AccountId: 011433970860
ContactId: be92954e-b49b-4ed3-944e-ba6556b02fb7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 747359 ms
Total Talk Time (AGENT): 377203 ms
Total Talk Time (CUSTOMER): 255989 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/24/be92954e-b49b-4ed3-944e-ba6556b02fb7_20250424T17:09_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].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Hello, is this [PII]? Yes, um, I had a question. Um, I had just received, um, my EOB, uh, for, um, one of my clients that I had, uh, last year, and it's saying that, um.
[CUSTOMER][NEUTRAL] Basically it was submitted for payment after the filing deadline for the plan so it this is like the, the 2nd or 3rd time I'm getting it you'll be so I'm just trying to see where there has been uh a breakdown because it should have been eligible under the plan so I wanted to see one, when was this originally filed, not the 2nd or 3rd filing, um, for, for this, and if we could find that out.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Absolutely yeah I can see when that original claim was received um and processed and then we can get clarification on all of that as well.
[CUSTOMER][NEUTRAL] I'm sorry. When was the original claim?
[AGENT][POSITIVE] Yes we can get that original.
[AGENT][NEUTRAL] Yeah we can get that original date and then a clarification as well um what was your name please?
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] Sorry, [PII]
[AGENT][NEUTRAL] OK, thank you. And then, uh, firstly, can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] 704.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. Do you have your policy number?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Uh, the I have the account number. I have the group number. Let me see.
[AGENT][NEUTRAL] Um, well, if you have one of those EOBs, um, you can give me one of those claim numbers and I can have the policy that way.
[CUSTOMER][NEUTRAL] OK, uh, the claim number is 202.
[CUSTOMER][NEUTRAL] 502
[CUSTOMER][NEUTRAL] 03
[CUSTOMER][NEUTRAL] 1198.
[AGENT][NEUTRAL] OK, so that's gonna be a bit too long to be one of our claim numbers unfortunately um let's do this um I can start using.
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] That claim number is going to be a bit too long to be one of ours, um, so if you, let's see, to make it easier, um, I can search using in your social.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 632.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK thank you one moment.
[AGENT][NEUTRAL] There we are. OK. And briefly, I'm just gonna verify some information really quick. Uh, can I get your uh date of birth, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And then can I get your mailing address?
[CUSTOMER][NEUTRAL] It is [PII], that's in [PII].
[AGENT][NEUTRAL] Perfect. The last thing I need is the email address we've got on file for you. uh, let's look at the [PII] account.
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] Awesome, thank you for verifying all of that. OK, so it looks like you've got 4 policies with us, um, you've got a hospital identity, accident, uh, term life, and dental. Uh, which claim was this for? Was this for accident?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Uh, no, this would be for, so it's a mammogram, so medical.
[AGENT][NEUTRAL] Oh, OK, OK. So for the hospital indemnity. OK, one moment.
[AGENT][NEUTRAL] OK, and then, um, before we proceed any further, [PII], do you want me to go ahead and give you this policy number so you've got it for your records?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Sure, yes, thank you.
[AGENT][NEUTRAL] OK yeah let me know when you're ready for that.
[CUSTOMER][NEUTRAL] Uh-huh, go ahead.
[AGENT][NEUTRAL] OK, so that is 02.
[AGENT][NEUTRAL] 41
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 5860.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 02415860
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] And this is for your medical. OK, so I did just look and I'm thinking this might be
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] This is going to be for a different policy. I only have one claim on file uh for this policy, and that was from [PII], so it's gonna be for one of these different ones. Um, give me just a moment, let me.
[AGENT][NEUTRAL] Check this out.
[CUSTOMER][NEUTRAL] So yeah, it is for [PII].
[AGENT][NEUTRAL] Oh, it is. OK, well, I just.
[CUSTOMER][NEUTRAL] So the claim I'm seeing here is the [PII], yeah.
[AGENT][NEUTRAL] Oh, OK, so I only see the one though, um, and this looks like it was processed [PII], and that's the only time I have on file for this policy.
[CUSTOMER][NEUTRAL] Right, so that makes sense because [PII] because the.
[CUSTOMER][NEUTRAL] The um appointment was on um April.
[AGENT][NEUTRAL] I have the date of service is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII], um.
[CUSTOMER][NEUTRAL] What do you have as the, the service, the type of service?
[AGENT][NEUTRAL] So for this
[AGENT][NEUTRAL] Yes, OK, so that looks like there were two items, um, and we did pay one that was $75. Give me just a moment, let me take a deeper look here.
[AGENT][NEUTRAL] So that's stating that that $75 met the maximum for the date of service, uh, and that's why we could not pay anything additional. So let me take a closer look. Um, this looks like it was for a sickness visit, uh, just a a doctor's visit. Um, does that sound right to you?
[CUSTOMER][NEUTRAL] Uh, doctor's visit for 11.
[AGENT][NEUTRAL] 411 [PII].
[CUSTOMER][NEUTRAL] Does it, do you have any additional information in terms of the service type of service or the provider?
[AGENT][NEUTRAL] Um, I have the provider as.
[AGENT][NEUTRAL] Texas Health physicians Group.
[CUSTOMER][NEUTRAL] OK, OK, so yeah, that's probably, um, yeah, I'm familiar with that.
[AGENT][NEUTRAL] Is that right?
[AGENT][NEUTRAL] OK, so yes, that's going to be the only claim we have on file for this policy. Uh, just for good measure, I did just take a look at your um accident policy. We've not received any claims for that one. So this is going to be the only medical claim we have on file for you.
[CUSTOMER][NEUTRAL] OK, so this ELB that I received is for um service date um back in [PII], and this was um for a mammogram and um
[CUSTOMER][NEGATIVE] This is basically being denied because it's saying it was submitted for payment after the filing date, so I'm not sure what happened because it was filed before. This is not the first time I'm getting and I wish I.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, uh, I don't know where the other one is, so.
[AGENT][NEUTRAL] I would check Ruthly on that I'm sorry to interrupt you, um, just based on the information that you gave me, especially that claim number, um, that doesn't sound like that's going to be through us because again this is the only record of any claim that we've ever received from you, um, so and especially if this, um, what does it say? Does it say American Public Life on it?
[CUSTOMER][NEUTRAL] I don't know
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Well, this is the 90 degrees benefits and it was to American public right.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Yes, OK, so their claims are a bit different than ours. They have, I know it's confusing, um, so this is a part of a multi plan so you've got your medical with us, but they, their policies are more for um wellness, so I can definitely get you over to them because that sounds like that's one of their claims.
[CUSTOMER][NEUTRAL] OK, so that, OK, so before we go, transfer, so you said.
[AGENT][NEUTRAL] Of course.
[CUSTOMER][NEUTRAL] Um, that there was one claim on the account which was for Texas health physician.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] And that's what it shows us the provider.
[AGENT][NEUTRAL] Yes, um, for [PII] of last year, yes.
[CUSTOMER][NEUTRAL] Yes, um,
[CUSTOMER][NEUTRAL] [PII] just trying to verify and what was, what was the the claim amount and what was paid.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Yes, OK, so again there were two essentially two codes. One was for $218.01 was for $65. We paid on, uh, we paid a total of $75 which was the maximum amount this policy can pay uh for office visits under this policy. That's the maximum. It's $75 max per day regardless of what you're being seen for.
[CUSTOMER][POSITIVE] Interesting, OK.
[AGENT][NEUTRAL] Did you want this claim number for your reference system?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, let me know when you're ready for that.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] OK, that is 34.
[AGENT][NEUTRAL] 60.
[AGENT][NEUTRAL] 364.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And so only $75 if that was paid because is it so is it just because it's a doctor's visit or I, I don't understand why.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, right, so this is, um, it's called a limited indemnity medical plan. So essentially what that means is that it's, of course, um, just pay a set dollar amount uh per covered procedure or office visit and for this policy, it pays a maximum of $75 per day that you go to the, excuse me, to the doctor.
[CUSTOMER][NEUTRAL] Mhm. And so any procedure is not covered.
[AGENT][NEUTRAL] Um, that's gonna be regardless of what you're being seen for in office. So there are going to be separate benefits for, um, for example, you know, there's, um, intensive care, uh, getting admitted to the hospital, hospital consignment, uh, things like that. This is simply the benefit for a doctor's office visit.
[CUSTOMER][POSITIVE] Interesting.
[AGENT][NEUTRAL] And again other benefits you could have would be through 90 degrees but that's going to be more along the lines of wellness so and I'm not sure what they offer, but I know that they have things like um that would be like vaccinations or um you know just a general wellness exam.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][POSITIVE] Yeah, OK, yeah, can you transfer me over to them please? Uh, I appreciate the information.
[AGENT][NEUTRAL] Absolutely, yes, do you want me to give you their phone number first in case there's a disconnect?
[CUSTOMER][NEUTRAL] So, go ahead.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alrighty, that is [PII].
[CUSTOMER][NEUTRAL] Because I called this number I called was the number that was listed on the on the EOB.
[AGENT][NEUTRAL] Right, and that is uh if it's the same number, is it the one ending in [PII]?
[CUSTOMER][NEUTRAL] And I
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, so those prompts are very confusing and that is the number. However, to reach 90 degrees you would, uh, select option one when you uh call that number.
[CUSTOMER][NEUTRAL] If
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Alright, sorry about all the confusion, um, I hope they're able to help you out. Uh, I'm just gonna put you on a hold and get them on the line for you and I sure hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] Thank you you too.
[AGENT][POSITIVE] All right. Thank you. Bye bye.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][POSITIVE] Thank you for calling 90 Degree. If you would like to participate.