AccountId: 011433970860
ContactId: c0d1b82a-8768-43a4-a20d-b5694b30f468
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1164699 ms
Total Talk Time (AGENT): 497292 ms
Total Talk Time (CUSTOMER): 399972 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/02/c0d1b82a-8768-43a4-a20d-b5694b30f468_20250402T14:19_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah, um, I'm calling regarding a claim, uh, that a, uh, uh, ER hospital put in, uh, for my son on [PII], and I'm just seeing, I'm trying to figure out what's going on because I got letters in the mail from you guys that saying it's not a covered procedure.
[CUSTOMER][NEUTRAL] I mean all he had was an X-ray and I think it drew blood. I don't think there was any procedure, so I wanna know because on the back it says.
[CUSTOMER][NEUTRAL] Um, outpatient rider only allows payment for outpatient surgery in an outpatient hospital or physician's office. Therefore, there are no benefits, so he didn't have a surgery, um.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So I don't know if we can discuss what's going on here. I can give you the claim number. There are 2 claim numbers here.
[AGENT][NEUTRAL] OK, um, first, well, I can definitely help you with the claim and looking into it and the denial and everything. Um, may I have your name and a good contact number just in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah my name is [PII] and my contact number is [PII].
[AGENT][NEUTRAL] Thank you for that. You said you have two claim numbers?
[CUSTOMER][NEUTRAL] Yeah, they came in like it's the same visit, but it must be under two claim numbers for some reason or another, but.
[AGENT][NEUTRAL] OK, I can take them.
[CUSTOMER][NEUTRAL] Alright, the first claim number is 3,581,690.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] OK, and what's the second one?
[CUSTOMER][NEUTRAL] 3579417.
[AGENT][NEUTRAL] Alright, and I have you here. I just need you to verify, um, we can just verify your date of birth, mailing and email address on file.
[CUSTOMER][NEUTRAL] Well this is in my wife's the policy. I'm also covered here under the family plan, but I can give you my do you need her information or mine?
[AGENT][NEUTRAL] Oh, it doesn't matter. Um, yours is fine, just your date of birth and the mailing address.
[CUSTOMER][NEUTRAL] Uh, my date of birth is [PII], and uh the mailing address is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information that's provided is a verification of benefits, not a guarantee of payment. And um Mr. [PII], do you mind if I place you on just a brief hold? I'm just gonna look at the claims and see what's going on.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. Hold on one moment. You're welcome.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Wait, what's 2 you want? 80 or 60?
[AGENT][NEUTRAL] Oh, neither 190, and 17. OK.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] First of all,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, Mrs. [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] All right, thank you so much for holding. I apologize for that wait. So I did, I do see what's going on. OK, so,
[AGENT][NEUTRAL] For the hospital indemnity policy that you all have?
[AGENT][NEUTRAL] It's more so for if you're admitted into the hospital or if you're confined to the hospital or if there is a surgery needed for a sickness or accident, but in an outpatient facility or physician's office. So what that denial reason is saying, because he went to the or because it was at the emergency room, the policy doesn't have any coverage for emergency room. It's after admission or the surgeries or diagnostic testing.
[AGENT][NEUTRAL] Um, let me see if you said X-rays were done?
[CUSTOMER][NEUTRAL] Yeah, we were referred to there by the doctor. We originally went to the doctor and he said I need to refer you to the emergency room to have them evaluate what was going on with his knee.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, so under the diagnostic testing, some, so some policies is just any imaging, any diagnostic testing. For this policy, it specifies, um, the diagnostic testing, the medical imaging is for like an MRI, a CAT scan, a CT scan, or a PET scan, and then there's like advanced testing or follow-up.
[AGENT][NEGATIVE] But that's what the denial reason is saying that it's not covered by the the place of service is not covered by the policy, not so much what was done.
[CUSTOMER][NEGATIVE] But why? I don't understand. So how, you can't get admitted unless you go to the emergency room.
[CUSTOMER][NEUTRAL] They're not going to admit you.
[CUSTOMER][NEUTRAL] You know what I mean? Like you need to go to the emergency room first before you're admitted into the hospital if there was that reason.
[AGENT][NEUTRAL] Correct, and some policies have coverage for emergency rooms or urgent care facilities like outpatient facilities, and that's where the coverage would come in at, but this policy doesn't have that. It has the coverage once admission and confinement has begun.
[CUSTOMER][NEUTRAL] OK, so you're saying the policy doesn't cover if you had to go to the emergency room.
[AGENT][NEUTRAL] Right, because it doesn't have any like outpatient coverage. It's hospital admission and hospital confinement, but admission happens, you know, after you're admitted and then confinement is anything over 18 hours consecuti[PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that's why that's saying that for this claim.
[CUSTOMER][NEGATIVE] So what does it say it must be the same because we never, we never left the ER. We went to the ER and then that was it, like we left. They didn't keep us there overnight.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] So it doesn't cover an X-ray regard just because of where it took place or because it's an X-ray cause the CT scans are more advanced imaging than an X-ray. I would that doesn't really make a whole lot of sense.
[AGENT][NEUTRAL] So, for this policy, it's not so much um well this one is different because it specifies what's considered diagnostic testing. Some of them just say diagnostic testing and then it could be any imaging, but this one has diagnostic testing benefit and then it has medical imaging tests, and it lists which tests are covered on the policy.
[CUSTOMER][NEUTRAL] And you're saying an X-ray is not covered.
[AGENT][NEUTRAL] No, sir. It only shows the MRI.
[CUSTOMER][NEUTRAL] But he is.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] An MRI is covered, but an X-ray is not covered.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] That doesn't make any sense. Like, you know what I mean? Like an X-ray is so much cheaper than an MRI.
[AGENT][NEUTRAL] That could be why this policy, I, I mean, I, I, I don't know, that could be why this policy covers the more expensive products, uh.
[AGENT][NEUTRAL] I can't really speak on what was covered on the policy or not. It's just X-rays are not covered.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] Cause we pay extra like enhanced benefits through this insurance that my wife had, and I don't understand, you know what I mean? Like I read through it and I understood that we had a certain percentage of a hospital visit. I, it it wasn't clear that you had to stay overnight at the hospital.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, yes, sir. That unfortunately, that's
[AGENT][NEUTRAL] If it had outpatient benefits, then the ER, that's where the emergency room is covered, urgent care is covered, um, that's, that's all considered outpatient.
[CUSTOMER][NEUTRAL] But I'm saying, are you seeing that we have an enhanced cover like we paid for like an enhanced cover, so we paid extra.
[CUSTOMER][NEUTRAL] I looked through it and it had like hospital I OK let's pay for the extra.
[CUSTOMER][NEUTRAL] I, I, I'm not looking at it in front of me again. I'd have to look at it again, but it wasn't clear that it said it said hospital and all this other stuff, but it didn't say, oh you had to spend the night. It just said it covered this percentage of hospital and I knew it wasn't gonna be all of it, but like.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] The only other thing I can think of is, so since this is through the employer, let me see if it is, hold on one second.
[CUSTOMER][NEUTRAL] See here if I can get.
[AGENT][NEUTRAL] You could just, I mean, it won't help you for this claim, but moving forward, if you wanted to, you could call benefits and a card and see what other like plan options they have because there are some that have like the emergency or the urgent care added to their policy. I would see if that was supposed to be added. If so,
[AGENT][NEUTRAL] Then they would just notify us in writing and then we could reprocess. If this is correct, then if this is the correct enrollment.
[AGENT][NEUTRAL] For this policy, then
[CUSTOMER][NEUTRAL] I mean, we, we pay for the enhanced coverage, whatever that would be the most that you could get.
[CUSTOMER][NEUTRAL] The most that they offered is what we paid for.
[CUSTOMER][NEUTRAL] That's what I signed up for.
[AGENT][NEUTRAL] OK, so then I would definitely reach out to and the reason I'm saying reach out to benefits in a card is because all of our policies come through the employer, so we can't make any changes unless they notify us in writing. So that's the only reason I'm saying that you have to go through them, um, because they have to notify us and then we can make, if we need to make changes, we can, but this is how it came over to us, so.
[AGENT][NEUTRAL] I mean, we can correct it if it needs to be.
[CUSTOMER][NEUTRAL] OK. I, I, I remember we said we wanted the enhanced so she's been getting billed for the enhanced coverage. It was like whatever they offered, it was like the most, you know what I mean? I, I, I don't exactly how it was described.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][POSITIVE] Um, but it was the most coverage that we could get.
[CUSTOMER][NEUTRAL] In terms of medical.
[AGENT][NEUTRAL] So then either I would
[CUSTOMER][NEUTRAL] Let me see if I can
[AGENT][NEUTRAL] So that makes sense to me. I would either, um, the first thing I would do is reach out to benefits and a card and let them know, hey, I paid for the enhanced, I have this added, but I got this claim and it was denied because it said I didn't have it. So we would have to start from there and then if they need to
[AGENT][NEUTRAL] Make changes to your enrollment and send it to us so that we can make those changes, we can go from there and then if it does need to be reprocessed, we can definitely reprocess.
[CUSTOMER][POSITIVE] OK, I'll take a look and see what they, what they, I'll call them all right, thank you.
[AGENT][NEUTRAL] Did you need their, did you need their phone number?
[CUSTOMER][NEUTRAL] I might have it here um.
[CUSTOMER][NEUTRAL] I have here I thought I had their card up here somewhere.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I have their card.
[CUSTOMER][NEUTRAL] What I do with it? I had their card just here the other day.
[CUSTOMER][NEUTRAL] Um, sure, go ahead and give it to me, the benefits and the card number.
[AGENT][NEUTRAL] OK, so it's, oh, let me know when you're ready.
[CUSTOMER][POSITIVE] I'm ready.
[AGENT][NEUTRAL] Alright, so it's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I'll give them a call and see what I can get through and and if they end up saying because I'm gonna say do I'm we should have the enhanced coverage.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] And at that point I'm assuming that that covered because I remember something like that and I looked through it and I was like, oh it's worth it to get the enhanced coverage and um.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Anything that they, if, if they did send it over to us with the wrong elections, it, it can definitely be fixed and reprocessed. If this is correct.
[AGENT][NEUTRAL] Being like the the um enrollment.
[AGENT][NEUTRAL] The options. If it is correct, you can, you do have the options to make changes to your existing policy. So they can help you with that too, and then they'll send everything to us in writing and we'll, you know, make the adjustments as we need to.
[CUSTOMER][NEUTRAL] OK, no, I, I know we paid for the, we asked for the enhanced.
[CUSTOMER][NEUTRAL] I'm just looking here hold on I mean I'm just trying to find um.
[AGENT][POSITIVE] Well, take your time.
[CUSTOMER][POSITIVE] Something here let me see benefits.
[CUSTOMER][NEGATIVE] I don't know if this makes a difference, but she gets charged weekly 101 and 22 cents.
[CUSTOMER][NEUTRAL] That's for medical then we have dental and vision that are also charged.
[CUSTOMER][NEUTRAL] Does that seem about right that's weekly that gets charged out.
[AGENT][NEGATIVE] Well, so for, for me, I mean, I can't, that doesn't really help me because I'm not in customer service to work with premium, so.
[AGENT][NEUTRAL] I don't want to, you know, I don't want to give you the wrong information.
[CUSTOMER][NEUTRAL] OK, I didn't know if that's that, but I, I don't know. I'm trying to find all the documents. I know like, you know, um.
[AGENT][NEUTRAL] But now I would tell them that when you call because they'll be able to, when you call benefits in a card, they're going to be able to look up what is enrolled, what you're paying, and then versus what you should have and what you're paying. So they'll be able to give you, now that would make sense to them because they have all that information there.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] So you can see I'm paying this, what, what should the coverage be for this amount because I'm supposed to have enhanced and this claim came back denied.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Because there's no emergency room coverage there, you know what I would, I would mention, I should, or I thought I should have had coverage for out for outpatient facilities.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] There you go. And that covers the emergency room, urgent care.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Because right now it's like you only have surgery in an outpatient facility coverage.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I'm looking here, let me try to might have came from somebody else but um.
[AGENT][NEUTRAL] And if you like, I can transfer you over. Did you want to call at another time?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] I'll call in a little bit, yeah, just give me a minute. I, I'll call them and just we'll go from there. I'm just looking through my wife's email they sent over all the explanation of all the benefits. There was like an email that had it all and I looked it over and um.
[AGENT][NEUTRAL] You sure?
[CUSTOMER][NEUTRAL] I just can't seem to find it right now, um, back in it because it was August of last year.
[CUSTOMER][NEUTRAL] And um that started with this OK alright so you're saying right now we don't have the enhanced coverage.
[AGENT][NEUTRAL] The
[AGENT][NEUTRAL] Well, see
[CUSTOMER][NEUTRAL] What.
[AGENT][NEUTRAL] So how it shows on your end like your plan names, once they, once they being benefits in the car, sends it to us, like on my end, I don't see anything that says enhanced. I just see hospital indemnity and like your product number, but on your end it may say enhanced. I just don't see that on mine. So I don't want to say yes and it's or no, and it that is enhanced. We just don't have the same plan names when they send it over to us.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, all right.
[CUSTOMER][NEGATIVE] OK, because it doesn't make sense that the enhanced coverage would not cover.
[CUSTOMER][NEUTRAL] And and hot ER visit, like, you know what I mean like, but you have to stay in the hospital to get covered like.
[CUSTOMER][NEUTRAL] That doesn't make sense, but you know, uh, how, what do I know? you know what I mean? And it doesn't.
[AGENT][NEUTRAL] That's the part to stress to them about the outpatient facility because that's what you're that's what you're saying like the ER is an outpatient facility, so make sure you say.
[CUSTOMER][NEUTRAL] Typically you have to go to
[AGENT][NEGATIVE] I I thought I should have had coverage for outpatient facilities.
[AGENT][NEUTRAL] Then that will cover everything.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][POSITIVE] OK, all right, I will call them. I appreciate it thank you.
[AGENT][POSITIVE] You're very welcome. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] No that's it I appreciate it thanks.
[AGENT][POSITIVE] Alright, Mr. [PII]. You're welcome. Thanks for calling APL. Have a great day.
[CUSTOMER][NEUTRAL] Alright.