AccountId: 011433970860
ContactId: dc046e19-4f14-4703-b727-ae896696f054
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 495980 ms
Total Talk Time (AGENT): 161349 ms
Total Talk Time (CUSTOMER): 211870 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/01/dc046e19-4f14-4703-b727-ae896696f054_20250501T12:27_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Um, I filed a claim for a wellness benefit. Um, it is an old claim, but I was told I didn't realize we had this well wellness benefit, and I've had the policy since [PII] and I was told that I could go back um and file until the very first day that we had the policy.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEGATIVE] So I did do one from [PII] and it was denied saying that um.
[CUSTOMER][NEUTRAL] The services were rendered prior to coverage.
[CUSTOMER][NEUTRAL] And I'm assuming it's because
[CUSTOMER][NEUTRAL] It's older, I don't know.
[AGENT][NEUTRAL] Let me take a look. Do you have your policy number?
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Or the claim number?
[CUSTOMER][NEUTRAL] Let's see, it should be on here.
[CUSTOMER][NEUTRAL] I have the claim right here.
[CUSTOMER][NEUTRAL] Um, the claim number is 359-586-4.
[AGENT][NEUTRAL] OK, let me pull this up.
[AGENT][NEUTRAL] All right. And then I need to verify the name and date of birth, please, on the policy.
[CUSTOMER][NEUTRAL] The policy is my name. It's [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][NEUTRAL] Thank you. And then if I could verify please [PII], the address on file as well.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] So for [PII], it looks like the effective date was different. Um, it looks like the effective date for [PII] was [PII], and this one was in [PII], so that's why.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So [PII] was not online from the very beginning.
[AGENT][NEUTRAL] Mm mm, it doesn't show [PII] from [PII] um until [PII].
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] OK, I'd have to go look at my pay stubs because
[CUSTOMER][POSITIVE] I'm almost positive.
[CUSTOMER][NEUTRAL] I had it on both of us from the very beginning.
[AGENT][NEUTRAL] Yeah, I mean if
[CUSTOMER][NEUTRAL] Can you look at um
[CUSTOMER][NEUTRAL] I think y'all also have our hospital.
[AGENT][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] Yes, so let's look at that.
[AGENT][NEUTRAL] So, on the hospital, it shows [PII]'s effective date [PII].
[CUSTOMER][NEUTRAL] Yeah. So I had him on, if I had him on that one, I had him on both.
[AGENT][POSITIVE] Yeah, so I would definitely
[AGENT][NEUTRAL] Contact your employer.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Cause they would need to send us the correction like if it's being, if it's been deducted this whole time and you know, it's an error, we would need something from the.
[AGENT][NEUTRAL] To correct the date and then it could definitely be reprocessed.
[CUSTOMER][NEUTRAL] OK, so you're showing to effective [PII].
[AGENT][NEUTRAL] [PII], uh huh, correct.
[CUSTOMER][NEUTRAL] Oh, what did you say? I'm sorry.
[CUSTOMER][NEUTRAL] [PII]. OK, but now the hospital you had it back to [PII] just the cancer was [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, correct. Uh-huh.
[CUSTOMER][NEUTRAL] OK, so now [PII] I can still file his wellness benefit.
[AGENT][NEUTRAL] Yeah, absolutely. You could go ahead and do those and you wouldn't have any issue because of the um date, the effective date, but it makes sense why that one was denied because of the dates were different.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It it does I I don't agree with the dates, but I know that's not your fault. I'll look more into that, um, now I do have one more question about um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The hospital.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] On that one there's two different I'm trying to scroll to it so I don't know what I'm talking about I'm sorry.
[CUSTOMER][NEUTRAL] Um, there's two different lines for surgery. It's got surgery in a hospital and surgery in a physician's office.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] If you have it in the physician's office and then later in the same year, you have a bigger surgery like in the hospital. Are those two separate claims, can you, can you file on those?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] I would, I would think so. I'm pulling up your policy here to look at it.
[AGENT][NEUTRAL] Yeah, so those are those are separate benefits, it looks like. Um, but it's only gonna pay the one day maximum for each surgery. Does that make sense?
[CUSTOMER][NEUTRAL] Right, yeah, but you can file each if you have two separate surgeries, one in the office, one in the hospital.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yeah, absolutely.
[CUSTOMER][NEUTRAL] OK, and my next question is um hostile admission.
[CUSTOMER][NEUTRAL] Um, he was admitted in April, um, so I'm getting ready to file that claim.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] But that just once per year? What if he has another.
[CUSTOMER][NEGATIVE] illness, he's hospitalized again like.
[CUSTOMER][NEUTRAL] The end of this year, is that just one time per year regardless?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, yes, it looks like it. Maximum of one day per calendar year per covered person.
[CUSTOMER][NEUTRAL] OK, so no matter what we just, we keep paying it for the whole year and there's no more payout benefits at all.
[AGENT][NEUTRAL] I don't believe so because um let me see if there's anything else on here.
[AGENT][NEUTRAL] Yeah, it looks like that's all that's on the schedule with benefits, um.
[AGENT][NEUTRAL] So, it looks like it is the one admission benefit.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] And do I need to let you know now that
[CUSTOMER][NEUTRAL] And I'm gonna be filing that claim. Is there like a time period that I have to do it?
[AGENT][NEUTRAL] No, absolutely not, so there's no time limit as far as when they have to be filed by, um, so yeah, you can just do it when you have everything together and you're ready to do it.
[CUSTOMER][POSITIVE] OK. All right, that sounds good. I appreciate it.
[AGENT][POSITIVE] You're welcome. Anything else I can check on for you?
[CUSTOMER][POSITIVE] That's all I needed. Thank you.
[AGENT][POSITIVE] Thank you for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][NEUTRAL] Bye bye.