRAL] Now the clinic is, as I mentioned before, is sort of like an office visit, and because the office visits aren't covered, or treatment within the physician's office is not covered, that is why this was not uh a case.
[AGENT][NEUTRAL] Um, because, uh, even if, if your physician's office is it.
[CUSTOMER][NEGATIVE] This is very strange, uh, uh, this, you know, this is very strange. I never go to the hospital. One time I go to the hospital and it's not covered.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] This is, uh, you know, surprising because that was the purpose of me having a, a, a secondary insurance if it's not gonna cover.
[CUSTOMER][NEGATIVE] I mean, I, I pay every month, instead of paying, uh, the insurance, I'd rather pay myself and then when I get a, a problem, I go and pay, pay to the hospital. But this doesn't make sense and I'm gonna talk to, to our group, uh, so that we know what we're standing for because this was never explained to us that uh this is not covering my uh visits to the doctor.
[CUSTOMER][NEUTRAL] I mean, I, I go to the clinic to talk to the doctor. If that's not gonna cover then.
[CUSTOMER][NEGATIVE] It doesn't make sense for me to, to have the insurance.
[AGENT][NEUTRAL] Well
[AGENT][NEUTRAL] Yes, sir, I understand. It's, uh, what it will do is it will cover the office visit, uh, excuse me, I'm sorry, it does not cover the office visit. What it will cover is if you had like the emergency room or if you had to go to the hospital, those are the things that it covers, but they could build this as an office visit, as a clinic or an office visit, and those things are not covered by.
[AGENT][NEUTRAL] Your policy. So if, if you were if you were actually admitted to the hospital or if you went for the urgent care or the ER, uh, outpatient surgery, those things are covered, but this office visit is or clinic visit is not, and that's why that was denied.
[AGENT][NEUTRAL] But that's what the coverage is, is for, is for outpatient hospital, but not this office.
[CUSTOMER][NEUTRAL] OK, I'm gonna talk to her, OK.
[CUSTOMER][NEUTRAL] OK, I'm gonna talk to our people and see why if this is uh.
[CUSTOMER][NEUTRAL] If, if, if this is the case, then I have to see if, if I keep paying the insurance.
[CUSTOMER][NEUTRAL] Because if maybe it doesn't make sense.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Is there any other place that I can look up for you, um?
[CUSTOMER][NEGATIVE] No thank you.
[AGENT][NEUTRAL] I
[AGENT][POSITIVE] OK, well, thanks for contacting me. You have a good day.
[CUSTOMER][NEUTRAL] OK.