AccountId: 011433970860
ContactId: d3734805-09f1-42d6-97c9-dd4c2c8b0fd1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1444079 ms
Total Talk Time (AGENT): 483297 ms
Total Talk Time (CUSTOMER): 246096 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=-1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/d3734805-09f1-42d6-97c9-dd4c2c8b0fd1_20250207T20:28_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII], um.
[CUSTOMER][NEUTRAL] I work at a Mashmier Concrete and I had a stroke back in November.
[CUSTOMER][NEUTRAL] And I received the um short term.
[CUSTOMER][NEUTRAL] This is where I think it is.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] But I haven't received the money for the stroke or the hospitalization.
[CUSTOMER][NEUTRAL] And I was wondering what's the hold up on it.
[AGENT][NEUTRAL] Like the um like the benefit you get if there if there is a stroke like that first occurrence.
[CUSTOMER][NEUTRAL] Yeah, the stroke.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I can look into um the first occurrence benefit for you um and see what the update is. Excuse me on that. Mr. [PII], may I have a good contact number in case we're disconnected and your policy number?
[CUSTOMER][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] 588-0401
[AGENT][POSITIVE] Thank you and your policy number whenever you're ready.
[CUSTOMER][NEUTRAL] Uh, I don't even know what my policy number is.
[AGENT][NEUTRAL] OK, um, I can look your policy up with your social.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, 466-611-004.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, so it just popped up here and
[AGENT][NEUTRAL] And I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, date of birth is [PII].
[CUSTOMER][NEUTRAL] Mailing address is [PII].
[CUSTOMER][NEUTRAL] And date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. Um, Mr. [PII], do you mind if I place you on just a brief hold, so that first occurrence benefit isn't in the short-term disability, but I see you have the accident and the critical illness also, and I believe that's on one of those. I just want to check and then I'll be able to follow up on what happened.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, I, it'll be just a few moments, OK?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] No, this is critical.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, Mr. [PII].
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] All right, thank you so much for holding. I do apologize for that wait. So, um, yes, it is what I thought. So on for the critical illness policy, you do have a stroke um benefit, the policy will pay $10,000. Is that what you're referring to?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so this is, um, this is what I'm gonna do.
[AGENT][NEUTRAL] I just want to let you know that I just found that I'm gonna reach out to claims. I believe you're gonna have to file the claim. You have to file a claim under the uh critical illness policy with your pathology report and everything.
[AGENT][NEUTRAL] Um, I'm just gonna ask them if the, if you have to file the claim or if the documents.
[AGENT][NEUTRAL] Wait a minute, but that's two different policies. I was thinking maybe the documents from the short-term disability could be used, but because it's two different products, that's two different processors, so that's, yeah, it will be best to file the claim.
[CUSTOMER][NEUTRAL] Well, I, I filed 33 papers.
[CUSTOMER][NEUTRAL] I filed one for hospitalization.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] One for the stroke and one for the short term disability.
[AGENT][NEUTRAL] So then
[CUSTOMER][NEUTRAL] So I already filed the claims.
[AGENT][NEUTRAL] So I am gonna
[CUSTOMER][NEUTRAL] And I sent in my medical reports.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I send the medical report and the detailed billing statement.
[CUSTOMER][NEUTRAL] That's what I was told I had to do so.
[CUSTOMER][NEUTRAL] I did everything I was told.
[AGENT][NEUTRAL] Let me see if there's a way we can like use the file because everything is basically everything is under short term everything that was processed is under short term disability. So I'm gonna reach out to claims and see if there's a way they can go ahead and process under group critical illness with the documents that were received for the short-term disability.
[AGENT][NEUTRAL] Because everything is under short term disability. When I looked under the other um policies, it's like blank, like we haven't filed or processed the claim, so I'm gonna see what we can do or if if it needs to be submitted for that under that policy number for that policy. You see what I'm saying?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, do you mind if I place you on just another brief hold while I reach out the claims?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, go ahead, yeah.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Let me see if there's something under there.
[AGENT][NEUTRAL] 2244.
[AGENT][NEUTRAL] 454.
[AGENT][NEUTRAL] Hold on, what's this denial reason?
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] So that's the hospitalization he's talking about. They need the
[AGENT][NEUTRAL] OK. So let me put that in the notes. For the
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Referring.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. You're speaking with [PII]. How may I help you today?
[AGENT][POSITIVE] I'm so glad I got you, Ms. [PII]. This is [PII]. How are you doing?
[CUSTOMER][POSITIVE] I'm doing good, [PII].
[AGENT][NEUTRAL] I have a question. If um, so you want me to give you a policy number to tell you what's going on?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh huh, give me a, give me a policy number.
[AGENT][NEUTRAL] OK, um, 224-473-3.
[CUSTOMER][NEUTRAL] And this is for [PII], uh-huh, OK.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] So he submitted a whole bunch of documents.
[AGENT][NEUTRAL] He has different products. We paid out for the short-term disability.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The hustle indemnity, um,
[AGENT][NEUTRAL] Some of them were denied, but like it needed the the bill and stuff like we can still process that. But he's asking, so he had a stroke. He's asking about his critical illness policy.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] He would need to fill out a critical illness claim form and it's one out there, you know, I'm sure y'all, so when you fill it out, he got to fill out his portion and he gotta fill, let the doctor fill out the doctor portion of the critical illness claim form.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, I just didn't know, so because he's, I told him he's gonna have to submit it under critical illness and he's like, well, I already submitted everything.
[CUSTOMER][NEUTRAL] Yeah, he would. You can, you can't, he can't, he can't do it on a disability. Disability policy is a whole different policy from the critical illness. It asks specific questions on the doctor claim form on the critical illness claim form. That's why it's two different claim forms.
[CUSTOMER][NEUTRAL] So he would have to get the critical illness fill out for to get the critical illness benefit because it's a one-time lump sum benefit for that on the critical illness PI BFT. Let me make sure he ain't got nothing else on ours. No, he don't. And if he's still off work because I paid him up to uh what I paid him up to uh uh I paid him up to.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, well, I guess [PII], I believe, yeah, if he's still off work, he would need another disability claim fill filled out his portion and the doctor portion for any benefits to be paid, be paid past uh [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, I got it. Thank you, Ms. [PII].
[CUSTOMER][POSITIVE] You're welcome. All right, bye bye.
[AGENT][NEUTRAL] Alright, bye bye.
[AGENT][NEUTRAL] Hello, Mr. [PII].
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Alright, thank you so much for holding. So I just got the answer um from claims. So yes, critical illness is different. That's why it has a different claim form because it adds different questions and your doctor has to fill out a portion.
[AGENT][NEUTRAL] Um, of that uh of the critical illness claim form. So that's why we couldn't pay out on that versus the other two. And I did see for your emergency room visit, it was denied, but it was denied asking for the itemized bill from the hospital. So once you send that in, we can continue processing for that part.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I sent all that in.
[CUSTOMER][NEUTRAL] I sent the itemized billing statement.
[CUSTOMER][NEUTRAL] I sent in 4 claims forms.
[CUSTOMER][NEUTRAL] I sent in my medical records.
[AGENT][NEUTRAL] OK, let me look at the documents that were received to see if it was the itemized bill from the hospital or your itemized bill because they're asking for the coding, so it sounds like it might have been your patient bill.
[AGENT][NEUTRAL] But let me look and see.
[AGENT][NEUTRAL] It's coming up now hold on one moment.
[AGENT][NEUTRAL] All right, so this is the hospital indemnity claim form.
[AGENT][NEUTRAL] Where's the bill? Hold on one second. I got it, um, I'm just going through the pages.
[AGENT][NEUTRAL] OK, yeah. See, this is your patient bill. There's a bill that your bill is, um,
[AGENT][NEUTRAL] There's a bill that your bill is generated from. It's called a universal bill. That's what we're needing. It has all the coding, all the charges, that way we can see this here just shows the treatment. We need the diagnosis so we can prove medical necessity for those treatments and that's how we pay out, that's how we're able to pay out on the claim. So all you'll need to do is reach out to Cleveland Clinic.
[AGENT][NEUTRAL] And ask them for an itemized bill, they may call it a universal, I would say universal bill since it's a hospital, and that has all the charges.
[CUSTOMER][NEUTRAL] Yeah, that's what I
[CUSTOMER][NEUTRAL] Yeah, that's what I did and that's what they sent. I asked for the billing statement.
[CUSTOMER][NEUTRAL] With a UBO4 form.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And that's what they sent.
[AGENT][NEUTRAL] You said you already have?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] They said that they sent that that paper right there. I don't know what a UBO4 is, but I asked for the detailed billing statement with the UBO4.
[AGENT][NEUTRAL] OK, because
[AGENT][NEUTRAL] So, this is, let me see what time it is. I could probably call them for you. Hold on one second, because no, this is not, this is not a UBO4, this is your, your name is at the top of it, like this is your patient bill, um.
[CUSTOMER][NEUTRAL] OK, that's where they.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] A universal bill is, is literally their their hospital bill, and from that it breaks, it breaks off into your patient bill and it because this bill doesn't have the coding that we need, which is why we can't determine the medical necessity.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I don't understand about the net medical necessity because all my physician filled out the uh forms.
[AGENT][NEUTRAL] Right, OK, so what I'm saying is, so, yes, the physician filled out the forms, but in billing, it, we can't use the patient bill to prove what the hospital did. That's just showing you this is what we gave you, this is what it paid for. We need to know why they gave you that. So, yes, the doctor signed the forms, but that coding is what we need, that's on the universal bill, um.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I wish there was a way I I could talk to them for you, but I'm a third party, um.
[AGENT][NEUTRAL] Let me think.
[AGENT][MIXED] The the best thing to do, I mean, if you want, if you wanted to give them a call, I'll hold and talk to them, but yeah, this is not a universal bill. I would tell them it needs to have the diagnosis codes, the procedure codes, and then all the charges.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That's on the universal bill.
[CUSTOMER][NEUTRAL] So it's called a
[CUSTOMER][NEUTRAL] It's called a universal bill? OK.
[AGENT][NEUTRAL] Mhm. UB 04, that's Universal bill, 04.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and then once we get that, we can continue processing for the um emergency room. You'll get a decision for that, and then because it's critical illness and it has that big payout, we have to have the critical illness claim form because your doctor signs off on that also.
[CUSTOMER][NEUTRAL] OK, yeah, I already know that she filled that out. I gave it to [PII].
[CUSTOMER][NEUTRAL] A benefits lady. So I talked to her to see if she still has it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then once you send that um critical illness uh claim form in, if you have the pathology report showing that it was a stroke, I mean, of course, we know that we just have to have the paper, right, the the paperwork, um, saying that it was a stroke, just send that in together and that's how you, the pathology report shows that it was a positive diagnosis and then that's how the payment is generated with the bill.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] All right, Mr. [PII]. Was there anything else I could assist you with today? Oh, go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] Alrighty. Well, thank you so much for calling APL. I hope you have a good weekend.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Alright thank you.
[CUSTOMER][NEUTRAL] Oh
[AGENT][POSITIVE] You're welcome. Bye-bye.