AccountId: 011433970860
ContactId: d8f3f813-6ee8-4143-a828-ab8a3fa705f5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 627299 ms
Total Talk Time (AGENT): 256087 ms
Total Talk Time (CUSTOMER): 126198 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/04/d8f3f813-6ee8-4143-a828-ab8a3fa705f5_20250204T20:02_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] My back.
[CUSTOMER][NEUTRAL] Hey, [PII], my name is uh [PII], and I have um
[CUSTOMER][NEGATIVE] Filed a claim, but I, I, I got denied and I was wondering if I can get more detail on.
[CUSTOMER][NEUTRAL] I know.
[AGENT][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Why and whatnot.
[AGENT][NEUTRAL] OK, well, I can look into the claim for you. And may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, area code is [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you for that. And may I have your policy number?
[CUSTOMER][NEUTRAL] 02
[CUSTOMER][NEUTRAL] 15
[CUSTOMER][NEUTRAL] 585 9
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And I have your policy here. I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] It's uh [PII] and then my address is [PII].
[CUSTOMER][NEUTRAL] And the email is uh it might be [PII].
[AGENT][NEUTRAL] This, this 1 may be, mhm.
[CUSTOMER][NEUTRAL] Or [PII] Alvarado telescopes.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Alright and thank you so much for verifying your information. All the information provided is a verification of benefits, not a guarantee of payment. Is the claim for you or your spouse or dependent?
[CUSTOMER][NEUTRAL] Dependent.
[AGENT][NEUTRAL] Um, and which one?
[CUSTOMER][NEUTRAL] Is [PII]?
[AGENT][NEUTRAL] OK, hold on one second.
[AGENT][NEUTRAL] And would it be for both of the claims here that were um were received on [PII]? OK. Hold on one moment.
[CUSTOMER][NEUTRAL] Yes, both the claims are on.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And do you mind if I place you on just a brief hold while I look over the two claims?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 73, OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What's this one.
[AGENT][NEUTRAL] Hello, Mr. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So,
[AGENT][NEUTRAL] It looks like the two services, well, the services that were done between the two claims are not covered on the policy. Um, diagnostic testing is not covered, and then the labs um were not covered either. So this is a um hospital indemnity policy. So it covers like if you were to be admitted into the hospital or confined to the hospital.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I think, I think the, the issue is when I uploaded the, the statement of services like my bill, like the first page was lab work and I get that but then the second page is the.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Because my son was admitted into the hospital.
[CUSTOMER][NEUTRAL] So it's, I have the, the second page of my statement is where you had, you know, emergency room, EKG uh everything you had overnight stay, everything on there.
[AGENT][NEUTRAL] OK, hold on one moment. You said for the second one, which, um, the claim number ending in 56873?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It closes.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Yeah, 873.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] I can see here. I'm just bringing up the documents.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I'm on the portal too. I can see on the view file I can see that.
[CUSTOMER][NEGATIVE] I can see why it might have been confusing because it's the 1st page is lab work, 2nd page is the hospital stay.
[AGENT][POSITIVE] OK, it's coming up now. It goes page by page, sorry about that.
[CUSTOMER][NEUTRAL] You're fine.
[AGENT][NEUTRAL] Uh, OK, so I do see your, um, see what was submitted.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Is there anywhere?
[AGENT][NEUTRAL] The EKG, that's the diagnostic they're gonna say.
[AGENT][NEUTRAL] Like where it says the specialty room treat and observation?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] This is what you should do because you're gonna have to resubmit it.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] I would give Roosevelt Hospital a call and ask them for the universal bill.
[AGENT][NEUTRAL] For date of service
[CUSTOMER][NEUTRAL] All right, just down.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Or date of service?
[AGENT][NEUTRAL] Um, data service [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then the universal bill, it has the diagnosis codes, it has the procedure codes, all the charges, it shows the admission date and discharge date. Um, it's basically everything that happened that whole day that you were in in the in the hospital, um.
[AGENT][NEUTRAL] And that way they'll be able to see that it's a hospital stay versus just a hospital bill with charges.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] I got you.
[AGENT][NEUTRAL] Um, but that would, but that information wouldn't be available on your patient document, so it has to be the universal bill, and then, um, I would submit it if you're trying to claim for the hospital admission and confinement.
[CUSTOMER][NEUTRAL] OK. And then the other one, I can do that and I do I do a whole new, uh, report, like a whole new claim?
[AGENT][NEUTRAL] Oh yeah, this would be like a whole new claim because the other one, yeah, because it was denied and it didn't ask for additional information, so yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So my other one, he had a, I mean he had a fracture on top of his foot, so that doesn't cover.
[AGENT][NEUTRAL] The other one, let me see.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] The office visit.
[AGENT][NEUTRAL] So on [PII], I say [PII]? Yeah, [PII], there was an office visit. Now office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And then let me see what the, for diagnosis. Hold on.
[AGENT][NEUTRAL] Yeah, and there's no diagnostic testing on this policy. So those two services, the office visit and the diagnostic testing aren't covered on this policy.
[CUSTOMER][NEUTRAL] OK, but as long as I could show that he had an overnight stay and all the codes match up, I can do it. I should be OK with this other one, right?
[AGENT][NEUTRAL] Right, as long as he was in the hospital for 18 to 24 consecutive hours, um, let me see if this policy specifies, but he was, he was admitted though, right?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So we, um, so for the admission, that's a separate benefit and then I'm gonna check.
[AGENT][NEUTRAL] Um, for the policy to see if they, if it specifies confinement, sometimes it's 18 hours, sometimes it's 24.
[AGENT][NEUTRAL] So hold on one moment.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, for this policy it's um at least 18 consecutive hours for consignment.
[AGENT][NEUTRAL] So depending on how long
[CUSTOMER][NEUTRAL] From, from
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So depending on how long he was there, um, you could probably use both the hospital admission and the confinement.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alrighty, well, was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] No, that's it. I will, I'll work on getting it in here by tomorrow.
[AGENT][POSITIVE] Alrighty, uh, Mr. [PII], well, thank you so much for calling APL. I hope you have a great day.
[CUSTOMER][POSITIVE] All right thank you.
[AGENT][POSITIVE] You're welcome. Bye bye.
[CUSTOMER][NEUTRAL] Bye.