AccountId: 011433970860
ContactId: e6e84a66-6d12-4edd-9212-e2a3852cb34a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 896840 ms
Total Talk Time (AGENT): 376674 ms
Total Talk Time (CUSTOMER): 408164 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/05/e6e84a66-6d12-4edd-9212-e2a3852cb34a_20250605T18:22_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], it's [PII] with the APL care team. Um, I have a Gonzalo on the line. He is questioning why his claims keep getting denied. um, I, it, it shows that he's meeting the benefit maximum, um, and he's saying that he's only visited one time and he doesn't know why they keep getting denied and I, I can't do any more research on why they're getting denied.
[AGENT][NEUTRAL] OK, what was the policy number?
[CUSTOMER][NEUTRAL] Uh, policy number is 25.
[CUSTOMER][NEUTRAL] 82675
[CUSTOMER][NEGATIVE] I am showing that 2 claims have been um paid and then all the rest have been denied um.
[CUSTOMER][NEGATIVE] But I'm just not able to see why.
[AGENT][NEUTRAL] OK. Let me take a look here.
[CUSTOMER][NEUTRAL] That was his hospital indemnity plan. He made it sound like it's an accident though, so I'm wondering if if they file a claim under their hospital indemnity and it ends up being an accident policy, are they allowed to, does it go do we transfer it over to the correct policy, or do they need to resubmit?
[AGENT][NEUTRAL] Um, normally we would check to see if they have another policy, and then we would just move it over for it to be reviewed under both. Um, I can check real quick to see if they've.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, uh, yeah, I do see that he did file a claim this year for his accident policy too, um, let me see.
[CUSTOMER][NEUTRAL] Yeah, the one he gave me is his hospital indemnity policy, so I didn't know if.
[CUSTOMER][NEUTRAL] Uh, we need to give them more research or if you need to get more information from him as to if it needs to be processed through the other claim. I, I don't know, he gave me the, the hospital indemnity policy and.
[CUSTOMER][NEGATIVE] I was told we can't research care team shouldn't be researching into claims.
[CUSTOMER][NEUTRAL] Um, and frankly, I would, I would know what to.
[CUSTOMER][NEUTRAL] Look for all I can give him is the benefit amount and he's wondering how.
[AGENT][NEUTRAL] Uh sure.
[AGENT][NEUTRAL] OK, yeah, I'm just taking a quick look, so I just know what to tell him as soon as you transfer him over.
[CUSTOMER][NEUTRAL] That's OK.
[CUSTOMER][POSITIVE] I enjoy learning from you guys, especially if I end up transferring and it shouldn't be transferred. I, I want to know if I'm doing it right or wrong.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] No one's told me so far that I've done it wrong, but I want to, to make sure and then I kind of want to know the processes too, so, um, that I can better understand next time someone calls.
[AGENT][NEUTRAL] Uh, sure, so let me see, so from what I'm seeing we've already paid there's like a maximum um benefit for that data service and so that was already paid and so that's why it's being denied because he keeps sending it more information for the same data service, um, so I can go ahead and let him know that that the maximum benefit for that data service has already been maxed.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, yeah, and I told him I gave him the claim remark and he was like not understanding how it could have been maxed out after one visit.
[AGENT][NEUTRAL] Yeah, it's just because we pay a maximum for like the office visit 2 $75 per visit and so that's what was paid.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, um, I'll, I will go ahead and transfer him over to you um I will I'll introduce you first just so that he knows it's not the voices aren't the same, so give me just a moment.
[AGENT][NEUTRAL] So, yeah.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Hi [PII], I have [PII] from uh claims and she's gonna be able to help you with that information, OK?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] Good afternoon. This is [PII], and how can I help you today?
[CUSTOMER][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Uh, I went to the doctor in January and you guys rejected the claim.
[CUSTOMER][NEUTRAL] So I have to pay for that bill. Uh, the lady before you told me that I maxed up the my account. How could it be if it's the beginning of the year?
[AGENT][POSITIVE] Oh sure, I can help you with that.
[CUSTOMER][NEGATIVE] So why you guys checked, yeah, tell me all the claims that I have with you.
[CUSTOMER][NEGATIVE] If you reject them all, cause I, I, I'm gonna have another bill coming.
[CUSTOMER][NEUTRAL] And I am seeing the paperwork that you sent to me on for [PII] or, or something like that, that says that you are paying 0. So, are you rejecting all my claims? What, what, what's the deal?
[AGENT][NEUTRAL] Sure, I can help you with that. Um, so I do see that we had, so far we have paid um two claims, um, one that was released on [PII] for the date of service, [PII], um, for your outpatient sickness visit, um, so that was paid with that $75.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, that was released on [PII] and then there was a second claim that was paid, um, it looks like that benefit was released on [PII] for the date of service of [PII], um, for that outpatient sickness benefit as well for $75.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, so for that outpatient sickness benefit under your policy, it does pay a maximum of 5 visits per calendar year, and the maximum is $75 per visit. So it looks like for that date of service of [PII], that benefit had already been maxed. So if you were to have a different date of service.
[CUSTOMER][NEGATIVE] How? You, you're, you're making no sense. 5 visits per period. 5 visits. I didn't have 5 visits.
[AGENT][NEUTRAL] Sure, so Mr. [PII], I, I'm, I'm trying to make sure you understand what I'm, what I'm saying. It is for that date of service, it has been maxed. I'm not saying you've had a max of visits, it's the date. You're, you've sent in two other claims for the, the same date of [PII] and we've already paid that date. So if you were to have a different date, say if you went on [PII], then that would be a separate date with a separate benefit.
[CUSTOMER][NEUTRAL] You're counting just 2.
[AGENT][NEUTRAL] It's not the max number of visits, it's the max payable for that date of service.
[AGENT][NEUTRAL] Does that make more sense?
[CUSTOMER][NEUTRAL] Yes, but, but.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] If they send the claim to you all on the same date, doesn't mean that I went to the doctor 3 times on the same day.
[CUSTOMER][NEGATIVE] That is the part that doesn't make any sense. Maybe the provider decided to send the claims to you, all three on the same date.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But I didn't go to the doctor uh 3 times in one day. Think about it. I mean, would you do that?
[AGENT][NEUTRAL] So you're saying you did go to 3 different doctors in the same day?
[CUSTOMER][NEUTRAL] No, I went to doctors different dates.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] If they send the claim to you all in the same day, that's not my fault. But I didn't go to a doctor or, or to 3 doctors in one day.
[AGENT][NEUTRAL] Oh right, so we go by the date of service, not the date that they send the claim. So the date of service for those other two claims that were denied were for [PII].
[AGENT][NEUTRAL] So we go by the actual date that you were seen by the doctor.
[CUSTOMER][NEUTRAL] OK, [PII], I went to Doctor [PII], and it's just one doctor.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that that claim for [PII] was paid on um on [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And you're saying that there are 2 more for the same date. Who are the providers?
[CUSTOMER][NEUTRAL] Can you see what doctor I was seeing?
[AGENT][NEUTRAL] Sure, we received.
[AGENT][NEUTRAL] Sure, we received one claim on [PII] and another claim on [PII], and one of the, the provider was for SSM Health Medical Group.
[AGENT][NEUTRAL] And then the other one was, well I guess they were both, I guess I think it looks like they, they sent two separate claims for the same data service.
[AGENT][NEUTRAL] And they were they both of those claims were for [PII].
[CUSTOMER][NEUTRAL] Right, and
[CUSTOMER][NEUTRAL] Let me ask you this other question. What happened in [PII]?
[CUSTOMER][NEUTRAL] Because I went to the doctor, to [PII].
[AGENT][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] What happened on
[CUSTOMER][NEUTRAL] Yeah, [PII]. What happened with that visit? Because you reflected that the bill was 789, I fall from the from the ladder, I hit my back, I went to the doctor because of the pain.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, sure.
[CUSTOMER][NEUTRAL] Uh, he ran some X-rays.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] and give me some, some meds.
[CUSTOMER][NEGATIVE] So, um, recently, I have to pay that bill because they say that you guys rejected that, uh, that claim.
[AGENT][NEUTRAL] Yes, sir. So I can take a look at that for you. Uh, bear with me just a moment.
[AGENT][NEUTRAL] OK, yes, I do see we received that claim on [PII], and it looks like it was denied as the um this policy only pays for a sickness. It doesn't have benefits for an accidental injury.
[AGENT][NEUTRAL] Um, so that's why that claim was denied.
[CUSTOMER][NEUTRAL] Oh my God.
[CUSTOMER][NEGATIVE] Sorry, but you guys suck.
[CUSTOMER][POSITIVE] It it's incredible.
[CUSTOMER][NEGATIVE] What is the point of having a coverage if you're not gonna be paying? Yeah, definitely, I, I made a mistake, uh, accepting the this benefit clearly.
[AGENT][NEUTRAL] I do think you have.
[AGENT][NEUTRAL] Um, I do see that you did receive benefits under your accident policy, um, for that, that injury. So for your hospital indemnity.
[CUSTOMER][NEGATIVE] No, I didn't receive anything.
[AGENT][NEUTRAL] Oh, OK. Um,
[CUSTOMER][NEGATIVE] From my accident on, on, on January, I didn't receive anything.
[AGENT][NEUTRAL] OK, yes, that was paid. It looks like it was a a provider claim, so it, it did, it did reimburse to your provider towards your bill with your provider's office.
[AGENT][NEUTRAL] And that claim was was processed.
[CUSTOMER][NEUTRAL] I pay all the bills.
[CUSTOMER][NEUTRAL] 789.
[CUSTOMER][NEUTRAL] Is that the number that you're seeing?
[AGENT][NEUTRAL] Um, so it looks like it went to, uh, let's see, you might wanna check with your provider's office if they were the ones that sent us the claim, but it was Saint Peter's bone and joint.
[AGENT][NEUTRAL] Is the provider's name.
[CUSTOMER][POSITIVE] Yes, exactly. That's where I went. Exactly, that one.
[AGENT][NEUTRAL] Yes, sir. So they sent us a claim for your your accident policy and there was a benefit provided.
[CUSTOMER][NEUTRAL] They can
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I, I'm not understanding. Did you pay?
[CUSTOMER][NEUTRAL] Part of the bill or not?
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] OK, how much do you pay and to whom? Because they were saying that you didn't say anything.
[CUSTOMER][NEGATIVE] So if you did, then I have to call them and complain to them.
[AGENT][NEUTRAL] OK, sure.
[AGENT][POSITIVE] Yes, sir. I will take a pull that up for you, just a moment please.
[AGENT][NEUTRAL] Yes, so it went to a payment of $50 to Saint Peter Phone and Joints, um, that's the provider and it looks like the check was cashed on [PII].
[CUSTOMER][NEGATIVE] Can you please uh send me an email with everything that you are seeing because I'm gonna have to get to this uh two providers and complain about what's going on. Like, uh, you received 3 claims on the same day. I didn't go to 3 doctors on the same day, so I will have to complain to them about that.
[CUSTOMER][NEUTRAL] And the other one is, how is that you send.
[CUSTOMER][NEUTRAL] $50 you said?
[AGENT][NEUTRAL] Yes sir.
[CUSTOMER][NEUTRAL] All right, and they were saying that the claim was rejected.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] So I, I need to come to talk with both providers and complain about this situation.
[CUSTOMER][NEUTRAL] But I need to have something on right because I, I need to see what, what is on your end.
[CUSTOMER][NEUTRAL] To, to argue with them about it.
[AGENT][NEUTRAL] Uh sure.
[AGENT][POSITIVE] Well, what you have the option, um, is that if you have an online service center account with us you are able to view all your estimation of benefits, um, or the if you it's very easy to sign up if you like to sign up for that is because you can also submit claims online as well um and we could we receive those a whole lot faster and they can get processed and released much quicker than by mail or by fax.
[CUSTOMER][NEUTRAL] I do not.
[CUSTOMER][NEUTRAL] All right. I am asking you if you can send to me, if you can send to me via email.
[CUSTOMER][NEUTRAL] This information and you're not saying either yes or no, you're saying that I can uh subscribe to the, to the website.
[CUSTOMER][NEUTRAL] So can you or can you not send me an email?
[AGENT][NEUTRAL] Uh yes, sir. I was giving you your, your options.
[AGENT][NEUTRAL] Um, yes, sure, I was just giving you the options that you have available for those explanation of benefits. So that is one option is the online service center and then the other option is that I can mail you the copy. Um, I will not be able to email that information as it is considered sensitive, um, so that's why I was trying to give you a quicker option, but I can also mail you the copies of those explanation of benefits to your home address if you like.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yes, I would like that, yes.
[AGENT][NEUTRAL] OK. Can you please verify with me your um your physical address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Sure, Mr. [PII] and I'll go ahead and I will get those mailed out to you. And was there anything else I could do to help you today?
[CUSTOMER][POSITIVE] No, that's it. Thank you.
[AGENT][POSITIVE] Yeah, sure, thanks for calling APL. I hope you have a wonderful day.
[CUSTOMER][NEUTRAL] Right.