AccountId: 011433970860
ContactId: e289a287-35be-446b-b48f-858c5322f91e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 660000 ms
Total Talk Time (AGENT): 439287 ms
Total Talk Time (CUSTOMER): 172575 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/14/e289a287-35be-446b-b48f-858c5322f91e_20250514T16:21_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hey, this is hey, this is [PII] over in customer care. How are you?
[AGENT][NEUTRAL] Hello.
[AGENT][POSITIVE] Doing well, [PII] thank you how are you?
[CUSTOMER][NEUTRAL] I'm good. I have an insured on the line who has a question about a denied claim, and I was wondering if you could help her with that, please.
[AGENT][NEUTRAL] Certainly, what's the policy number?
[CUSTOMER][NEUTRAL] Her policy is 02312467.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then I have the claim number.
[AGENT][NEUTRAL] Let me pull that up.
[AGENT][NEUTRAL] And it's for [PII]?
[CUSTOMER][NEUTRAL] Um, mhm. Um, no, it should be for [PII].
[AGENT][NEUTRAL] Oh, did I put the wrong number in?
[CUSTOMER][NEUTRAL] Yeah, let me give that to you again it's 02.
[AGENT][POSITIVE] Oh, I got it. I, sorry about that. I transposed the number my fault, my fault.
[CUSTOMER][NEUTRAL] OK. That's OK.
[CUSTOMER][POSITIVE] No, it's all good.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] And go ahead, my claim number.
[CUSTOMER][NEUTRAL] Um, and then the claim number is gonna be 360.
[CUSTOMER][NEUTRAL] 0539.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I did read the policy and pulled it up. It's basically for um childbirth pregnancy.
[CUSTOMER][NEUTRAL] And I see the limitations and exclusions like a waiting period talking about for pregnancy, but there is no waiting period on the.
[CUSTOMER][NEUTRAL] Certificate, so I was a little confused myself and then I even asked, asked her, I said, were you in the hospital for 18 hours? She says yes, but the way I'm reading it, it looks like it was outpatient, not inpatient.
[AGENT][NEUTRAL] OK, I'm gonna pull up those documents real quick and just double check it, but that's what it looks like it looks like it was denied because if we didn't have the um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It it looks to be outpatient services so I'm gonna double check that it looks like though she.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Did indicate she was there for.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And [PII], what's her callback number?
[CUSTOMER][NEUTRAL] Her call back is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, because it looks like these are just the professional charges that she sent in to us so it looks like probably what we're gonna need for this if she was inpatient is the hospital charges because it does show maternity care delivery, however, it only indicates that one date.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And so with this policy it looks like she only has like inpatient benefits so we would need that um that hospital bill that shows that you know she was confined and there's a room and board charge so if you wanna um transfer over to me I'll explain that to her.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][POSITIVE] OK, absolutely, and I will keep that in mind for next time to check that and um I can advise on that. I appreciate your help. Thank you so much.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] No problem, sir, and everything's been verified for her, right?
[CUSTOMER][POSITIVE] Yes, ma'am, here she, yep, and here she comes.
[AGENT][NEUTRAL] I did I already ask that? I'm sorry. OK, thank you, [PII].
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] No no it's fine. You're welcome.
[AGENT][NEUTRAL] It's been a Monday, a Wednesday, Monday.
[CUSTOMER][NEUTRAL] I, I, I hear you, I hear you.
[AGENT][POSITIVE] Have a good day, sir.
[CUSTOMER][NEUTRAL] Here she comes.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] You too.
[AGENT][NEUTRAL] Hi, [PII].
[CUSTOMER][NEUTRAL] Hi.
[AGENT][NEUTRAL] Hi there, my name is [PII]. I'm on the claim support team and Ms. [PII] transferred you over to me to give you some further information regarding your claim. So, um, it looks like you were hospitalized on the [PII] through the [PII] for it looks like, um, labor and delivery, is that right?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, well, first of all, let me just say congratulations, um, hope all is well. You're welcome and um just I'm looking over the claim that you submitted to us, so it looks like that bill that you sent in to us is just indicating that it was um the surgery, like the surgery maternity care delivery. So for your policy because it's strictly uh inpatient um inpatient services.
[CUSTOMER][POSITIVE] Mm thank you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] So it's when you're um confined to uh you know admitted to the hospital and confined. So what we're needing is some kind of documents that would verify that you were admitted and there's a room and board charge. So um do you have any additional um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I know, did you obtain this from Presbyterian this itemized billing statement?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so if you look on it, it does indicate that it's professional charges only and even though it does indicate the admission and discharge dates on there we're still needing that like that room and board charge so if you're able to obtain that information from the hospital or perhaps did they give you like a discharge summary when you were um discharged?
[AGENT][NEUTRAL] You know,
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Usually they give you some paperwork when you're discharged that shows what you were hospitalized for and then what your um instructions are for a follow up like if you're following up with your primary care doctor or you know what to do in the case of uh complications, that sort of thing. Do you know if you have any of that paperwork?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah. It's like a, it's a pretty big packet.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, so we won't need all of it, um, usually that first page it'll it'll say like discharge summary or aftercare summary. Do you see that page in your paperwork?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and it usually will list like I said um it will have your name and then it will have to admit and discharge date. Does it show that on there?
[AGENT][NEUTRAL] And for maternity care?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It has
[CUSTOMER][NEUTRAL] Um, like next steps, um, like a postpartum visit, it does have the date.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] And it has like um
[CUSTOMER][NEGATIVE] Why I was hospitalized.
[AGENT][NEUTRAL] Yeah it does OK yeah and that's all I think that's all we would need um you were just in there for the one day, correct?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so you went in on the [PII], discharge on the [PII], so if you just wanna send that page into us, um, that you know has those uh discharge information or that like I said that aftercare if you wanna send that into us, um, otherwise you can obtain.
[AGENT][NEUTRAL] The billing for Presbyterian, but you need the hospital charges. But if we have that document that just shows, you know, that you were admitted this date to this date discharged and what the reason is, you know, usually like I said they'll say maternity care or you know, um.
[AGENT][NEUTRAL] Uh, labor and delivery or whatever, mhm.
[CUSTOMER][NEUTRAL] It says that
[CUSTOMER][NEGATIVE] Yeah, it says labor pain is why I was hospitalized.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then um
[AGENT][NEUTRAL] Like I said, if you wanna just go ahead and submit that, that should be sufficient. Otherwise, like I said, you could contact Presbyterian and see if they can give you that hospital bill that shows the hospital charges that have the room and board charge on it, um, but usually that information from the discharge is sufficient, you know, like I said, as long as it has your name, the dates, the hospital, of course, and then the reason for the hospitalization, we usually can accept that um for uh for that.
[AGENT][NEUTRAL] Uh, particular, uh, visit to the hospital.
[CUSTOMER][NEUTRAL] OK. Um, so where would I
[AGENT][NEUTRAL] Now do you have um.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So you already submitted your claim form that's OK. I don't mean to talk over you my apologies, um, so you already submitted your claim form so actually all we need is that document just to verify if you're able to um go ahead and upload it through the portal because it looks like you do have a um active portal where that where you submitted your claim, you can go ahead and submit that document through there um.
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And if you'd like um you know I can review it to make sure it's what we need and if there's anything additional needed I can give you a call back um and just let you know that but like I said if you wanna go ahead and upload that document I'll be happy to review it uh once we receive it and then um like I said if anything additional is needed I can give you a call back.
[CUSTOMER][NEUTRAL] OK, um, so would I just submit it.
[CUSTOMER][NEUTRAL] Like, in addition to, I don't, I see where I can submit like upload file. It's OK if it's not like attached to that claim.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes, because it's what's what's happened here is that like I said we'll see that there's additional information and they're usually what happens is when we receive additional documents we'll go back and review those documents that are, you know, were previously um you know uh submitted to the system and then for this particular one like I said I'm gonna note your file and I'm actually because I'm on the claim support I'm actually gonna um view.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That document once you submit it you like I said you don't you could just do it like you're doing a new claim, but you don't have to do the claim form just go ahead and upload that document and it'll come through as a new piece of mail and like I said I'll review it and um and we'll kind of move forward uh with it that way and like I said if I think if I if we think we need anything additional I'll be you know sure to give you a call back and let you know.
[AGENT][POSITIVE] Um, I can actually give you a call back either way and let you know what we received and you know if it's sufficient enough and we'll go ahead and continue processing your claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, that sounds good.
[AGENT][NEUTRAL] And um your callback number [PII] is the best number to reach you?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] Yeah, perfect.
[AGENT][NEUTRAL] OK, alright, so like I said I'll keep an eye out for that document and once I review it I'll give you a call back and um just gonna give you an update.
[CUSTOMER][POSITIVE] OK, perfect. Thank you so much.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You're welcome, Miss [PII] and. Did you have any other questions at this time?
[CUSTOMER][NEUTRAL] Um, I don't think so.
[AGENT][POSITIVE] OK, alright, well I'll be speaking with you shortly and thank you so much for your patience and thank you for calling APL.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Alright have a great day and congratulations again.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][POSITIVE] Mhm. Thank you. Bye-bye.
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] Bye.