AccountId: 011433970860
ContactId: f1188ad5-f082-4880-b476-edf53fd48ef5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 860020 ms
Total Talk Time (AGENT): 226681 ms
Total Talk Time (CUSTOMER): 180675 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=-0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/14/f1188ad5-f082-4880-b476-edf53fd48ef5_20250514T22:50_UTC.wav
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[AGENT][NEUTRAL] Calling APL, my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] Hi, [PII], um, I have put in a claim and I was, I, I.
[AGENT][POSITIVE] I'm glad you called back.
[AGENT][NEUTRAL] Something happened and I couldn't hear you. OK.
[CUSTOMER][NEUTRAL] Yeah, just call back.
[CUSTOMER][NEUTRAL] Yeah, it's got, I'm here.
[AGENT][NEUTRAL] OK, I was asking you for your uh callback number.
[CUSTOMER][NEUTRAL] Yeah, I gave it to you, but maybe I couldn't hear you either, but we're on now, so you want my callback number now?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And your policy number?
[CUSTOMER][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] Uh, in hospital, so would it be the certificate number?
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] OK, 02406268 ML 7.
[AGENT][NEUTRAL] OK, if you could please verify your name, date of birth, and email address.
[CUSTOMER][NEUTRAL] Sure. My uh my name's [PII]. My date of birth is [PII].
[CUSTOMER][NEUTRAL] And my email is [PII].
[AGENT][POSITIVE] Thank you for that one moment.
[AGENT][NEUTRAL] OK, let me pull up the.
[AGENT][NEUTRAL] OK, I'm just pulling up the um paperwork that you sent in so I can see because I can see why they denied it but.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And what type of facility is the Casa Palmera Care Center?
[CUSTOMER][NEUTRAL] Casa Palmera is an inpatient um
[CUSTOMER][NEUTRAL] It's a mental health hospital.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEGATIVE] It was denied because.
[AGENT][NEUTRAL] It says benefits payable under the certificate are limited to those outlined on the schedule of benefits.
[AGENT][NEUTRAL] It's not a covered loss. Um, it very well may be the place of service.
[AGENT][NEUTRAL] Since that is
[CUSTOMER][NEUTRAL] It, it is a
[AGENT][NEUTRAL] Because that is coming up.
[CUSTOMER][NEUTRAL] Now that I've never heard before. I got the, you know, the 3 or 4,
[CUSTOMER][NEGATIVE] denials, but nothing ever said that that was in question.
[CUSTOMER][NEUTRAL] I mean it's a it's a legitimate.
[CUSTOMER][NEUTRAL] Like medical care.
[AGENT][NEUTRAL] OK, so in this case, you would just um you would just file an appeal at this case that way the appeals team can look further and dig further, um.
[CUSTOMER][NEUTRAL] We have doctors and
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] Was that the reason that they.
[CUSTOMER][NEUTRAL] Oh, denied it the 1st 3 times?
[CUSTOMER][NEUTRAL] Before they were just telling me it was a matter of getting the right explanation of benefits to them.
[CUSTOMER][NEUTRAL] And I sent them like everything that I have. And then now it's something else.
[AGENT][NEUTRAL] Well, no, I'm saying based on the denial code that they used.
[AGENT][NEUTRAL] It's saying that, um.
[AGENT][NEUTRAL] The treatment, it was not a covered like like it's not covered, so.
[AGENT][NEUTRAL] And I was just looking at that's why I said you need to file an appeal.
[CUSTOMER][NEUTRAL] Do you know what about it is not covered?
[AGENT][NEUTRAL] The only thing that it looks as though
[CUSTOMER][NEUTRAL] Like what, what are they saying is
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] I don't know. I'm just going by. I just have the information that you have where it says benefits payable under the certificate are limited to those outlined in the schedule of benefits. This is not a covered loss under the plan.
[AGENT][NEUTRAL] And being that you have the inpatient hospital.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So I, so at this point you can file an appeal because if you send it back they're just gonna keep denying it as a duplicate so you have to appeal that way it can go to the appeals team and they can take a look and then they can um dig deeper and request medical records and and just go through the whole process.
[CUSTOMER][NEUTRAL] OK. I, I
[CUSTOMER][NEUTRAL] I wanna make sure because I don't know what to appeal about. I mean if we're sure that they're questioning the facility.
[AGENT][NEUTRAL] But it's looking as though the inpatient, well, actually, now that I look at the first time you sent the claim.
[AGENT][NEGATIVE] It looks as though the hospital stay was fully covered. There, there was no patient responsibility.
[CUSTOMER][NEUTRAL] Like I didn't have to pay anything?
[AGENT][NEUTRAL] I'm looking at the EOB that you sent in, and it's showing under the Casapermera Care Center.
[AGENT][NEGATIVE] Um, the build amount was $5000. They gave you a they must have been an in-network hospital, so you got a discount, so it was only $1270 and the plan paid $1270. So you didn't have any patient responsibility for that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I, I had a deductible of 6000 something. And I think that's the latest, the latest paperwork, the latest paperwork I sent probably showed that.
[AGENT][NEUTRAL] Oh, OK. Well, the, maybe the one I'm looking at.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Oh, OK. I see what you're saying.
[AGENT][NEUTRAL] OK, because the one from the first time, it looks like there there was no patient responsibility.
[AGENT][NEUTRAL] OK, so yeah, you would just need to.
[AGENT][NEUTRAL] Um, sending an appeal so they can, um, have someone take another look at.
[AGENT][NEUTRAL] The claim
[CUSTOMER][NEUTRAL] OK, how do I, can I do it online or do I have to call someone?
[AGENT][NEUTRAL] No, you would just, it's just uh um you basically writing a statement and you can upload it online um how did you submit the other claims?
[CUSTOMER][NEUTRAL] Online
[AGENT][NEUTRAL] OK, so yeah, you would just um write a statement letting them know that you wanted to appeal the decision and then put the claim number on there.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I, I'm
[CUSTOMER][NEUTRAL] It's hard to write an appeal when I don't know.
[CUSTOMER][NEGATIVE] Exactly why they're denying it. It's hard to like
[CUSTOMER][NEGATIVE] You know what I'm saying? I, I don't know what to appeal. I'm not, they're saying it's not covered.
[CUSTOMER][NEGATIVE] Um, and I don't understand why that would not be covered.
[AGENT][POSITIVE] Yeah, I agree, um.
[CUSTOMER][NEGATIVE] You know what I'm saying? How do I appeal it when I don't really even know why they didn't, I don't.
[AGENT][NEUTRAL] Uh, let me.
[CUSTOMER][NEUTRAL] Is anybody that I could talk to, or you could talk to?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, let me send this to my um let me send this to my, well she's gone for the day. I'm gonna send this to my team lead.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Give me a moment to type up this email. One moment please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I've sent that to my team. We once I get a response um tomorrow, I'll give you a call back, but I'm gonna have her just look over that and make sure that it was denied correctly before we have you submit a pill or if it's even gonna be necessary to do that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. Well, outside of that, was there anything else I can assist with today?
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] No, that's it. Thank you for your help. I appreciate it.
[AGENT][POSITIVE] OK, well thank you for calling APL you have a good day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Mhm bye bye.