AccountId: 011433970860
ContactId: cae93a58-55f2-4641-b29b-2597fc3bae10
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1328500 ms
Total Talk Time (AGENT): 694445 ms
Total Talk Time (CUSTOMER): 329767 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/24/cae93a58-55f2-4641-b29b-2597fc3bae10_20250124T15:46_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How may I help you?
[CUSTOMER][NEUTRAL] Hello, calling in regards to one of the policyholders that we work with is she submitted a bunch of wellness claims and then resubmitted to us to have resubmitted.
[CUSTOMER][NEUTRAL] But there was plenty of them to go through and I just was calling to see if any of them have paid and in specific which ones have paid because I see on the website they'd all processed but I'm not so sure which ones were paid and which ones were denied.
[AGENT][POSITIVE] OK, I'd be happy to help you with that claim inquiry. um, can I have your name please?
[CUSTOMER][NEUTRAL] Uh, this is [PII].
[AGENT][NEUTRAL] Thank you and um you're calling, are you the uh are you calling in the from the agent or?
[AGENT][NEUTRAL] The admin? OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] The agents.
[AGENT][NEUTRAL] And which agency?
[CUSTOMER][NEUTRAL] Is uh R&B Insurance Services.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And can I please have a callback number in case we get disconnected and I can call you back?
[CUSTOMER][NEUTRAL] It is [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And I'll have you verify some information for me please if you don't mind um you can go ahead and give me the uh policy number for the member.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah it is 2444.
[CUSTOMER][NEUTRAL] 982.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Alright, just give me one minute.
[AGENT][NEUTRAL] I'm going to pull up that policy. I'll have you verify some patient information and then I'll also have you verify um.
[CUSTOMER][POSITIVE] Mhm. No problem.
[AGENT][NEUTRAL] Just give me one moment.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] And can I have you verify uh the patient's information, uh, their name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, it is [PII] and then the date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And do you have uh the mailing address for Ms. [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, yeah.
[CUSTOMER][NEUTRAL] Should be [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And just give me one moment I'm gonna have you verify.
[AGENT][NEUTRAL] Your uh
[AGENT][NEUTRAL] Contact if you don't mind.
[CUSTOMER][NEUTRAL] You're fine.
[AGENT][NEUTRAL] And what would be the uh contact information uh can you give me the address?
[AGENT][NEUTRAL] And then the email address?
[CUSTOMER][NEUTRAL] Um, do you mean for me or for [PII]?
[AGENT][NEUTRAL] Uh, for the, for the, uh, agency.
[CUSTOMER][NEUTRAL] Alrighty, um, I'm not, is there a specific email address that was listed for us?
[AGENT][NEUTRAL] Um, it looks like it's the company, the, the R&B.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, um, it should be either [PII].
[CUSTOMER][NEUTRAL] Uh, support maybe at [PII]&B Insurance Services or maybe [PII]urance Services. I did just give um that email yesterday.
[CUSTOMER][NEUTRAL] Or this morning too I called
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, I got it OK.
[CUSTOMER][NEUTRAL] And then the address for our agency is [PII]n, PA 17745.
[AGENT][NEUTRAL] OK, it does have a um the RMB insurance but it has a different name um as the agent.
[AGENT][NEUTRAL] Is there a
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] It could be
[CUSTOMER][NEUTRAL] Kim W
[CUSTOMER][NEUTRAL] Ashley red are.
[CUSTOMER][NEUTRAL] Or um.
[AGENT][NEUTRAL] Yeah, that's it. That's Fred R. My apologies. I'm not trying to quiz you.
[CUSTOMER][NEUTRAL] OK, that's, I kind of figured that was coming up. No, no, you're good. I haven't had to provide that, so I just wanted to, I know it's one of ours. I just don't know who else.
[AGENT][NEUTRAL] Oh yeah
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, OK, well thank you for verifying that information for me. I appreciate that. OK, so it, it does look like we do have uh some claims here so let me just take a look and.
[CUSTOMER][NEUTRAL] Yeah, of course.
[CUSTOMER][NEUTRAL] Yeah, of course.
[AGENT][POSITIVE] I appreciate you being patient.
[CUSTOMER][NEUTRAL] I'm not mistaken, a lot of them are, oh yeah, no problem. I, I understand, um, if I'm not mistaken, going back through the ones she sent and then the ones we also submitted, there are a lot of duplicates so because she submitted a few of the dates of service for on their own claim form and then also submitted them in like groups of data services for a different claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK and this um would be uh.
[AGENT][NEUTRAL] For this calendar year, correct?
[AGENT][NEUTRAL] For this plan year for 2025.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Not all of them. There is one that's in 2025, but a few of them, majority of them are in 2023. There was 4 for her accident policy and then a bunch for her critical illness, but we can just do the accident policy since that's where I got you on the.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] On the keypad calling in.
[AGENT][NEUTRAL] OK, so it does look like um this is under the accident policy that's that policy number you provided for me so it does look like um so there was a claim for 2025 that was finalized um under uh.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] I can provide you the claim number, but that was uh data service was January 9, 2025, and these are uh.
[AGENT][NEUTRAL] The most recent, so then we received uh.
[CUSTOMER][POSITIVE] Ready.
[AGENT][NEUTRAL] Let me look at this one.
[AGENT][NEUTRAL] So then we did receive some duplicate claims for 2023, um, I have a March 6th. Would you like now you said you can see the claim, can you see the claim numbers on the portal?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, I can see the claim numbers for the ones we submitted. Yes, I can't see the ones that she submitted herself, no.
[AGENT][NEUTRAL] For the claim information?
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I have all the dates of service for all of them, so if you just wanna go by the dates of service that I paid that's fine by me as well.
[AGENT][NEUTRAL] Certainly.
[AGENT][NEUTRAL] OK, so on the January 14th of this year we finalized the claim for January 9, 2025 and we did pay a benefit on that claim.
[CUSTOMER][NEUTRAL] 3.
[AGENT][NEUTRAL] Of $50.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] And then that would um that with that payment then that lets them know on that explanation of benefits that it's uh that that exhausts the benefit so um but that was a $50 payment and then uh let's see.
[AGENT][NEUTRAL] Now under the accident policy, that is the only one I see that um.
[AGENT][NEUTRAL] It's paid.
[CUSTOMER][NEUTRAL] So none of the ones for 2023 paid?
[AGENT][NEUTRAL] Let me see what happened with those.
[CUSTOMER][NEUTRAL] Brady.
[AGENT][NEUTRAL] Because it looks like we do have a lot of the submissions so.
[CUSTOMER][POSITIVE] Yeah, I kind of figured that was gonna be the case. I apologize for that.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] That's OK.
[AGENT][NEUTRAL] OK, so then we did have a um a claim for June 30th, 2023, um, and that claim that denied due to it was prior to the policy effective date.
[AGENT][NEUTRAL] Under uh for that data service.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And again that was June 30th.
[AGENT][NEUTRAL] And then um let's see what this one says.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so then we have a few others that are the same, uh, denial 1127, 2023.
[AGENT][NEUTRAL] Also prior to the effective date.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] 95 2023.
[AGENT][NEUTRAL] Uh, that again was denied, uh, prior to the effective date.
[AGENT][NEUTRAL] And it looks like because it looks like the effective date is December 1st of 2023, is that correct?
[CUSTOMER][NEUTRAL] Um, yes, I do believe so. So now looking back on it, I understand.
[AGENT][NEUTRAL] And uh, yeah, OK.
[AGENT][NEUTRAL] Yeah. And
[CUSTOMER][NEUTRAL] Why those were denied
[AGENT][NEUTRAL] And then I have
[AGENT][NEUTRAL] Data service 5-19 2023.
[AGENT][NEUTRAL] Also prior to that effective date.
[CUSTOMER][NEUTRAL] Yes, is that the same? Sorry, I might be jumping the gun here. Oh wait, you don't know about the critical illness policy, never mind, OK.
[AGENT][NEUTRAL] And then that
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I can look at that if you'd like since we've already verified if you have.
[CUSTOMER][NEUTRAL] Uh, yeah, if you don't mind.
[AGENT][NEUTRAL] Certainly.
[AGENT][NEUTRAL] So, um, yeah, that
[CUSTOMER][NEUTRAL] Yeah, because those are the only accident claims that I had for 2023.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] For the accident or for the accident policy.
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] Yeah, that last day of service looks like it was March 6, 2023, and again it was that same prior to effective date that that was all the claims that are under that policy. Like I said, we did, um, you know, pay out that benefit on that January 9, 2025.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that one is.
[AGENT][NEGATIVE] And then the rest of them that were submitted they were denied as duplicate because they were dates of service that we previously received and denied for prior to the effective date.
[CUSTOMER][NEUTRAL] OK, I kinda.
[CUSTOMER][NEUTRAL] I understand that now.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, the critical owners policy is the one where there was a lot of submissions for.
[AGENT][NEUTRAL] OK, let me take a look.
[CUSTOMER][NEUTRAL] And if that's the
[CUSTOMER][NEUTRAL] I can go through the dates of service for those as well if for the ones that were prior to if that's the same date of service if that's the same uh effective date.
[AGENT][NEUTRAL] Yeah, it does appear to be the same effective date um as the accident policy. It is at 12-1-2023.
[AGENT][NEUTRAL] Now
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Um, I do show again that benefit was paid for the 2025 date January 9th.
[AGENT][NEUTRAL] Under the critical illness, so we did pay that screening benefit as well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And then it appears that those additional dates are gonna be um that same uh denial let me.
[CUSTOMER][POSITIVE] Alrighty.
[AGENT][NEUTRAL] Um, they just use a bit different of the remark code due to the type of policy that it is, but they do all appear to be, uh, that prior to effective date and then it looks like we do have some dates that were duplicate.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Was there
[CUSTOMER][NEUTRAL] For the wellness benefits for the accident policy and the critical illness, is it a one per calendar year for each for the individual policies?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] It, yes, well, it, it does depend on um the type of so.
[AGENT][NEUTRAL] I think you're asking if the, if it's one per policy, right?
[AGENT][NEUTRAL] I'd have to look at the actual policy itself I believe that accident, um, the accident is one, per year and it it's based on whether it's a plan year or calendar year. So calendar year is usually that Janu uh this I'm sorry, January through December that's the calendar year if it's a plan year um.
[CUSTOMER][NEUTRAL] Uh, yeah, for like.
[AGENT][NEUTRAL] I'd have to look at that and if it's a plan year it would just be plan year to plan year which would be in this case it would be December 1 to December 1 if it's a plan year.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, or if it
[CUSTOMER][NEUTRAL] OK, because
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Alright, the only reason I'm asking is because some of the, well, actually a decent amount of the claims were for, uh, 2024, and a lot of them were for like April 2024 for the critical illness wellness. That's why that's the only reason I was asking that's the one that I think should have been paid like we had but we had some of them that were in the effective date, but I don't see, don't think any of them were paid.
[AGENT][NEUTRAL] Yeah, I, I do see some paid. I can go over those dates, my apologies. Yeah, I was just looking at the most recent and yeah, yep, I can go back and look um I was looking at the recent submission so it does look like I have, um, do you want me to provide you those dates of service?
[CUSTOMER][POSITIVE] Well, you know, you're good. I just wanted to make sure.
[CUSTOMER][NEUTRAL] Uh, yeah, just for the critical illness on 2024 and on the 2023 1 wouldn't be effective, so just the 2024 is fine.
[AGENT][NEUTRAL] I see um it it was February 19, 2024.
[AGENT][NEUTRAL] Um, it looks like now again, um, those benefits are depending on what the service is if it's qualified under that screening benefit under the critical illness, that's when it, you know, we would pay that screening benefit. So in this case it looks like it was a diagnostic test so that was paid for for data service February 19, 2024, so we did pay a benefit for that date.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] OK awesome and then.
[CUSTOMER][NEUTRAL] Excuse me because you probably already said that said this, but for the accident policy, the wellness for 2024 there as well, that was nothing was submitted for that or except approved or denied.
[AGENT][NEUTRAL] Um, let me go back on that. I don't think I saw that. Now, um, again, I would need to, I'm gonna let me check first of all that, um.
[AGENT][NEUTRAL] I'm gonna check that plan benefit for the calendar year.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Alright, thank you so much. I, I know I'm probably being a pain in the butt this morning.
[AGENT][NEUTRAL] Oh no, you're fine.
[AGENT][POSITIVE] That's absolutely fine that's what we're here for, so.
[CUSTOMER][POSITIVE] I appreciate it.
[AGENT][NEUTRAL] And then you know when we have a lot of uh of the you know the claim submission it's it's better to you know go over like we're doing now OK.
[AGENT][NEUTRAL] So to make sure we've got everything covered.
[CUSTOMER][POSITIVE] Yeah, for sure.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Just give me one moment to look through this.
[AGENT][NEUTRAL] Information.
[CUSTOMER][POSITIVE] Yeah, take your time.
[AGENT][NEUTRAL] Yeah, so the under this critical illness policy there's 1 per covered person up to 4 per family. So that's how the benefit is. So it would be 1 per calendar year if um.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] And I'm just verifying that it is uh.
[AGENT][NEUTRAL] One, so it's one per I believe it's calendar year under the critical illness. So now I'm gonna look at the.
[CUSTOMER][NEUTRAL] Sure
[AGENT][NEUTRAL] Accident again and check that data service um and again it would be we'll just make sure that it was an eligible service if I don't.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I didn't see the 219 but let me put that in.
[AGENT][NEUTRAL] OK, and I don't see it under the accident policy.
[AGENT][NEUTRAL] Just bear with me for one moment.
[CUSTOMER][POSITIVE] All good.
[AGENT][NEUTRAL] Um, would you prefer that I call you back or do you mind, uh, staying on the line? I mean, I don't wanna hold you up either.
[CUSTOMER][NEUTRAL] No, I don't mind it staying on the line, but if it's, if you're more comfortable just give me a call back that way you can work in be then while I'm not on the phone, that's fine by me too. I understand.
[AGENT][NEUTRAL] Well it should just be one second. I'm just gonna look up this information because like I said for um I I don't see it under, but it is that um like I said it does have to be a particular type of screening um to be eligible under that accent so that's what I'm gonna determine now because I do not see it, uh, processed for uh that benefit under the um.
[AGENT][NEUTRAL] Hospital, uh, I'm sorry, the accident policy I'm looking at it under, um, you know that that was that, like I said, that diagnostic test. So, um, I'm gonna see, I'm gonna determine if it's eligible and then if it is we're gonna, uh, have it reviewed, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Alrighty.
[AGENT][NEUTRAL] So that's what I'm doing at the moment.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] My apologies, I have to open each one individually, so just takes kind of a moment for it to.
[CUSTOMER][POSITIVE] No you're good. I'm just working in the background, so take your time you're fine. Thank you though.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Appreciate your patience.
[CUSTOMER][NEUTRAL] Of course.
[AGENT][NEUTRAL] OK, so that is um what I um verified now. So that is because it's a diagnostic test, it looks like it was a mammogram that's not eligible under the accident screening. So that accident screening needs to be just that, um, you know, where usually if you go for a physical to the doctor, usually they do, you know, kind of a screening as if you're wearing your seat belt and that sort of thing. So that's why the um uh.
[AGENT][NEUTRAL] Benefit is under the critical illness it's a screening for like a diagnostic test is eligible. We're under the uh accident policy would need to be an accident screening and that wouldn't uh include a mammogram.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Does that
[CUSTOMER][POSITIVE] Alrighty, well that is all I had today, so I really appreciate it. I will go back to them, go back to the policy holder with that information so just so I'm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Now, um, yeah, go ahead. I have one other thing to let you know, yeah, but go ahead.
[CUSTOMER][NEUTRAL] I was just gonna make sure.
[CUSTOMER][NEUTRAL] OK, I was just gonna make sure that we.
[CUSTOMER][NEUTRAL] So is the one a wellness and then the two critical wellness wellnesses that were paid and that there's only 3 of them that were paid so far.
[CUSTOMER][POSITIVE] Well paid at all.
[AGENT][NEUTRAL] Yeah, I show, right, I show again that um under the accident policy we paid that January 9th under the critical illness the.
[AGENT][NEUTRAL] February for 2024 and then also that January 9th for 2025, both of those screenings were paid under critical illness.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Perfect. Alrighty, thank you so much for explaining that.
[AGENT][NEUTRAL] And just so, so you're aware, the accident policy does appear to be plan year so again that plan year would fall from December to December. So just so you're aware um of that.
[AGENT][NEUTRAL] So what that means is it's not the calendar year, it's the plan year.
[CUSTOMER][POSITIVE] Alrighty.
[CUSTOMER][NEUTRAL] Yeah, so it would only be from her effective date a year ahead and then.
[CUSTOMER][NEUTRAL] It would be like a year from the effective date, right? OK.
[AGENT][NEUTRAL] Right from
[AGENT][NEUTRAL] Right, so anything that falls in that plan year would be con you know, um, if we pay that benefit, excuse me, it would be exhausted then for the plan year.
[CUSTOMER][NEUTRAL] OK, got you.
[CUSTOMER][POSITIVE] Alrighty.
[AGENT][NEUTRAL] And did you have any additional questions, Mr. Rene?
[CUSTOMER][NEUTRAL] Well that is all I had for today.
[CUSTOMER][POSITIVE] Nope, I think we're good.
[AGENT][POSITIVE] OK and thank you so much for uh your patience I appreciate it.
[CUSTOMER][POSITIVE] Thank you for everything you've been more than helpful today, so thank you.
[AGENT][POSITIVE] You're welcome. um, thank you for calling APL, and I hope you have a great, uh, rest of your day and a great weekend.
[CUSTOMER][NEUTRAL] You as well bye.
[AGENT][POSITIVE] Thank you bye bye.