AccountId: 011433970860
ContactId: e37bcbf9-b139-4059-bee5-fe9356fafc2e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 585880 ms
Total Talk Time (AGENT): 296984 ms
Total Talk Time (CUSTOMER): 142501 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=1.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/20/e37bcbf9-b139-4059-bee5-fe9356fafc2e_20250520T12:16_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII] in [PII], how you doing?
[AGENT][POSITIVE] I'm good, [PII]. How are you today?
[CUSTOMER][POSITIVE] Doing great, doing great, just trying to see if I can check on a claim for one of our customers.
[AGENT][NEUTRAL] Sure, you're needing claim status on a member.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Yes, sir. I can help you. And [PII], what is your callback number?
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Thank you and the member's policy number?
[CUSTOMER][NEUTRAL] OK, policy number should be 2605156.
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][NEUTRAL] And it looks like there's one that ends in 83 and one that ends in 95, one's on herself and one's on her daughter [PII].
[AGENT][NEUTRAL] On all, all of the policies there are claims?
[AGENT][NEUTRAL] Or just this one.
[CUSTOMER][NEUTRAL] The main ones are, uh, the main ones I'm looking at are the accident on um on the accident policy. It looks like there's one that was just processed on [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so first off, let's um let's do our verification that we have to do as you know any information provided will be a verification of benefits and not a guarantee of payment. So if you'll first verify [PII]'s uh date of birth for me.
[CUSTOMER][NEUTRAL] Yes ma'am. Date of birth for her is [PII].
[AGENT][NEUTRAL] OK, thank you, and then also your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so you're calling on the claim.
[AGENT][NEUTRAL] What is the data service, [PII], for her, for [PII]?
[CUSTOMER][NEUTRAL] I can tell you I don't know the date of service I know it ends in 083, the claim number.
[CUSTOMER][NEUTRAL] Date of the accident [PII], I believe.
[AGENT][NEUTRAL] OK, so I can see that at this point, this, this claim has been denied. Um, the reasons for the denial on here, [PII].
[AGENT][NEUTRAL] Maybe I can
[AGENT][NEUTRAL] OK, so on.
[AGENT][NEGATIVE] There was one X-ray that has been denied.
[AGENT][NEUTRAL] Because the benefit amount has been, it's a long paragraph.
[AGENT][NEUTRAL] Um, the X-ray benefits been exhausted for the plan year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's one of the reasons.
[AGENT][NEUTRAL] Then on
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Another code for that same data service.
[AGENT][NEUTRAL] State benefits payable under this certificate are limited to those outlined on the schedule of benefits. This is not a covered loss under the plan. Therefore, no amount of pay is payable for this expense.
[AGENT][NEUTRAL] Let's see, um.
[AGENT][NEUTRAL] There's 2 codes that have that remark.
[AGENT][NEUTRAL] And then one of the denial remarks states the physician means a practitioner of the healing arts. He's legally qualified and licensed to practice medicine and who is practicing within the scope of his or her license in the state where so licensed. Based on the information received, the treating provider does not meet the definition of a physician under the policy. Therefore, no benefits are payable.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Wow.
[CUSTOMER][POSITIVE] Wow, OK.
[CUSTOMER][NEUTRAL] We, we've had multiple claims paid here so I'm curious.
[CUSTOMER][NEUTRAL] Where they're going with that, you know, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'll have to come back to that. That's a big, that's a a lot to swallow there, OK.
[AGENT][NEUTRAL] That's a lot, yes, I know that those are, yeah, those are.
[CUSTOMER][NEUTRAL] For
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] In this place is like they do chiropractor, spine, rehab. I mean these are doctors, they're not uh.
[AGENT][NEUTRAL] I
[CUSTOMER][NEUTRAL] He's not just like a, you know what I mean, pop up shop in a mall or something, you know, um.
[AGENT][NEUTRAL] Are they an MD or like therapist? I, I, I mean, I don't know. I can just, again, I can only read that definition to you, um, [PII], for the, or the remark, not the definition, but the remark.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I'm gonna try to find out
[CUSTOMER][NEUTRAL] So, but I know we've paid like 5 claims in this group, um, which is making me wonder why they're addressing that now, you know what I mean? Um.
[CUSTOMER][NEUTRAL] See if you don't mind if you can look under [PII], the daughter and see if it's the same scenario.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] What is her date of birth, please, [PII]?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because now this woman's gonna say she was targeted.
[CUSTOMER][NEUTRAL] Because other people got their claims paid, you know what I mean?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Now, it looks like there is a benefit paid.
[AGENT][NEUTRAL] On this claim for [PII].
[AGENT][NEUTRAL] And the amount of $300.
[AGENT][NEUTRAL] This one did just processed yesterday as well.
[AGENT][NEUTRAL] On here
[CUSTOMER][NEUTRAL] Alright, so they did process the daughter.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Uh, there was
[AGENT][NEUTRAL] Partial, let's see, just one second.
[AGENT][NEUTRAL] So there was on one of the codes.
[AGENT][NEUTRAL] Trying to see which one the benefit was paid on. Bear with me just a second, [PII].
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so there was an X-ray. The $300 was paid on an X-ray.
[AGENT][NEGATIVE] And then the other two codes were denied. With the X-ray, that states with the payment of this service line, this benefit is exhausted for this covered person for the plan year.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] One code states benefits payable under this certificate are limited to those outlined on the schedule of benefits. This is not a covered loss under the plan. Therefore, no amount is payable for this expense.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And the other one is denied with that same reason that I read to you about the physician.
[AGENT][NEGATIVE] Based on the information received training provider does not meet the definition of a physician under the policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Therefore, no benefits are payable.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now this
[CUSTOMER][NEUTRAL] OK, I'm gonna have to go do some recon.
[AGENT][NEUTRAL] OK, because this one you should be able to see I can see you all filed it.
[AGENT][NEUTRAL] All these claims, you should have access to that later today, I believe, [PII] EOB.
[CUSTOMER][NEUTRAL] You know it's funny on my side, they don't allow us to CEOBs, which is crazy because um.
[AGENT][POSITIVE] Uh, well, that's, uh, that's true. That's true. I'm so sorry. I need some more coffee.
[CUSTOMER][NEUTRAL] You know
[AGENT][NEUTRAL] That's right. Yeah, you can't, um, she can do that. Mhm.
[CUSTOMER][NEUTRAL] I know, I hear you. But, but what's funny is
[CUSTOMER][NEUTRAL] They don't have it available on my screen, but then if I email the care team or claims, they just email me the EOBs. So it's like just put it on my screen so we could save a lot of time here, you know.
[AGENT][NEUTRAL] And with the new.
[CUSTOMER][NEUTRAL] Um, because that's what the other vendors do.
[AGENT][NEUTRAL] With the new OSC, I think that that's something that you all, and I don't even think that I can see it yet since it just went through nightly processing. I can see it on my screen, but like the actual EOB I don't think it's there for me either to.
[AGENT][NEUTRAL] Um, just to, yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, yeah, it's not, it's not pulling, it's not, I can just see the claim, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I will, uh.
[CUSTOMER][POSITIVE] I'll work on it from here. I appreciate your time this morning.
[AGENT][POSITIVE] Oh, you're welcome as always, [PII]. Um, is there anything else at the moment that I can help you with?
[CUSTOMER][POSITIVE] That's it. Have a great day.
[AGENT][POSITIVE] I hope you have a great day too. Is it hot down there?
[CUSTOMER][POSITIVE] Yes ma'am, very.
[AGENT][POSITIVE] Yeah, very, yeah, it's not a very humid, humid, very humid. But anyway, OK, [PII], well, it's nice speaking to you as always and again, thank you for calling APL this morning and I hope you have a great day.
[CUSTOMER][POSITIVE] That's right.
[CUSTOMER][POSITIVE] You too. Thank you.
[AGENT][POSITIVE] But you're welcome. Thank you.
[CUSTOMER][POSITIVE] Take care bye bye.
[AGENT][NEUTRAL] Bye bye. You too. Bye bye.