AccountId: 011433970860
ContactId: c80c2325-67bd-429e-8bb4-201909581412
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 432589 ms
Total Talk Time (AGENT): 123108 ms
Total Talk Time (CUSTOMER): 154853 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/c80c2325-67bd-429e-8bb4-201909581412_20250117T15:11_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, hi, my name is [PII]. I believe I spoke to you yesterday, coincidentally. May I give you my claim number, please, or do you need the policy number?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Claim number is fine.
[CUSTOMER][NEUTRAL] 355
[CUSTOMER][NEUTRAL] 2994
[AGENT][NEUTRAL] What's a good call back number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And your complete mailing address?
[CUSTOMER][NEUTRAL] I live at [PII].
[AGENT][NEUTRAL] And what's your date of birth?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and what's your email address on file, [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK and how can I help you today?
[CUSTOMER][NEUTRAL] The reason I'm calling is that um it looks like my claim has been denied.
[CUSTOMER][NEUTRAL] Um, and I was wondering if you have that letter yet.
[AGENT][NEUTRAL] The primary explanation.
[CUSTOMER][NEGATIVE] Or I should be receiving.
[AGENT][NEUTRAL] Is it the we we did not, yeah, we denied it for a copy of the primary explanation of benefits.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] When did you send that? Have you sent that to us?
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] The thing is, it hasn't been prepared by Aetna yet. Um, the company, the company that completed the, I had an endoscopy. The company that completed the endoscopy already sent the information, um, and, and that's the printout that I received from them. So, and then I called up Aetna and Aetna says, no, you still have to wait on that. I go, well, and so then
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I just wanted to know if you could explain, I mean, is that something that's crucial, um.
[CUSTOMER][NEUTRAL] So my claim with you all, or?
[AGENT][NEUTRAL] Yeah, we'll need it in order to complete the processing of your claim since our policy is secondary, uh, we need to know how the primary uh process your claim and what amounts were applied towards your deductible co-insurance and or co-pay amounts, if any.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] I see, I see. OK. Would you do me a huge favor? Can you tell me a little bit about the policy that I have in, in place? Um, is it, I mean, is there a limit? I mean, because I paid $1000 out of pocket. Um, is that too much or too little based on the policy that I have?
[AGENT][NEUTRAL] Uh, let me check your benefits. That was for outpatient facility?
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][POSITIVE] Certainly thank you.
[AGENT][NEUTRAL] Thank you for holding, Arturo. So the maximum out, the maximum outpatient benefit under this policy is up to $350 per calendar day.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] So that's the max the policy will pay per day per calendar day for any outpatient service.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Per outpatients, so the maximum I'd get would would be 3 if if it pays $350 is that correct?
[AGENT][NEUTRAL] Alright, depending on how your primary process the claim would determine what APL will pay, but yes, that would be the general um way it's handled or processed.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Now, since I haven't.
[CUSTOMER][NEUTRAL] OK, since the explanation of benefits is still forthcoming, um, and my claim is denied on your end, I mean, I mean, am I able to reapply again when I have it?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So when you, uh, when they've processed your claim, just download a copy of their explanation of benefits, making sure that the document that you download does show the deductible co-insurance and co-pay amount on it, and you can just upload it online. That's all you'll need to send.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And we'll know to attach it.
[CUSTOMER][NEUTRAL] Oh, that's only I don't have to reapply completely and add all the documents on again. Oh, OK.
[AGENT][NEUTRAL] No, no, just, just the ELB only and then we'll know to attach it to um the previous claim. Now you did give me the claim number, so you may wanna write the claim number, you know, at the top of the explanation of benefits.
[CUSTOMER][POSITIVE] Consider it done. OK, that's a good idea. Alright, so, well, I, I guess at this point I'm literally at the mercy of the uh Aetna insurance they. They're talking. So I mean there's nothing I can do on my end. All right, well, listen, thank you so much for your time and for your explanation. I do appreciate it, all right?
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Yes, exactly.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] You're, you're welcome, [PII]. Did you have anything else I can answer for you?
[CUSTOMER][POSITIVE] That's, that's all have a great weekend and thanks again.
[AGENT][POSITIVE] You as well and thank you for calling APL. Have a good day.
[CUSTOMER][POSITIVE] Thank you.