AccountId: 011433970860
ContactId: d902b471-34b9-410d-bd52-fcceb3929e6a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1212839 ms
Total Talk Time (AGENT): 413203 ms
Total Talk Time (CUSTOMER): 230534 ms
Interruptions: 3
Overall Sentiment: AGENT=0.8, CUSTOMER=-1.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/14/d902b471-34b9-410d-bd52-fcceb3929e6a_20250114T20:39_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEGATIVE] Hi [PII], I was calling because, um, just to go over some claims I've been submitting them and every time I submit they denied and they asked for some additional information on this last one I sent it, and they process the uh data service in [PII]. Why? I don't know because I didn't even have you guys in [PII].
[AGENT][NEUTRAL] OK. All right. Uh, I can help you with your claim information. Can you please give me your name and your callback number?
[CUSTOMER][NEUTRAL] [PII] my call back number is [PII].
[AGENT][NEUTRAL] OK, thank you. And then what is your policy number?
[CUSTOMER][NEUTRAL] 245-509-0.
[AGENT][NEUTRAL] OK, let me pull in that policy.
[CUSTOMER][NEGATIVE] It's confusing because um my company gave us this gap insurance and nothing else, no details, or how it works or anything, and just prior to the end of the year, it's like, oh, don't leave money hanging out there, you know, you guys wanna.
[AGENT][NEUTRAL] Mhm. OK.
[CUSTOMER][NEGATIVE] I'm like, OK, how do you do it because nobody ever got a card. So then it was me inquiring I find out that we have a policy that cards are not issued, but they ended up sending me a card. So I'm just submitting all these claims and nothing is getting paid, everything is getting denied because for not being covered or whatever reason.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I understand. All right, um.
[AGENT][NEUTRAL] Miss [PII], I'll be able to help you with your policy. First, I need to verify some information for security reasons. Can you give me your date of birth?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you so much. And then what is your address, phone number and email address that we have on the policy for you?
[CUSTOMER][NEUTRAL] Uh, phone number [PII]. My address is [PII], and the email address should be [PII].
[AGENT][NEUTRAL] OK, thank you. I appreciate you verifying that. OK, so I'm looking at your claims, um, let's let's just, I'm just gonna pull a couple of them in and see what's going on.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Let's start with the very last one because that's the one that asked for the additional information that I sent in and then I get a text this morning, oh, your claim is complete, and it's the service date of [PII]. I don't know what that processor was even thinking trying to process that.
[AGENT][NEUTRAL] OK, OK, I understand.
[CUSTOMER][NEUTRAL] I didn't get so up until last year.
[AGENT][NEUTRAL] Oh my. OK. Um.
[AGENT][NEUTRAL] Yeah, I can understand your frustration. um.
[AGENT][NEUTRAL] OK, so I'm looking at
[AGENT][NEUTRAL] The last one.
[AGENT][NEUTRAL] It was a duplicate claim. I'm seeing that.
[CUSTOMER][NEUTRAL] That you are received on.
[CUSTOMER][NEUTRAL] The last one that you received, let's see claim number 355-0900.
[AGENT][NEUTRAL] I'm
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, that was submitted I submitted.
[CUSTOMER][NEUTRAL] Um, EOB, they requested EOBs and information pertaining to the data service 5, where is that, one second.
[CUSTOMER][NEUTRAL] 51 and 52.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And so I submitted the EOBs which had that information on it because they needed the codes and all of that stuff.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's what that submission was for 18.
[CUSTOMER][NEUTRAL] That I submitted and you received on [PII].
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] All right, so what I'm going to do.
[AGENT][POSITIVE] I am going to take this a step further for you.
[AGENT][NEUTRAL] Because you have so many questions about your claims, there's only a certain amount of paperwork that I'm allowed to see on the end so I'm gonna take a step further. I'm gonna put in a request for somebody in the claims department to call you and go over your claims with you.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I thought that's who I was talking to.
[AGENT][NEUTRAL] Ma'am, what did you say?
[CUSTOMER][NEUTRAL] I thought you were the claims department. I selected claims and they gave me this phone number.
[AGENT][NEUTRAL] No, I'm
[AGENT][NEUTRAL] Right, I'm in the care team and so like we're the first point of contact before you get to the claims department so what I'm gonna do is I am gonna put in a request for somebody in the claims department to call you back um it could be up to 24 hours but I'm gonna put that uh request while you and I are on the phone together.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then I'm gonna get back with you and kind of briefly describe what kind of policy that you have so you have a little more information and then also uh that you have a copy of your policy so that you can have that on hand too, OK? You're welcome. It's gonna be a brief hold. I'm gonna put that request in for you first.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're so very welcome.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Oh OK, thank you so much for holding.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] I, um, I'm finishing up my note real quick. Um.
[CUSTOMER][NEUTRAL] OK, go ahead.
[AGENT][NEUTRAL] I just didn't want you to have to hold much longer.
[CUSTOMER][NEUTRAL] Oh, you're fine.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] I've got you all ready now.
[AGENT][NEUTRAL] So now this is just to verify your coverage. It's not a guarantee of payment on this policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's a gap insurance. It's a
[AGENT][NEUTRAL] Insurance that's billed after your primary insurance. So that insurance is billed first, this one is billed secondary. This one goes by helps with deductible, co-pay, or co-insurance, only those three things. So you have um
[CUSTOMER][NEUTRAL] Right.
[AGENT][POSITIVE] Benefits for inpatient and outpatient.
[AGENT][NEUTRAL] Once that benefit amount is met for the year, then the benefit is exhausted. So when you send in your claim.
[AGENT][NEUTRAL] The explanation of benefits needs to come from your primary insurance along with the itemized statement with the diagnosis codes and procedure codes, as you know, cause you've been sending in claims. Then this one picks up.
[AGENT][NEUTRAL] If it's a covered procedure, it will help with the deductible co-pay or co-insurance. And I just wanted to explain that to you because a lot of people think that.
[AGENT][NEUTRAL] It picks up whatever the first one, the primary doesn't and that's not correct so I just wanted to explain to you how it worked and then also.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEGATIVE] My co-pays have been denied. That's what I'm, I'm, I'm tripping on because my co-pays have been denied.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And they said it didn't cover so fast.
[AGENT][NEUTRAL] OK, well, I've got that. Mhm.
[AGENT][NEUTRAL] OK, um, I've got that request in for the claims department to review that for you with you to call you back and review that and um and like I said it has to be a covered procedure covered facility for the copay to be paid, um, not every.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] A covered procedure at a cover facility.
[AGENT][NEUTRAL] Right, at a covered facility. So, um, looking at your outpatient benefits, just looking at a glance, you have, um.
[AGENT][NEUTRAL] Let's see, you have.
[AGENT][NEUTRAL] ER urgent care center.
[AGENT][NEUTRAL] Places that you can go to, you have um.
[AGENT][NEUTRAL] Physician office visits, you get so many of those a year.
[AGENT][NEUTRAL] For your, for your benefits.
[AGENT][NEUTRAL] Where it's covered. And then, of course, you know, the hospital, if you're in the hospital for more than 18 hours.
[AGENT][NEUTRAL] But I'm also going to
[CUSTOMER][NEUTRAL] OK, so
[AGENT][NEUTRAL] Just make sure that I have your email address correct because I'm gonna send you a copy of your policy by email to you so that you can read it and you can see it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then I'm also gonna request that one be um mailed to your home address.
[CUSTOMER][NEGATIVE] OK, because I submitted urgent care, it was denied. I submitted office visits and my co-pays and all that, and this last claim was charges from an office visit and uh I had to take a stress test.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEGATIVE] At um at a cardiology office and all of that was denied.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK alright so when um.
[AGENT][NEUTRAL] When the claims adjuster calls you.
[AGENT][NEUTRAL] Just let them know that you have questions about that and why was it denied. Just ask them to go over it with you and explain.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] How they come out with the outcome so it can make so it can be clear for you so you can understand exactly how the process went.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so I've got um [PII], is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] OK, I'm gonna make sure I get that to your email. I'm gonna do that while we're on the phone together because I don't want anything to happen. I wanna make sure that we're still on the phone as I send this to you, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] So I'm gonna, I'm gonna put you on hold so you can do what you need to do while I get this taken care of for you.
[CUSTOMER][POSITIVE] No problem, I'm working too, so take your time.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, [PII].
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Hey Ms. [PII], I got a quick question for you.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Are you near a fax machine? I can fax it to you.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, alright, I thought I'd ask you because I knew that it was a large file so I didn't know if it would be OK to do it through your email but since you're not, I'm gonna go ahead and do it through the email, just thought I'd run that by you OK you're welcome.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Oh, I can do it there.
[AGENT][POSITIVE] OK thank you.
[AGENT][NEGATIVE] No, it won't let me do it there.
[AGENT][NEUTRAL] OK, that's why.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, Ms. [PII], I have got your email on the way and I have requested for a policy to be mailed to your home address.
[CUSTOMER][NEUTRAL] OK, I just received the email.
[AGENT][POSITIVE] Good, yay, good deal.
[CUSTOMER][POSITIVE] All right. Thank you so much.
[AGENT][NEUTRAL] You're welcome and if you have any more questions, um, just please pick up the phone if you can think of anything else we can add it to that hub request if we need to, but I've got that request in for somebody to call you back within 24 hours.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] You're welcome. You have a great day. Thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Mhm bye bye you too.