AccountId: 011433970860 ContactId: d2acd52d-7e74-4f24-8757-bf34adaa5791 Channel: VOICE LanguageCode: en-US Total Conversation Duration: 1243449 ms Total Talk Time (AGENT): 715115 ms Total Talk Time (CUSTOMER): 497684 ms Interruptions: 8 Overall Sentiment: AGENT=0.5, CUSTOMER=0.3 Redaction Types: PII Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/26/d2acd52d-7e74-4f24-8757-bf34adaa5791_20250326T15:40_UTC.wav -------------------------------------------- [AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you? [CUSTOMER][NEUTRAL] Hey, [PII], it's [PII]. How are you doing today? [AGENT][POSITIVE] Doing fine, [PII] thank you how are you? [CUSTOMER][POSITIVE] I'm doing well, thank you for asking. I have. [CUSTOMER][NEUTRAL] A lady that needs some help on her husband's policy which she has given us permission to speak to her regarding this call. Now she's gonna have a question on. [CUSTOMER][NEUTRAL] The [CUSTOMER][NEUTRAL] Short-term disability and hospital indemnity. Can you help her with both? [AGENT][NEUTRAL] I can try. You said short term disability and hospital indemnity. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] Yeah. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] So the short term disability policy number is 260. [CUSTOMER][NEUTRAL] 576 4 and we did discuss the claim um information and that they're needing a list of all the doctors see and she's wanting to know specifically, and again, he did give us permission. Um, is it just the doctors that he's seen in the hospital or is it just for the, when he was there in the hospital? [CUSTOMER][NEUTRAL] Or is it any doctor regarding that diagnosis? So, so they just need a little bit more information on the list of doctors seeing what's needed. That's all that is. So she's good on that. [AGENT][NEUTRAL] Yes, the last year. Yeah, it's for the last year that they're looking, it, it looks like they're looking for uh pre-existing probably. And so that's why when they get that list of physicians. [CUSTOMER][NEUTRAL] The last year. [CUSTOMER][NEUTRAL] Oh, see, I didn't see anything. [AGENT][NEUTRAL] Yeah, um, it looks like this. [CUSTOMER][NEUTRAL] And I looked in on bases to see. [AGENT][NEUTRAL] Yeah looks like the shape did put a note in regarding it. [CUSTOMER][NEUTRAL] Well, did I just overlook that? [AGENT][NEUTRAL] I'm not sure. [CUSTOMER][POSITIVE] Well, it, I sure did. I'm so sorry. [AGENT][NEUTRAL] That's OK. Yeah, so it's the physicians he's seen in the last year, um. [CUSTOMER][NEUTRAL] I see. Even though it's not regarding that diagnosis. OK. [AGENT][NEUTRAL] For neurosurgeon. [AGENT][NEUTRAL] Right. Probably because usually when that happens, it means that um it's [CUSTOMER][NEUTRAL] Preexisting [AGENT][NEUTRAL] Right, or they're looking, they're doing a look back to make sure that there was no preexisting. In other words, that they weren't pay for that kind of uh. [CUSTOMER][NEGATIVE] Gotcha. [CUSTOMER][NEUTRAL] Well, [AGENT][NEUTRAL] Go ahead. [CUSTOMER][NEUTRAL] Can I just say that that note wasn't there a minute ago? [AGENT][NEUTRAL] You can, sure. [CUSTOMER][NEUTRAL] I think I, I think I scanned it super quick because first we were looking for because she's sending the authorization form but it's not on this policy so we talked about so many things at one time. I apologize [PII] I just probably scanned right over there and was looking for authorization form and just didn't even go back and look. I apologize but. [AGENT][NEUTRAL] Yeah. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] Her or his hospital indemnity policy, she's got several questions regarding claims. We have tried, uh, we've been looking at it we've looked at the policy cert in the portal together to see what's covered, so she's understanding that now, but she's asked, she's got questions for claims from [PII], and 25, um, it did tell her that the first occurrence benefit. [AGENT][NEUTRAL] Uh-huh. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Um, what year that was maxed out, I mean, the hospital admission benefit and her daily hospital benefit, they're his, um, what was paid in each year. And then we did talk about the emergency room and sur maybe an accident diagnosis only. The hospitalization can be sickness if it's not indicated as accident only and that kind of thing. So those are the things we've been talking about, but she needs a little further detailed information regarding the claims. [AGENT][NEUTRAL] Mhm. OK. [CUSTOMER][POSITIVE] And she's really nice. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] OK. [CUSTOMER][POSITIVE] I like nice people. [AGENT][POSITIVE] Yeah, for sure. [CUSTOMER][NEUTRAL] And her callback number is [AGENT][NEUTRAL] And her [AGENT][NEUTRAL] Go ahead. [CUSTOMER][NEUTRAL] [PII] [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] [PII]. Her authorization has been received on the hospital indemnity policy. She's um emailing the authorization form for his disability policy. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] We only put it on the indemnity policy. Her name is [PII] [AGENT][NEUTRAL] [PII] and it's [PII] as well. So if I call her Mrs. [PII], that's OK. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Uh, [CUSTOMER][NEUTRAL] [PII], I think is her last name. Let me check again cause it's in the notes. See, I, I saw that. [CUSTOMER][POSITIVE] [PII], that's right. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] All right, so we just need to, you said clarification on the hospital indemnity, some of the benefits she's questioning and then the form for the disability as far as the physicians, correct? [CUSTOMER][NEUTRAL] Mhm [CUSTOMER][NEUTRAL] You called that note. [CUSTOMER][NEUTRAL] Mhm it's more the claims on the hospital indemnity. They just found out that he had this policy, so they're going back and trying to file claims, so it's more of the claims. [AGENT][NEUTRAL] Yeah. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] I will do my best to assist her. [CUSTOMER][POSITIVE] I really appreciate it if you don't mind holding just. [AGENT][NEUTRAL] And you said these were from [PII] or? [AGENT][NEUTRAL] The claims she's questioning about the house. [CUSTOMER][NEUTRAL] 2024, 23, 20, yeah, 23, 24 and 25. All of them, all the claims. [AGENT][POSITIVE] I have found that many. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] All the claims under hospital phone and then they got it OK. [CUSTOMER][NEUTRAL] All right, you ready? [AGENT][NEUTRAL] I am. [CUSTOMER][POSITIVE] As you'll ever be. Thanks, [PII]. I appreciate it. Let me get her on the line. [AGENT][NEUTRAL] Yeah. [AGENT][NEUTRAL] You're welcome, [PII]. OK. [CUSTOMER][POSITIVE] All right, Ms. So, thank you for your patience. I was just given um [CUSTOMER][POSITIVE] We've got [PII] on the line and I was giving her the background of what is needed and um the information that you're requesting and she's gonna help you further, OK? [CUSTOMER][POSITIVE] Thank you so much for your help. My pleasure, Ms. [PII]. Thank you for calling APL. I hope you have a great afternoon. Thank you, [PII]. Bye bye. [AGENT][POSITIVE] You're welcome, [PII], thank you. [AGENT][NEUTRAL] Hi, Miss Mrs. [PII], this is [PII]. I'm in the claims support team. Hi there. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Hi. [CUSTOMER][NEUTRAL] Hey, [PII]. How are you? [AGENT][POSITIVE] I'm doing well thank you how are you? [CUSTOMER][POSITIVE] I'm doing fantastic. [AGENT][POSITIVE] Good, OK, so hopefully I'll be able to assist you, uh, further with your claims question, um, we can um. [CUSTOMER][NEUTRAL] Yes. [CUSTOMER][NEUTRAL] I got questions, yes. [AGENT][NEUTRAL] Yeah, so as far as uh well I'll go ahead and answer that question on the disability portion um because that one seems like a little bit more uh um. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] You know, straight to the point. It looks like we had requested a physician, uh, statement, um, and we are looking back for um. [AGENT][NEUTRAL] It would be the physicians that he's seen um. [AGENT][NEUTRAL] In the last year. So that any physicians that he's seen you. [CUSTOMER][NEUTRAL] For that particular for this issue? [AGENT][NEUTRAL] Well, any physicians in the last year, um, that he's seen, go ahead and list those on that um document that they sent to you as, as far as the physicians. Um, let me. [CUSTOMER][NEUTRAL] Or just any physician? [CUSTOMER][NEGATIVE] I don't have I didn't I haven't gotten anything. [AGENT][NEUTRAL] OK, so let me just take a look here. [AGENT][NEUTRAL] You will receive that. Let's see, go ahead. [CUSTOMER][NEUTRAL] Now [CUSTOMER][NEUTRAL] OK, because he just, he's off work because he ended up having to have emergency surgery. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] That's what the disability is, so you need to know about his kidney doctor and. [CUSTOMER][NEUTRAL] His general practitioner, not what's related to this illness. [AGENT][NEUTRAL] Right, it's a, a list of all doctors seen in the past year. So um the claim was finalized and I believe that document should be on its way to you, um, along with that explanation of benefits with that remark code letting you know what is needed under the disability. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] So because the the remark code on the explanation of benefits that you'll receive for this claim, the claim number is 358-0229. [AGENT][NEUTRAL] And again this is under the disability policy it says we received your request for disability benefits, but before we can consider your request, we must obtain medical records to verify the disability is not resolved of a preexisting condition, um, and then we'll, uh, what we need is the list of physicians that he's seen in the last year. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] OK, it's just only 2 doctors, but OK. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] OK, alright, good. OK, now I understand you have um a couple of questions in regards to the claims that were processed under the hospital indemnity. [CUSTOMER][NEUTRAL] Yes. [AGENT][NEUTRAL] And what questions now. [CUSTOMER][NEUTRAL] And just trying to see if I thought, well, we didn't understand what was paid and why and then the why nots I guess. [CUSTOMER][NEUTRAL] We didn't understand that. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] Cause we know it's not that it was an accident, but just the hospital indemnity. You know, we originally called because he didn't even know he had the benefit. We um [AGENT][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] We applied, we, they told me to go ahead and upload all of them going back to 23. [AGENT][NEUTRAL] OK. [CUSTOMER][NEGATIVE] Which I did, because he had a, a couple, but then they were all denied. [CUSTOMER][NEUTRAL] And I don't know if it's because I uploaded them all together with all of the things together, should I have done them individually? [CUSTOMER][NEUTRAL] Would that have helped [AGENT][NEUTRAL] Well, um, it looks like what happened is some of the benefits that looks they look like they were paid, so we can go over um what was paid and then what we're requesting the information for um now um I'm gonna start with the first claim that was processed and I can go over those dates with you so um this claim, uh, the claim number is 35. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Yes, please. [AGENT][NEUTRAL] 73 [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] 000. OK, let's see. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Yes, ma'am. [AGENT][NEUTRAL] 4:29 to 53. OK, so. [AGENT][NEUTRAL] That claim again uh was the finalized. [AGENT][NEUTRAL] Date is [PII]. [AGENT][NEUTRAL] The dates of service, um, it looks like we paid a hospitalization, um, so that's that, um, hospital, uh. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] Admission benefit which is payable uh once per calendar year that was for admission to Texas Health Plano from 429 to 53. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] Yes, ma'am. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] OK, so we pay the hospital admission benefit. We pay the, uh, daily hospital benefit that's the confinement like the room and board charges. So it looks like we paid the uh admission benefit and then the hospital, uh, daily hospital benefit it was for 4 days. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] And let me just pull that up. I can go line by line on it, OK, so um. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] And just to verify, the 420, uh, let's see. [AGENT][NEUTRAL] Because it looks like there's some older dates on the same claim, so the 429 to 53, yeah. [CUSTOMER][NEUTRAL] Yeah and that's what I was asking did I need to change it uh-huh, OK. [AGENT][NEUTRAL] Well, not necessarily because I can tell you what basically what's needed, um, so the 429 to 53 again we pay the hospital admission benefit we paid the room and board for 4 days, so, um, that combined benefit was uh $4000 for that admission. [AGENT][NEUTRAL] Um, and then it looks like. [CUSTOMER][NEUTRAL] OK, so that was 4:29 to 53 you said? [AGENT][NEUTRAL] Yes, ma'am. Mhm. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] Now, um. [AGENT][NEUTRAL] We paid um an additional room and board charge for dates of service 618 to 620 for two days. [AGENT][NEUTRAL] So we paid an additional $500 and this is all under that same claim number I provided you, the $3,573,000. OK, so again that hospital admission benefit was um denied due to that it was maxed for the calendar year. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] And then we paid the two additional days for hospitalization from [PII] to [PII] again from from the admission to [PII] how Plano. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] OK, so but the 424. [CUSTOMER][NEUTRAL] 23, cause those are all, those are all 24s. [AGENT][NEUTRAL] Yes, OK, and that's what I was just gonna go over with you, so the 424 23, it was an emergency room charge, um, was that due to an accident? [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] Or this is all illness. [CUSTOMER][NEUTRAL] Um, that was illness. [AGENT][NEUTRAL] OK, because that's how. [CUSTOMER][NEUTRAL] And then he ended up going back and staying OK. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] So yeah, because it looks like there's a [PII] uh that's an ER visit and that was denied due to uh the diagnosis. Let me just make sure that's what it says here. [AGENT][NEUTRAL] So you're, for the emergency room, outpatient sickness or um any emergency room, you have the um what's called the outpatient uh I'm sorry, the uh it's for accident only diagnosis. It's so in other words, it doesn't meet the, yeah, it's an outpatient accident treatment benefit. [CUSTOMER][NEUTRAL] OK [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] So if it's not uh related to an accident, it will be denied as non-covered um because it doesn't cover a sickness diagnosis, only an accident. [CUSTOMER][NEUTRAL] OK, that makes more sense to me, OK. [AGENT][NEUTRAL] Now. [AGENT][NEUTRAL] OK, so now there was an additional emergency room visit for [PII]. [AGENT][NEUTRAL] And we had asked for, and this is about, now was that accident or illness as well? [CUSTOMER][NEUTRAL] Mhm, which was not. [CUSTOMER][NEGATIVE] No, that's an, that's an illness. [AGENT][NEUTRAL] OK. Because we did ask for a diagnosis. Yeah, cause it, we did ask for a diagnosis code for that date because it wasn't clear whether or not it was an accident or a sickness. So instead of denying it and saying that it wasn't, um, you know, it wasn't eligible, we asked for that diagnosis code. So that's just so you're aware that, that's what was on that claim for the [PII]. [CUSTOMER][NEUTRAL] I think he had COVID or something. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] OK. OK. [AGENT][NEUTRAL] And then there was an additional visit for the ER on [PII] that was also denied as not uh an accident. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Right, understood that, OK. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] All right. Now, [CUSTOMER][NEUTRAL] So only when he stays, only when, if it's not an accident, it's only when he has to be admitted. [AGENT][NEUTRAL] That's correct. Now he does have some additional benefits that we paid for like um preventative services or wellness visit. So there it looks like we process some yeah we process some um benefits for that as well. [PII] we paid a wellness benefit, um, that was a $50 benefit under claim uh 3572818. [CUSTOMER][NEUTRAL] Mm, OK. [CUSTOMER][NEUTRAL] Mhm, I saw those. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] I am missing some dates then because there was a hospital stay in [PII]. [CUSTOMER][NEUTRAL] It was a couple actually, but [AGENT][NEUTRAL] OK, [AGENT][NEUTRAL] Let me look at that. [CUSTOMER][NEUTRAL] And maybe I didn't [AGENT][NEUTRAL] Now, I'm seeing some services that were provided for. [CUSTOMER][NEUTRAL] I may not have maybe I didn't admit it, I mean submit it, but. [AGENT][NEUTRAL] Looks like [PII]. [CUSTOMER][NEUTRAL] I think that's the one that that's the outpatient I think. [AGENT][NEUTRAL] Yeah, because it just shows the emergency room services. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] And again, for that [PII], we asked for that diagnosis because we couldn't determine whether or not it was an accident related to an accident. So they asked for a diagnosis code for that. [CUSTOMER][NEGATIVE] Yeah, I won't [CUSTOMER][NEGATIVE] But it's not. [CUSTOMER][NEGATIVE] I won't even submit that because it's not I'm I can tell you that it's not. [AGENT][NEUTRAL] OK, alright. [CUSTOMER][NEUTRAL] I know what that was, that was COVID. OK, so I need to get the list of, OK, so this is every doctor that he has seen, well, which is just. [AGENT][POSITIVE] Got you OK. [CUSTOMER][NEUTRAL] Do I need to find out the name of all of the doctors in the hospital? [AGENT][NEUTRAL] No, um, it would just be like, yeah, it would just be anyone that treated him, um, in the past year. So kind of like a PCP or even a specialist that he's seen for that, um, for any kind of uh treatment. [CUSTOMER][NEUTRAL] I don't unders I mean [AGENT][NEUTRAL] So I don't think you need to list like necessarily, not the physicians in the hospital cause a lot of times you probably don't even know who those physicians are. [CUSTOMER][NEUTRAL] OK, so not just related because. [CUSTOMER][NEUTRAL] Cause this [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] We've all been through that, right? [CUSTOMER][NEGATIVE] No, I don't, and that's, I mean, and that's why I'm saying this was a, I didn't understand why they needed to know about his kidney doctor if it had nothing to do with his back surgery, which is what he's on disability for. [AGENT][NEUTRAL] Well, again, they're just trying to verify because um let me go back to that date on your disability. [AGENT][NEUTRAL] Again, what they're just trying to do is verify that it wasn't a preexisting condition. So basically, if he's not um been seen for his back, um, with, so you would just list that kidney doctor, you know what I mean? And any doctor that's treated him in the past year, like I said, they're just trying to verify that it's not a preexisting. So any information that you can provide. [CUSTOMER][NEUTRAL] Uh he is not. [CUSTOMER][NEUTRAL] Oh, OK. And if it were, so if it was preexisting, they wouldn't cover it if it was pre-existing. [AGENT][NEUTRAL] Um, more than likely because the effective date of the policy is [PII] now. [CUSTOMER][NEUTRAL] Oh, that's what. OK, so they're trying to see that. [AGENT][NEUTRAL] Right, so for the disability policy they'll, they do look back, um, and like I said they'll go back 12 months basically so that's why it's been within the last year because the effective date is [PII] so they're just trying to verify that it wasn't something that was preexisting so the information that you provide to us what they'll do. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] Is um if they need to reach out for medical records or um just verify that information that's what will happen that's why they need that authorization you know or I'm sorry, that information regarding the physician so that um if indeed they do need to request medical records they'll know who to request them from. [CUSTOMER][NEUTRAL] Alrighty, I, um, do I just need to. [CUSTOMER][NEUTRAL] Can I just give that to you or does it need to be on the form? Because I can tell you who they are. [AGENT][NEUTRAL] Yeah, it should, it should be in writing if you'd like I can send that form to you, um, because as long as it doesn't have any yeah I was gonna say I can send an email as long as it's not, um, so in other words I can send you the blank form and then you'll have. [CUSTOMER][NEUTRAL] By email? [AGENT][NEUTRAL] But because you otherwise you'll have to wait for it to come in the mail um so I can send it over to you via email if you're able to um download the form and then go ahead and complete it and then you can either um send it you can either go ahead and upload it back through the online portal um or you can uh fax it to us. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] I can. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][POSITIVE] OK, I can upload it. [AGENT][NEUTRAL] OK, because generally we don't email that information. A lot of times it contains private health information or you know, so we don't like to use the email it's not secure, right? And because it's a blank form that I'm sending to you, I can email that to you, but my recommendation would be either uploaded or fax it because they're both secure means of transmitting information. [CUSTOMER][NEUTRAL] I just need to get it, OK. [CUSTOMER][NEUTRAL] Yes, and for the hipA. [CUSTOMER][NEUTRAL] I understand. [CUSTOMER][NEUTRAL] OK. Yeah, I'll upload it. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] Alright, did you have any other questions, Miss [PII]? [CUSTOMER][NEUTRAL] Um, that's it. [AGENT][POSITIVE] OK great alright. [CUSTOMER][POSITIVE] I think that'll do it and I'll work on this uh as soon as I get that. [AGENT][NEUTRAL] And I'm just gonna, can I have you verify where you'd like me to send it with the email? [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Uh, you can send it to his email address [PII]. [AGENT][POSITIVE] OK, I'll send that over to you momentarily. [CUSTOMER][POSITIVE] Alright thank you so much have a good day. [AGENT][POSITIVE] You too, Miss [PII]. Thank you so much for calling APL. Have a great day.