AccountId: 011433970860
ContactId: d78df7ff-936d-48d3-a0db-5f655bf75f79
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 940130 ms
Total Talk Time (AGENT): 382682 ms
Total Talk Time (CUSTOMER): 323399 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/26/d78df7ff-936d-48d3-a0db-5f655bf75f79_20250326T18:14_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] Hi, [PII]. Uh, my name is [PII] and I'm calling from the broker's office, uh, to assist an employee in a claim status update.
[AGENT][NEUTRAL] OK, well, I can definitely help you with the claim status. And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] Thank you. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] 247-866-2
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And I have it here. I just need you to verify the member's first and last name and date of birth.
[CUSTOMER][NEUTRAL] [PII] 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. And may I have the date of service for the claim?
[CUSTOMER][POSITIVE] Yes, I actually have uh claim numbers if that helps.
[AGENT][NEUTRAL] OK, does it end in 33 and 26?
[CUSTOMER][NEUTRAL] Yes, well,
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, on my end it's 330 and then 26.
[AGENT][NEUTRAL] OK, so yes, um, for [PII].
[CUSTOMER][NEUTRAL] Let me double check, yes, for [PII], and then there is a [PII].
[AGENT][NEUTRAL] OK, now hold on let me see for [PII].
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] OK, that's the [PII].
[AGENT][NEUTRAL] What's on this one.
[AGENT][NEUTRAL] OK, so for the May dates of service, we don't have a claim on file, um, but we do have the the two claims with [PII] data of service.
[CUSTOMER][NEUTRAL] OK, um.
[AGENT][NEUTRAL] The main one is just to, just to make sure the main one is for him or one of the dependents cause I, I can look if you want me to.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] The main one is for him and it was uploaded on.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It was uploaded under the 330 claim on [PII].
[CUSTOMER][NEUTRAL] It was uh one attachment, well, it was, yeah, one attachment, but both.
[CUSTOMER][NEUTRAL] Documents were on that attachment.
[AGENT][NEUTRAL] Oh, we're on there.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, let me pull that up so I can um if I need to send this back to be reprocessed, we definitely can. I'm just pulling up the documents so that I can know how to explain it to them. Hold on one moment. Everything's coming up now.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No problem. I try and upload them separately, but because of the quality of this, I.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Didn't wanna have to print it out and then scan it back in it would it would have been illegible.
[AGENT][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, let me see, so page 4. If it comes up page by page, it's coming, hold on one moment, I'm sorry.
[CUSTOMER][POSITIVE] Yeah, take your time.
[AGENT][NEUTRAL] Office procedure.
[AGENT][NEUTRAL] The one for May.
[AGENT][NEUTRAL] You said it was on the one that ends in 330, right?
[CUSTOMER][NEGATIVE] It should have been uploaded yet, because they're attached together.
[AGENT][NEUTRAL] Let me just scroll through it all. Hold on one moment, [PII].
[AGENT][POSITIVE] It's good.
[AGENT][NEUTRAL] So, we received
[CUSTOMER][NEUTRAL] I believe they were because I'm I have uh the emails pulled up right now so.
[AGENT][NEUTRAL] So you'll have to resubmit the main part of the 4 pages, 21 is the cover sheet and then one is just like uh it just says document claims, it's just like a link.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then the 2, the 3rd and 4th page are the office procedures.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But both of them list [PII], so we
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We just need the ones from May, but we still have time. I mean, we can still process it. It just didn't come over.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] I'm gonna see if he can send this to me in a separate I'm gonna check my emails and see if I have a separate one. I'm just worried the first page says is for the um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, what was it? I'm looking for the date, the October date, yeah, the [PII] date, so I'm worried that that's gonna confuse them and.
[CUSTOMER][NEUTRAL] They'll say it was already processed.
[AGENT][NEUTRAL] Oh, I see what you're saying. Um.
[CUSTOMER][NEUTRAL] Yeah, so I, I, I'm gonna work on my end to see if I can get that separated, um, and just upload that one document so there's no confusion, but since I have you on the phone, um, what is the status for the [PII] claim?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So we, we have, hold on, let me go back to the claims.
[AGENT][NEUTRAL] So let me ask you this. So of the two, so we only have two claims for Mr. [PII]. Both claims have data service [PII]. Are you wanting the claim status for both or is there one in particular you're looking for?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Both claims.
[AGENT][NEUTRAL] OK, so the first claim um we received.
[AGENT][NEUTRAL] Let me see what date.
[AGENT][NEUTRAL] We received the first claim on [PII].
[AGENT][NEUTRAL] And that claim number is 3543326.
[AGENT][NEUTRAL] And let me see what happened with that claim, hold on one moment.
[AGENT][NEUTRAL] OK, so for that one, it was denied, no amount no amount is payable for any loss resulting from or cause, whether directly or indirectly by artificial insemination in vitro test tube fertilization, sterilization.
[AGENT][NEUTRAL] Tubal tubal litigation litany or a vasectomy and reversal thereof, so vasectomies are not covered on the policy.
[CUSTOMER][NEUTRAL] OK, so it's not a covered surgery?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] Like it's not OK then this other one probably won't be because it says US exam scrotum.
[CUSTOMER][NEUTRAL] Um, but we can try it for a, um.
[CUSTOMER][NEUTRAL] I can submit it and see if it qualifies for a uh.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] A visit at least.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then the other one, the second one we received [PII]. That's the one ending in, well, it's claim number 3,553,330.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then on [PII], that claim was denied, um, same, it's the same um denial reason.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, thank you so much um and then also while I have you on the phone um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I have another claim status update for um.
[CUSTOMER][NEUTRAL] Completely different company and employee.
[AGENT][NEUTRAL] OK, hold on one moment. Let me note this policy and then we can move on to that one.
[AGENT][NEUTRAL] OK, and what's the next member's um, policy number?
[CUSTOMER][NEUTRAL] Policy number is um
[CUSTOMER][NEUTRAL] 241-4260
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII]
[AGENT][NEUTRAL] Thank you for that. And may I have the member's, um, I was gonna say the member's policy number. I'm sorry, the date of service.
[CUSTOMER][NEUTRAL] The date of service is.
[CUSTOMER][NEUTRAL] Um, I believe [PII]. I have a claim number. It's ending in 903.
[AGENT][NEUTRAL] OK, yes. Hold on one second.
[CUSTOMER][NEUTRAL] I believe there's additional information needed when he called.
[CUSTOMER][NEUTRAL] He had spoken to somebody but he was very confused and wasn't making sense so I was just trying to see what was needed.
[AGENT][NEUTRAL] OK, so for this claim, uh, it was denied requesting an itemized bill?
[AGENT][NEUTRAL] Um, so he would just need or we would just need to reach out to the provider. They can either, let me see if they want an itemized bill or records. Sometimes it's just hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, so we need the itemized bill.
[CUSTOMER][NEGATIVE] And you're showing the full critical illness. I'm, I'm sorry, you can finish.
[AGENT][NEUTRAL] Oh, it's OK. Um, so we'll need the itemized bill for treatment received.
[AGENT][NEUTRAL] And then medical records for for the data service [PII] from the provider.
[CUSTOMER][NEUTRAL] OK, are, are you showing that the full claim critical illness claim form was uploaded, um, because I'm having trouble on my end.
[CUSTOMER][NEGATIVE] Viewing it even though we uploaded it, it's only showing one page and it's blank.
[AGENT][NEUTRAL] OK, let me see what we have.
[CUSTOMER][NEUTRAL] So I wasn't sure if I needed to resubmit the whole form where the physician filled everything out.
[AGENT][NEUTRAL] Um, hold on one moment. The documents are popu um, populating now.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's for the claim form, 903 yeah.
[AGENT][NEUTRAL] So this one was a total of 10 pages. I'm trying to get past the cover.
[AGENT][NEUTRAL] And that blank sheet
[AGENT][NEUTRAL] Let me see what page 3 is. Hold on one second. And which part of the claim form did you want me to look for or just to see if it's all here?
[CUSTOMER][NEUTRAL] I just wanted to make sure it was all there um.
[AGENT][NEUTRAL] Oh OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Now, that's the insured. Let me go to the doctor.
[AGENT][NEUTRAL] Did you sign it.
[AGENT][NEGATIVE] So, um, of the 10 pages that were received, I don't know if these blank pages are just like really blank in between or if there's something supposed to be here.
[AGENT][NEUTRAL] Uh, but it looks
[CUSTOMER][NEUTRAL] Um, so the pages that are supposed to be filled out and, and that's why I wanted to call as well because it, it was.
[CUSTOMER][NEUTRAL] Again, I, I can't see it on my end, which is weird. Nor if we upload it normally we're able to see it. um, so page 2.
[AGENT][NEUTRAL] Kind of weird
[CUSTOMER][NEUTRAL] Then page 4 was filled out and um then they have the attending physician statement, page 5 that was filled out.
[AGENT][NEUTRAL] OK, there goes 2.
[CUSTOMER][NEUTRAL] And then
[AGENT][NEUTRAL] Hold on one second. There goes number. Is it, uh, once I click on it, it takes a little bit to load. So I do see 2.
[AGENT][NEUTRAL] That's filled out completely. Uh, the date is missing, but I don't think they would deny it for that. Um.
[CUSTOMER][NEUTRAL] I did have him um resign it, um.
[CUSTOMER][NEGATIVE] Again, he was very he didn't make any sense so I had him resign it and um today's date since he resigned it again just in case that was needed.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so if it is needed I can submit that as well.
[AGENT][NEUTRAL] I would just to be on the safe side when you send the additional documents, um, but, but from what I see here, I see the insurance part and I see the doctors completely. So I don't, it doesn't look like you're missing anything.
[CUSTOMER][NEUTRAL] OK, and you show page 9 where the doctor signed and everything?
[AGENT][NEUTRAL] Hold on.
[AGENT][NEUTRAL] Let me see what page is this 8.
[AGENT][NEUTRAL] OK, so here we go. So, page 8 is the last page.
[AGENT][NEUTRAL] That we have.
[CUSTOMER][NEUTRAL] OK. I, I think that's why they were requesting the itemized bill because normally with the critical illness claim, if the physician fills that portion out, they don't need that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I'm um.
[CUSTOMER][NEUTRAL] I don't know if you wanna note in the system that I'm re uploading.
[CUSTOMER][NEUTRAL] The full form and
[CUSTOMER][NEUTRAL] I had the um employee resign it.
[AGENT][POSITIVE] Yes, I'm definitely I'm putting this in um putting that in the notes for you. And once we get the um the new upload.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And they reprocess it, so you want to wait to see.
[AGENT][NEUTRAL] Because like you say, usually when that part is signed, you don't need the extra, so you want to just wait and see, let them reprocess that and then if it is still needed, we can just send it in then, but I don't, I don't think it would be like you said, because that kind of cancels out the documents.
[CUSTOMER][NEUTRAL] Yeah, I'll go ahead and um send that in. I know he faxed some documents in or I think he faxed some documents in but I think they're the wrong documents um.
[CUSTOMER][NEGATIVE] Because it definitely wasn't the itemized bill so I don't think it would.
[CUSTOMER][NEUTRAL] I don't think that's what they were asking for, which is why I started looking into this because I'm like that's normally not the case so I'll go ahead and upload this and I appreciate that.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] You're very welcome, [PII]. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Uh, that was it.
[AGENT][POSITIVE] All right, well, thank you so much for calling APL. I hope you have a great day.
[CUSTOMER][POSITIVE] You too thank you bye.
[AGENT][POSITIVE] Thank you. You're welcome. Bye bye.