AccountId: 011433970860
ContactId: da6e9b55-ba8a-4763-81a9-80f6106a6204
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 587640 ms
Total Talk Time (AGENT): 276890 ms
Total Talk Time (CUSTOMER): 246875 ms
Interruptions: 3
Overall Sentiment: AGENT=0.4, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/14/da6e9b55-ba8a-4763-81a9-80f6106a6204_20250414T15:52_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] in broker Resources. How are you doing today?
[AGENT][NEUTRAL] Hey [PII], OK, so I'm so glad you're from Broker Reserves because the phone did not say anything at all. It was just silent. So maybe it's because it was internal. I'm like, that's why I hesitated.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] I'm sorry.
[CUSTOMER][POSITIVE] No, you're good. No, you're good. Do not worry about it it it happens because sometimes it's, it says like on my end it'll be like broker resources and I'm like what is that?
[AGENT][NEUTRAL] It was just silent and then I'm like, thanks for calling. OK, sorry. OK, what you actually, I'm sorry, that was weird.
[CUSTOMER][NEUTRAL] No, you're good. No, you're, you're good. Um, is this claims correct?
[AGENT][NEUTRAL] Is this claims? No, this is the care team.
[CUSTOMER][NEUTRAL] Care team, is there any way if you could see?
[AGENT][NEUTRAL] You're trying to get the claim?
[CUSTOMER][NEUTRAL] Yes, I, I thought this was claims.
[CUSTOMER][NEUTRAL] Or is there any way, do you, can you guys see if a claim was submitted on an employee?
[AGENT][NEUTRAL] Mhm. Um, what's the, um,
[AGENT][NEUTRAL] Policy number.
[CUSTOMER][NEUTRAL] I'm so sorry, the house number?
[AGENT][NEUTRAL] Uh, the policy number.
[CUSTOMER][NEUTRAL] Or do you say policy num? Oh, OK, policy number is 1341904.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] 1341904.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] For [PII].
[CUSTOMER][NEUTRAL] Yes, it was in last August, they said.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, um.
[AGENT][NEUTRAL] Yes, we have [PII].
[AGENT][NEUTRAL] We have some claims.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] And um do you know if they were paid?
[AGENT][NEUTRAL] Let's see, hold on one second.
[AGENT][NEUTRAL] So 3 were paid and 1 was denied. You want me to give you like the claim? Are, are y'all looking for like a specific provider?
[CUSTOMER][NEUTRAL] No, so I guess um the group, the broker met with the group last week and they didn't even know the status of the claim and so they were like, well we can follow up for you um and see maybe it would be best if I connect them to claims so they can explain maybe why some of it was denied.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Oh, you can send, if, if that's all they want, yeah, you can send them to me. I can help.
[CUSTOMER][POSITIVE] Oh, OK, perfect. I'll connect the two of you. Her name is.
[AGENT][NEUTRAL] Is this the broker or the um
[CUSTOMER][NEUTRAL] So this is the broker um she she's not the broker but she works with the broker I think maybe as like an admin.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And do you know if she, has she been verified?
[CUSTOMER][POSITIVE] OK perfect I'll have her join.
[CUSTOMER][NEUTRAL] No, I, I don't know how we verify them. We just normally like look and see if it's matched in line um to the broker's name like, uh, OK, OK, perfect. I'll have her join.
[AGENT][NEUTRAL] Oh, it's OK.
[AGENT][NEUTRAL] No, I'll verify it's fine. OK, and what's her name?
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] Her name is [PII].
[AGENT][NEUTRAL] [PII]? OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Hey [PII] are you still there? Yeah I am talking to myself if you heard me when you. No you're good you're good do not worry about it. I have I have [PII] on the phone with us as well and she's gonna be able to help you with that um claim she did verify that there was one in August and she can speak to you more about that OK? Perfect, thank you. All right thank you bye bye. Bye.
[AGENT][NEUTRAL] Hi [PII], how are you?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][NEUTRAL] I'm doing good. Um, so I do have the policy up here and can you just, um, you're with the broker's office, I just need to verify.
[CUSTOMER][NEUTRAL] I am. I'm with the broker's office. The broker's [PII]. My name's [PII] and I work in his office, so.
[AGENT][NEUTRAL] Alright, and I just need you to verify.
[CUSTOMER][NEUTRAL] What can I tell you? What can I tell you?
[AGENT][NEUTRAL] Um, just your, your email address.
[CUSTOMER][NEUTRAL] My email address is [PII]. [PII]'s email address is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So she asked me to look for any claims in August. Um, I see.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] Um, I see [PII]. So there was a total of 1234 claims on that day. Um, hold on, I'm pulling them all up now.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] And I'm sure it was an outpatient thing.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] It was cataract surgery. I can tell you that it's probably some type of an eye clinic.
[AGENT][NEGATIVE] So 3 of them were paid. 1 was denied, but it was denied. Let me see why. Hold on 1 2nd.
[AGENT][NEUTRAL] Looks like the max might have been met, but let me double check.
[CUSTOMER][NEUTRAL] OK, mhm.
[AGENT][NEUTRAL] Yes, the outpatient benefit for the calendar year has been met. Um, did you want me to give
[CUSTOMER][NEUTRAL] had been
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] I'm sorry. Did you want me to give you like the um policy number or like what if you just want to know that or did you need anything sent?
[CUSTOMER][NEUTRAL] Uh huh, no, no, go ahead.
[CUSTOMER][NEUTRAL] Well, tell me, did you pay the doctor's office or did you pay the the member?
[AGENT][NEUTRAL] We pay directly to the provider, the, the doctor's office.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, can you tell me was it it was 3 different claims you said?
[AGENT][NEUTRAL] Mhm. Let me see what.
[CUSTOMER][NEUTRAL] Can you tell me how much you paid them on each of those claims?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, hold on one second.
[AGENT][NEUTRAL] So you want me to give you like the claim number and how much was paid on it?
[CUSTOMER][NEGATIVE] I don't even need the claim number if you can just tell me how much you pay 3 different ones, yeah.
[AGENT][NEUTRAL] Oh, just some
[AGENT][NEUTRAL] OK, so,
[AGENT][NEUTRAL] Hold on, let me put it out. Mhm.
[CUSTOMER][NEUTRAL] And let me ask one other quick question, were they all to the same provider?
[AGENT][NEUTRAL] Oh, no, I'm getting ready to go through that now because, um, so I'm getting the claim numbers now and then I'll be able to pull each one and get more information.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Oh, OK, OK.
[AGENT][NEUTRAL] So let me see how much was paid and which provide, OK.
[AGENT][NEUTRAL] Hold on one moment, 2000.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] 7840 and this one was denied because [PII].
[AGENT][POSITIVE] OK. I got them all in the same spot now. I'm getting ready to pull them up. Hold on one moment. Thank you for your patience.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No, no, thank you. I'm very thankful that you were able to tell me this without making me go through a million hoops to get it.
[CUSTOMER][NEUTRAL] You know, especially when you're dealing with the principal at the group, you know, he says, you know what, I don't know, and, and it's just like how do you not know, but you know.
[AGENT][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] People are people so.
[AGENT][NEUTRAL] Right, OK, so let me see. So Quincy, so I have like the office, I don't see like a, like a doctor's name, that's OK?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] That's OK. Quincy I or something like that.
[AGENT][NEUTRAL] Mhm. Quincy Medical, um, we paid $278.40.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see who the second one is 595.
[AGENT][NEUTRAL] Oh, this one is Quincy also, $2,168.90.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] And let's see the last one.
[CUSTOMER][NEUTRAL] And those were all paid sometime in August or September, is that right?
[AGENT][NEUTRAL] Um, let me see, these were paid [PII] of [PII].
[CUSTOMER][NEUTRAL] OK, that's what I figured, OK.
[AGENT][NEUTRAL] And what's the last 1 395395 here it is. Oh, I clicked on the one above it. Hold on one second, I'm sorry.
[CUSTOMER][POSITIVE] That's all right you're doing good.
[AGENT][NEUTRAL] OK, and then the last one was also to Quincy Medical Group and we paid $522.53.
[CUSTOMER][NEUTRAL] OK, and those 3 numbers together are met his outpatient maximum, right?
[AGENT][NEUTRAL] Let me see what the max is.
[CUSTOMER][NEUTRAL] I think it's what I understood you to say.
[CUSTOMER][NEUTRAL] Because you said
[CUSTOMER][NEUTRAL] Well those numbers don't add up to a total.
[AGENT][NEUTRAL] Yes, so the, the max is 4000, but
[AGENT][NEUTRAL] Hold on 1 2nd.
[CUSTOMER][NEUTRAL] That's $2,969.83.
[AGENT][NEUTRAL] Right, but that's just for, let me see if he, he must have used had other outpatient expenses that year. Mhm.
[CUSTOMER][NEUTRAL] But it does
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Other claims earlier in the year or some.
[AGENT][NEUTRAL] Let's see, 1341904 for [PII].
[AGENT][NEUTRAL] I mean, if you want, I can try to search what the remain, you know, what that different, where the difference was paid to, but yeah, he used the full 4000 last year.
[CUSTOMER][POSITIVE] He used the 4000 full $4000 last year, but only 3 of them were for this August claim, but it was paid. There was almost $3000 worth. OK, that, you know what I'm, I'm good with that for now. OK, if I want more, I'll call back in, OK?
[AGENT][POSITIVE] Exactly.
[AGENT][NEUTRAL] You sure?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, was there anything else I can help you with today, [PII]?
[CUSTOMER][POSITIVE] That will do it thank you very much.
[AGENT][POSITIVE] You're very welcome. Well, thanks for calling APL. I hope you have a great week.
[CUSTOMER][POSITIVE] All right thanks you too bye bye.
[AGENT][POSITIVE] Thank you. Bye bye.