AccountId: 011433970860
ContactId: bcf56707-d8cb-4e2a-a57d-ad77a8fd8ecf
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 375079 ms
Total Talk Time (AGENT): 132275 ms
Total Talk Time (CUSTOMER): 122064 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/13/bcf56707-d8cb-4e2a-a57d-ad77a8fd8ecf_20250513T13:41_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey, this is [PII] in [PII]. How are you doing?
[AGENT][POSITIVE] Good, how are you?
[CUSTOMER][POSITIVE] Doing great doing great I'm just calling to check on a claim for one of our customers.
[AGENT][NEUTRAL] OK. Uh, do you have the member ID, [PII]?
[CUSTOMER][NEUTRAL] Yes, uh, the policy number is 2605149.
[AGENT][NEUTRAL] OK, and what's your email and callback number, [PII]?
[CUSTOMER][NEUTRAL] My callback number is [PII].
[CUSTOMER][NEUTRAL] And email is [PII].
[AGENT][POSITIVE] OK, perfect. Thank you.
[AGENT][NEUTRAL] And who's that, uh, who's the patient in their day.
[CUSTOMER][NEUTRAL] This is for [PII], and it should be the most recent claim in there. Uh, we received part of it on [PII] and part on [PII].
[CUSTOMER][NEUTRAL] To be the claim ending in 399.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] Uh, it says extended treatment benefit exhausted for plan year.
[AGENT][NEUTRAL] Uh, we'll extend the treatment benefit amount shown on the scheduled benefits for each day covered person receives chiropractic therapy, acupuncture, and mental health services under the certificate for treatment as a result of a covered accident.
[AGENT][NEUTRAL] Um, it's a really long denial. Treatment must begin with the number of days as specified by the policy certificate and rendered within 365 days after the covered accident occurs.
[AGENT][NEUTRAL] This benefits payable up to the number of days per plan year for each covered person as specified in the policy certificate.
[AGENT][NEGATIVE] Benefit has been exhausted.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] This particular, it's not for the, the, uh, she had a claim before where she injured her, her, um her knee, and that's where she exhausted the benefit at, but this is a new injury.
[AGENT][NEUTRAL] B
[CUSTOMER][NEUTRAL] That's supposed to start over every injury.
[AGENT][NEUTRAL] OK, um
[AGENT][NEUTRAL] So were they filed with a different diagnosis?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] Unfortunately, she had two. She had a, um, a knee injury and she just had an ankle injury on [PII]. So this is a new, it's a new claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, why don't I do this? Can I get you over to the claims department that way they can review this and then get this sent back through if that's applicable.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, hold on one moment, OK.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] Thank you for calling APO. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], it's [PII] in care team. Um, I've got a broker on the line that is checking on claim status denial, and he says that it should be processed, um, because it's a new injury. Can I give you that, uh, policy number for you to take a look and maybe help him out?
[CUSTOMER][NEUTRAL] Hey.
[CUSTOMER][NEUTRAL] Yeah, sure, go ahead.
[AGENT][NEUTRAL] Policy number is 2605149.
[CUSTOMER][NEUTRAL] OK, is it a claim that we've already denied and they're saying that they feel like it should have been processed or is it like a timely thing?
[AGENT][NEUTRAL] Yes.
[AGENT][NEGATIVE] No, it's a claim we've denied. We said the benefits exhausted it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] For [PII] and I verified him. His callback number is the one on the screen. He's with that CBOA, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] He said that this is a new accident. She had a prior knee injury, but this is a new accident, and he said that this should be considered since it's a new accident.
[CUSTOMER][NEUTRAL] OK, what, uh, what claim number specifically are we looking at? Do you know?
[AGENT][NEUTRAL] Uh, the 399-360-00399.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so let me just look real quick to kinda.
[CUSTOMER][NEUTRAL] OK, so they're saying new accident.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Previous injury but it's unrelated.
[AGENT][NEUTRAL] Unrelated, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I wonder was it like the same knee?
[CUSTOMER][NEUTRAL] And that's why
[CUSTOMER][NEUTRAL] Extended treatment that's why we did not.
[AGENT][POSITIVE] Usually I, I've talked to him several times and he's usually pretty sharp about these. Seems like he knows this stuff, so.
[CUSTOMER][POSITIVE] Yeah, I mean, yeah, that's great. I mean I'd rather you know than for me to be kind of philandering about, you know what I mean?
[CUSTOMER][NEUTRAL] OK, let's see, let me get the policy and the.
[CUSTOMER][NEUTRAL] Information pulled up.
[CUSTOMER][NEUTRAL] What was his name?
[AGENT][NEUTRAL] His name is [PII].
[AGENT][NEUTRAL] He's with that [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, um, OK, I'm ready when you are.
[AGENT][POSITIVE] OK, I'll introduce you and then I'll release it. Thank you.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, [PII], I've got [PII] on the line and she's gonna assist you with looking at that claim, OK?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][POSITIVE] Got it thank you.
[AGENT][POSITIVE] Thank you. Bye bye.