AccountId: 011433970860
ContactId: d4d35279-a1c5-4aa6-a012-29417208d08b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1389160 ms
Total Talk Time (AGENT): 357954 ms
Total Talk Time (CUSTOMER): 283524 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=-1.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/02/d4d35279-a1c5-4aa6-a012-29417208d08b_20250602T14:57_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. I have an insured on the line who was asking about her claim status, and I saw that it was in here. She said she got an an email or a text saying that it was ready, her claim was ready, and when I click on it, it says in the, uh, provider wrong insured.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Policy number is 25.
[CUSTOMER][NEUTRAL] 38022 [PII].
[CUSTOMER][NEUTRAL] And it's the only claim on file.
[AGENT][NEUTRAL] OK, let me see.
[CUSTOMER][NEUTRAL] Yeah, and then when I look at CLREM it just says data entry error, so I don't, I don't know what that what that means.
[AGENT][NEUTRAL] Yeah, it looks like this claim may have been under the wrong um.
[AGENT][NEUTRAL] And that's under the wrong person and so they basically just canceled it out did did she say that she filed a claim recently?
[CUSTOMER][NEGATIVE] Yes, she said she filed it um and she's been doing it on the portal and she can't access a she tried to create a new account in the in the new portal and it's not working.
[CUSTOMER][NEUTRAL] Um, so she's not able to resubmit it right now through the portal, um, because she was checking claim status.
[CUSTOMER][NEUTRAL] But it looks like she's the one who submitted it.
[CUSTOMER][NEUTRAL] So I don't know how it got on the wrong.
[AGENT][NEUTRAL] OK, yes, so you know it's, it was under the wrong participant, so it looks like she filed, it was this claim was for the under part 4, but it was put under her name, so that's why they canceled it out so it was actually a claim for part 4.
[AGENT][NEUTRAL] That was processed and released on the [PII].
[CUSTOMER][NEUTRAL] OK, so do you want me to go ahead and let her know?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, yeah, that's fine or I can just tell her. I mean that that's all it was is when they indexed it they indexed it under her as the primary but then whoever processed the claim noticed that it was actually a claim for part 4 and so they just canceled it out, canceled that claim under her name, so that, so that's, so that's what she sees.
[AGENT][NEUTRAL] So but the claim was processed under the part 4.
[CUSTOMER][NEUTRAL] OK, um, did you want me to transfer her to you?
[AGENT][NEUTRAL] That's fine, uh, whatever you're comfortable with.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, yeah, because we have a meeting at [PII].
[AGENT][NEUTRAL] OK, sure, um, do you have the callback number?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Right, I'll introduce you.
[CUSTOMER][NEUTRAL] [PII], are you still there?
[CUSTOMER][NEUTRAL] Yes, I am.
[CUSTOMER][POSITIVE] OK, I have [PII] on the line from claims support and she's gonna be able to help you with that claim, OK?
[CUSTOMER][POSITIVE] OK thank you right thank you so much bye.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][POSITIVE] Hi, good morning, Ms. [PII]. Um, this is [PII], and how can I help you today?
[CUSTOMER][NEUTRAL] Um, I was calling because I got a text message over the weekend saying my claim was completed, so I was trying to log in and see the status of that, but they changed the website, so I'm not able to do that, so I'm calling to see what was going on with it.
[AGENT][NEUTRAL] Uh, yes, and this was the claim that was under for part 4 for [PII].
[CUSTOMER][NEUTRAL] For
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh, yes, so I do see that the claim was processed and released on [PII].
[AGENT][NEUTRAL] So you should be receiving that deposit here soon it looks like it was for a direct deposit.
[CUSTOMER][NEUTRAL] OK, so what does
[CUSTOMER][NEUTRAL] OK, what is that amount?
[AGENT][NEUTRAL] The amount that was released was um $8100.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And um was that like for everything or is that like what does that cover?
[AGENT][NEUTRAL] Um, you want to see what benefits that were covered?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, sure, bear with me just a moment.
[CUSTOMER][NEUTRAL] Cause I know he had a hospitalization and he had ORIS and all that, so I was just trying to see.
[AGENT][NEUTRAL] Uh, bear with me just a moment. I'll take a look at that for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] OK, so there was a benefit for the closed fractured leg.
[AGENT][NEUTRAL] Um, there's also the X-ray benefit and the emergency room treatment benefit as well.
[CUSTOMER][NEUTRAL] OK. What about his ORIF and his um like he stayed in the hospital for 4 days, 3 nights and 4 days?
[AGENT][NEUTRAL] OK bear with me just a moment.
[AGENT][NEUTRAL] OK, you said ORIS?
[CUSTOMER][NEUTRAL] Yes, he had surgery on that leg fracture where they had to cut him open. They put 6 screws in a plate and.
[AGENT][NEUTRAL] Oh, yes. That was under that closed fractured leg benefit.
[AGENT][NEUTRAL] The $7500.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then his hospital admission.
[CUSTOMER][NEUTRAL] Was included in that too, right?
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] OK, so it looks like for that hospital admission that it looks like it was actually the um because he was meant the emergency room that there was the emergency room treatment benefit that under this policy, um, the hospital admission is not, is not payable for treatment in an emergency room, urgent care facility, or rehabilitation unit.
[CUSTOMER][NEUTRAL] Well, no, he didn't have his treatment in the emergency room. He had a treatment on the [PII] in the emergency room, and he was admitted, and then he had surgery on the [PII].
[CUSTOMER][NEUTRAL] Which was 2 days later.
[CUSTOMER][NEUTRAL] During his hospitalization. That's when the ORIF was, was on the [PII].
[AGENT][NEUTRAL] OK, let me take a quick look there. Do you mind if I put you on hold for just a moment?
[CUSTOMER][NEUTRAL] Yeah, because, um, real quick what they tried to do the [PII] in the ER was a closed reduction and it didn't work so then that's why they went in and did the open reduction internal fixation, um, like two days later on the [PII].
[AGENT][NEUTRAL] OK, but this was during the same admission he wasn't released and then admitted again this was during the same confinement?
[CUSTOMER][NEUTRAL] Yes, he got admitted on the [PII] and he was released home on the [PII], but the surgery was on the [PII].
[AGENT][NEUTRAL] OK, bear with me just a moment, um, I'll go ahead and put you on just on a quick hold.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hey there, do you mind looking at something with me real quick?
[AGENT][NEUTRAL] OK, it's on an accident claim and [PII] had processed it, but she's um busy right now.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] And I have the insured on the other line and she's asking about the admission.
[AGENT][NEUTRAL] Hospital benefit, I guess he was admitted into the hospital, but I see that we paid the emergency room.
[AGENT][NEUTRAL] Benefit
[AGENT][NEUTRAL] Um, I don't think that you're able to pay the admission and the emergency room benefit if that's correct.
[AGENT][NEUTRAL] But she's saying that like, I guess he didn't have treatment in the emergency room. He was just admitted and like in the, and then he received treatment days later.
[AGENT][NEUTRAL] So she
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, let me see here then.
[AGENT][NEUTRAL] Oh great, 50 pages. Let's see.
[AGENT][NEUTRAL] So we can't go by medical bills. We have to have the itemized bill for the hospital confinement.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] [PII] riding a motorbike in the world.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Yes, I'm kind of seeing. I was hoping to see like a discharge date because I see the admission date, but I didn't see it like the discharge. Let me.
[AGENT][NEUTRAL] Yeah, I didn't say anything about mission or discharge.
[AGENT][NEUTRAL] Uh yeah she said that they tried to do like a closed or open reduction or something like that, but it didn't work and so they kept him in and then they did the actual procedure on the [PII].
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Um, but yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I mean, so should we have paid that admission benefit then, or do we, should we still ask for the itemized bill?
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I mean, yeah, it definitely doesn't verify.
[AGENT][NEUTRAL] Like like yeah, he was admitted, but
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, there's a
[AGENT][NEUTRAL] From children's.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yeah, I don't see that in here.
[AGENT][NEUTRAL] Yeah, I ain't seen that in my still.
[AGENT][NEUTRAL] Or unless I don't know, maybe so a lot of blank pages in between, so I don't know.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Just like an email?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK, alright I'll do that thank you.
[AGENT][NEUTRAL] Bye bye.
[AGENT][POSITIVE] OK, I'm so sorry about that, Ms. [PII]. Are you still there?
[CUSTOMER][NEUTRAL] I am.
[AGENT][NEUTRAL] OK, um, if, if you don't mind, I'm gonna go ahead and have the, uh, adjuster re-review that admission benefit for you, um, if do you mind if, if they review and give you a call back sometime later today?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, that's fine, and I, I see where y'all would think that he was red in the ER and sent home because he actually was seen in one and transferred to a different hospital and then admitted. Um, he was seen at RA [PII], but then he got transferred via ambulance to Children's Hospital in [PII] and was admitted there and then later had his surgery during the admission.
[AGENT][NEUTRAL] OK, sure, so I'm sorry, so the date.
[AGENT][NEUTRAL] Um, he was initially admitted into the ER.
[AGENT][NEUTRAL] With the [PII]
[CUSTOMER][NEUTRAL] Was the night and then they sent him via ambulance to the Children's Hospital in [PII], um, that same day.
[CUSTOMER][NEUTRAL] And then he was admitted there at Children's. So when he first got to Children's, they had tried to do a closed reduction of that leg and um the surgeon didn't like the way everything lined up because he had 5 fractures in that leg. Um, so they admitted him like inpatient while he was there and then on the [PII] did an ORIF of tib fib.
[AGENT][NEUTRAL] OK. And what was the initial hospital he was admitted at?
[CUSTOMER][NEUTRAL] Our Lady of the [PII], and that was just the ER like they sent him via ambulance from Our Lady of the Angels ER to Children's Hospital.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I will go ahead and give this information to that adjuster for um them to review and then can I go ahead and just verify a good call back number for you?
[CUSTOMER][NEUTRAL] Yeah, my cell phone is [PII].
[CUSTOMER][NEUTRAL] And um so would that be, that would be a separate claim then the admission?
[AGENT][NEUTRAL] Yes, since this claim has.
[CUSTOMER][NEUTRAL] Or how would that work? Like how?
[AGENT][NEUTRAL] Oh, well, each time that we release a benefit it will be a separate claim number. It would still be under the same, the same claim with with this in with this accident, um, but it would just be under a separate claim number, um.
[AGENT][NEUTRAL] So when they review and they process additional benefits, it'll just have a different claim number but it'll be under the same diagnosis.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And we're actually seeing the surgeon again today, so if there's anything needed, um, if they'll just email me and I can ask for it while we're there.
[AGENT][NEUTRAL] OK, uh, sure, and can you, um, verify the email address on file that you would like for us to use?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, great. I do see that on file. OK, sure, Ms. [PII], so I do appreciate your patience and I will get this over to the adjuster for review, um, but until then, was there anything else I could do to help you today?
[CUSTOMER][POSITIVE] No, that's all. Thank you.
[AGENT][POSITIVE] Yeah sure, thanks for calling AP. I hope you have a good day.
[CUSTOMER][POSITIVE] You too thank you bye bye.
[AGENT][NEUTRAL] Bye bye.