AccountId: 011433970860
ContactId: c2c3b133-3079-4915-94da-d1f02735c87a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 787380 ms
Total Talk Time (AGENT): 315340 ms
Total Talk Time (CUSTOMER): 253280 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/19/c2c3b133-3079-4915-94da-d1f02735c87a_20250319T20:28_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII], and I'm calling on behalf of the agent's office to assist employee in a claim status update.
[AGENT][NEUTRAL] OK, Miss [PII], I can help you with a claim status update. Can you please give me uh the group number that you're calling for?
[CUSTOMER][NEUTRAL] Uh, yes, I, I have the policy number if that helps.
[AGENT][NEUTRAL] Yes, ma'am, please.
[CUSTOMER][NEUTRAL] Or I could give you the group number. OK, um, so it's two policies, uh, the first one is 2,605,150.
[AGENT][NEUTRAL] OK, let me look that up real quick.
[AGENT][NEUTRAL] OK, and Miss [PII], who is the insured?
[CUSTOMER][NEUTRAL] [PII] and her date of birth is [PII].
[AGENT][POSITIVE] OK, thank you, ma'am.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Is the claim going to also be for Ms. [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And Ms. [PII], can you verify the group for me real quick, please? Um,
[CUSTOMER][NEUTRAL] Yeah, the group is Homa Thibodaux spine and rehab number is 269-67.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Thank you so much. I appreciate you verifying that information for me.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] And you're working with the agent office uh for.
[AGENT][NEUTRAL] Who's the agent, please?
[CUSTOMER][NEUTRAL] For [PII].
[AGENT][NEUTRAL] OK, thank you. We know [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And do you know the date of service when Ms. [PII] had her claim filed or any information at all?
[CUSTOMER][NEUTRAL] Yes, so the date of service.
[CUSTOMER][NEUTRAL] Um, let's see, well, the accident date was [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me see if that's the same as the data service.
[CUSTOMER][NEGATIVE] Sorry, I gotta open up a different screen.
[AGENT][POSITIVE] That's fine. Take your time.
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] OK, let me look it up real quick.
[CUSTOMER][POSITIVE] And I have a claim number actually too if that helps.
[AGENT][NEUTRAL] Yes, let me, let me get that from you, please.
[CUSTOMER][NEUTRAL] OK, I actually have two of them because it's for a hospital and accident claim, um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 3, this is for the hospital. It's 357-729-0.
[AGENT][NEUTRAL] OK. Let me look that one up first and I that's the policy I'm in and then we'll go look up the other one when I get into the other policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, this one has a remark on it. Let me see what the remark says.
[AGENT][NEUTRAL] OK, so the remark on this policy is it's a non, not a covered loss under the plan. Benefits payable under this certificate are limited to those outlined on the schedule of benefits. This is not a covered loss under the plan, therefore, no amount is payable for this expense.
[CUSTOMER][NEUTRAL] OK, let me see here.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Because I mean, she was injured and went.
[CUSTOMER][NEGATIVE] And had to get X-rays and stuff, so that's not covered.
[AGENT][NEUTRAL] Yeah, according to this from the claims examiners, this is the um remarks that was taken um that the benefits payable under this policy are limited to those outlined on the schedule of benefits.
[AGENT][NEUTRAL] So according to her.
[CUSTOMER][NEUTRAL] I mean, the schedule of benefits shows that she has, you get.
[CUSTOMER][NEUTRAL] Uh, physician visits, ER visits, um, urgent care visits, this would fall under at least one of those.
[AGENT][NEUTRAL] OK, um, what we can do is after we look up the other one for you I can transfer you over to a claims examiner and let them go over it with you and that way they can come you they can let you know how they came to this decision.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] OK, perfect.
[AGENT][NEUTRAL] OK. All right. And what's the um next policy? Well, let me just look. You said accident I can look that up.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK, yeah.
[CUSTOMER][NEUTRAL] I mean, I have it if you need it.
[AGENT][NEUTRAL] No, it's OK. It's just 2 buttons and I have all her policies in front of me.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so I got her accident pulled up and let me go back it's gonna be the same day service, is that correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, and then what is the um claim number for the accident policy?
[CUSTOMER][NEUTRAL] 3,576,390
[AGENT][NEUTRAL] OK, let's look at that one.
[AGENT][NEUTRAL] OK, it looks like this one, let me pull up the.
[AGENT][NEUTRAL] I wanna make sure I'm telling you correctly on this one. She had a direct deposit payment of $350 on this claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, can I get a breakdown of that 350 payment?
[AGENT][NEUTRAL] It was um $50 was paid towards procedure 98941.
[AGENT][NEUTRAL] And then $300 was paid on procedure 73562.
[CUSTOMER][NEUTRAL] OK, so I'm assuming that the procedure is the doctor's visit and then the 300 is X-ray?
[AGENT][NEUTRAL] Let me see if there's any remarks.
[AGENT][NEUTRAL] One is X-ray, and then, yes, treatment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then there is a denial code on it too.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK, what, what is the denial?
[AGENT][NEUTRAL] OK. After that, after that payment, the um treatment.
[AGENT][NEGATIVE] Benefi was exhausted.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] OK, are you ready for me to transfer you on over to um claim support to see if they can help you further with that first o[PII]?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK. All right, Ms. [PII], is there anything else I can do for you before we transfer?
[CUSTOMER][NEUTRAL] Uh, that was it.
[AGENT][POSITIVE] OK, well, you have a blessed night and thanks for calling APL.
[AGENT][NEUTRAL] Bye bye now.
[CUSTOMER][POSITIVE] Thank you. You do the same.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Bringing
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], it's [PII].
[CUSTOMER][NEUTRAL] Hey [PII].
[AGENT][NEUTRAL] Hey, I've got Ms. [PII] on the phone. She's with, uh, well, [PII] is the broker, but uh she's calling about policy number.
[AGENT][NEUTRAL] 2,605,150.
[AGENT][NEUTRAL] It's one of the agents insured that they filed a claim for.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And claim number 3,577,290.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] was denied.
[AGENT][NEUTRAL] And she's she's saying that that's not how the policy so the schedule page reads so she wants to talk to somebody so she can get some clear answers.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, I can't say I blame her, but let me get that pulled up.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] And she's super sweet. I don't know if you talk to [PII] a lot, but she's real cool.
[CUSTOMER][NEUTRAL] I think I've spoken to her a time or two. let me see if I can actually find this policy sir.
[CUSTOMER][NEUTRAL] I didn't see one in all these.
[CUSTOMER][NEUTRAL] Alright, let's see here.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'll put my notes in real quick while I got you looking at that.
[CUSTOMER][NEUTRAL] OK, she had plan 4.
[CUSTOMER][NEUTRAL] Of course there's not. Why would there be? That would be too easy.
[CUSTOMER][NEUTRAL] OK, let me get the claim pulled up and let me see what's going on.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I'm wondering if it's a place to start this issue.
[CUSTOMER][POSITIVE] But I don't know because I got, I gotta look at that because she's got a lot of benefits so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Well, she mentioned all the places of service and she said it should fall under one of those.
[CUSTOMER][NEUTRAL] Let's see X-ray.
[CUSTOMER][NEUTRAL] 98941.
[CUSTOMER][NEUTRAL] Chiropractic care, hm.
[AGENT][NEUTRAL] You should I get back to her and let her know that you're searching your.
[CUSTOMER][NEUTRAL] Yeah let her know that I'm pulling up what was submitted so I can try and figure out what's going on here.
[AGENT][NEUTRAL] OK. All right. I'm gonna go back to her real quick.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Hi, this is [PII] again. So we haven't forgot about you. I've got [PII] on the other line and she's just researching and pulling up the um claim information getting it together so she'll be able to help you.
[CUSTOMER][POSITIVE] OK, perfect. No problem. Take your time.
[AGENT][NEUTRAL] OK, I just wanna let you know why you were having to wait.
[CUSTOMER][POSITIVE] I appreciate it. Thank you.
[AGENT][POSITIVE] No problem. You take care, Ms. [PII]. Bye-bye.
[CUSTOMER][NEUTRAL] OK bye.
[AGENT][POSITIVE] OK, she's good.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEGATIVE] There's not a place of service code.
[CUSTOMER][NEUTRAL] There's just a patient statement here.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Does she happen to know how like what place of service code they use?
[AGENT][NEUTRAL] I am not sure she will probably, she would probably know because [PII] is the one that filed the claim for her, so she may have information.
[CUSTOMER][NEUTRAL] OK, I can ask her about that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, because the only thing I'm thinking is they have outpatient accident and sickness in a physician's office.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And so.
[CUSTOMER][NEUTRAL] It appears to be maybe a physician's office because it is.
[CUSTOMER][NEUTRAL] Yeah, uh, I don't know if that's Homa, Huma. I don't, I think it's Homahibido spine and rehab. I would assume that's a physician's office, but I really don't know, um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] But we don't have a place of service code. I don't even know if there's an EOB note on here that kind of clarifies like hey we need.
[CUSTOMER][NEUTRAL] Clarification? There's not.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um, yeah, let me talk to her and see if she has more information so that I can kind of nail down what may we may be able to do or not do here.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK. OK, [PII]. I appreciate you helping her. You're welcome. All right, bye-bye.
[CUSTOMER][POSITIVE] Thank you, no problem.
[CUSTOMER][NEUTRAL] Bye bye.