AccountId: 011433970860
ContactId: c9ea1146-a0f6-4ec7-879f-9f8d23191346
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 355630 ms
Total Talk Time (AGENT): 141958 ms
Total Talk Time (CUSTOMER): 172670 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/23/c9ea1146-a0f6-4ec7-879f-9f8d23191346_20250123T16:33_UTC.wav
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[AGENT][NEUTRAL] APL, this is [PII]. How may I assist you?
[CUSTOMER][POSITIVE] Hi, good morning. How are you?
[AGENT][POSITIVE] I'm good, thanks for asking. How are you?
[CUSTOMER][NEUTRAL] Please.
[CUSTOMER][NEUTRAL] Good, good. I have a question. I was, uh, I had my gap insurance for so many years, and for some reason, I, uh, I attend to emergency room, uh, almost 2 years ago, and I was, um, charged for it.
[CUSTOMER][NEUTRAL] And I just noticed about it now. Can you please, um, I have a policy number. I'm sure, give me a second. I'm gonna give it to you, but I have a claim number.
[AGENT][NEUTRAL] Do you have a policy number?
[AGENT][NEUTRAL] But I need a policy number to pull up your policy.
[CUSTOMER][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] OK, so give me one second, I'm gonna put it out.
[AGENT][NEUTRAL] It should be on that the EOB that you have. Are you looking at the EOB with a claim from APL?
[CUSTOMER][NEUTRAL] No, I have the card with me, the APL card. It's gonna help you?
[AGENT][NEUTRAL] It should say a policy number, yes.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] I don't see policy number. I say insured coverage group number.
[AGENT][NEUTRAL] Will will say inpatient outpatient cert number?
[CUSTOMER][NEUTRAL] Yeah, oh yes, skin hospital benefit card number or outpatient benefit card?
[AGENT][NEUTRAL] Either one of them, it doesn't matter. It'll pull up the policy.
[CUSTOMER][NEUTRAL] OK, so the outpatient is 021.
[CUSTOMER][NEUTRAL] 527-53
[CUSTOMER][NEUTRAL] M as in Mary, L as in Leo.
[CUSTOMER][NEUTRAL] Number 8.
[AGENT][NEUTRAL] Thank you, can I have your name, mailing address, and your date of birth?
[CUSTOMER][NEUTRAL] Yes, my name is [PII], and the date of birth is [PII]. And the address is [PII].
[AGENT][NEUTRAL] Thank you and could you verify the email address that we may have on file for you?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] We have something different.
[CUSTOMER][NEUTRAL] Maybe you have [PII] at browser.
[CUSTOMER][NEUTRAL] They could uh.
[AGENT][NEUTRAL] Yes, that's correct. Callback number for you just in case the call is disconnected is the [PII].
[CUSTOMER][POSITIVE] Correct, ma'am.
[AGENT][NEUTRAL] Thank you. And you said you were calling because you had a claim from an emergency room visit?
[AGENT][NEUTRAL] And you wanted to verify if you can file it?
[CUSTOMER][NEUTRAL] Yes, and if you want me to, if you want me to give you the claim number, it's 345.
[CUSTOMER][NEUTRAL] 3106. For some reason, they say that they, the gap insurance was denied the claim.
[AGENT][NEUTRAL] Cause it's a duplicate.
[AGENT][NEUTRAL] 8 12 2023.
[AGENT][NEUTRAL] It's a duplicate.
[AGENT][NEUTRAL] Um, 5125.
[AGENT][NEUTRAL] 5125, it looks like the provider originally submitted it in April.
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Bear with me while I verify why I was denied the first time.
[CUSTOMER][NEUTRAL] It
[AGENT][NEGATIVE] But the second time it was submitted, it was considered as a duplicate.
[CUSTOMER][NEUTRAL] No problem. This is [PII].
[AGENT][NEUTRAL] 1624
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Ah
[AGENT][NEUTRAL] What was the reason for your hospital visit to the ER?
[CUSTOMER][NEGATIVE] I, I didn't feel good. I went to the ER.
[AGENT][NEUTRAL] The [PII].
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] So it, it says that it was for a screening.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] For what?
[AGENT][NEUTRAL] A screening. Like it says encounter for screening unspecified. So it's not listing a sickness.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] OK, and that's why they didn't uh approve it?
[AGENT][NEUTRAL] Right, because we don't pay for anything that's not a sickness. It says it was a screening, so you may want them to send it back to building to send it back to billing to the billing department to verify if it's coded correctly, like what was the diagnosis that you was there, the reason that she was there because as of right now on the claim it says that it was for a screening.
[CUSTOMER][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] All the.
[CUSTOMER][NEUTRAL] Yeah, but what if I want, yeah, but what if I went there for something like personal?
[AGENT][NEUTRAL] Right, either if it was something personal, it still should be on the UB saying if it was something personal then it still should be listed on the UB as coded that way, but it's not coded that way. It just says for screening.
[AGENT][NEUTRAL] And we don't cover screenings.
[CUSTOMER][NEUTRAL] I got it. So everything is because of the COVID, right?
[AGENT][NEUTRAL] Yes, it says that a screening is not a sickness. A screening can be for a wellness screening.
[AGENT][POSITIVE] But it doesn't have a sickness.
[CUSTOMER][NEUTRAL] OK, I got it.
[AGENT][NEGATIVE] And that's why I was denied.
[CUSTOMER][NEUTRAL] OK. And uh how much it was the claim for $250?
[AGENT][NEUTRAL] The claim was for $794.
[CUSTOMER][NEUTRAL] OK, and how much they didn't cover?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] What went towards your deductible amount?
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] was $250 went towards your co-pay.
[CUSTOMER][POSITIVE] OK, I got it. No problem. Thank you so much. I really appreciate it.
[AGENT][POSITIVE] You're welcome. Is there anything else that I can assist you with today?
[CUSTOMER][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] No, that's all.
[AGENT][POSITIVE] Thanks for calling APL. Have a great day.
[CUSTOMER][POSITIVE] Thank you bye bye.