AccountId: 011433970860
ContactId: f49bf8bb-8138-4a68-abd7-e31fd957629a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 468179 ms
Total Talk Time (AGENT): 287591 ms
Total Talk Time (CUSTOMER): 82753 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/29/f49bf8bb-8138-4a68-abd7-e31fd957629a_20250529T19:27_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], um, I have a broker on the phone, uh, calling about a claim for insured children, and there was one where, um, looks like the claim processes benefits of max for the plan year. It's on a, um, critical illness plan, but it's only showing that they've only used one wellness for last year, but not for this year, so I was confused.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, what's the policy number?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] 248-050-6
[AGENT][NEUTRAL] OK, let's
[CUSTOMER][NEUTRAL] And it's on part 2.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] 1 per person up to 4 per family.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, and I saw that but only so I didn't see any others that uh he had for this year, so I was kind of confused on it as well.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Yeah, it doesn't look like they've used any for [PII].
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Child wellness screening. Let me see what that.
[AGENT][NEUTRAL] Says exactly.
[AGENT][NEGATIVE] This benefit has been exhausted for the plan here.
[AGENT][NEUTRAL] Um, what?
[CUSTOMER][NEUTRAL] Right. Yes, I was kind of confused.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] I know if it was probably for some other reason.
[CUSTOMER][NEGATIVE] Besides that, because it didn't look, look strange to me.
[AGENT][NEUTRAL] It doesn't look like it. I'm gonna double check and make sure they didn't put in a wrong.
[AGENT][NEUTRAL] Date of service or something.
[AGENT][NEUTRAL] Like maybe they put [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] But it actually shows [PII] on the claim, and that's just an error with
[AGENT][NEUTRAL] You know what I mean?
[AGENT][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] No, it's [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] 324, 25 wellness checkup and then.
[AGENT][NEUTRAL] COVID, flu and RSV test.
[CUSTOMER][NEUTRAL] First, I thought it was that maybe cause I saw COVID, but I didn't know.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] If that would be covered or not, but I didn't know.
[AGENT][NEUTRAL] Well, so for this policy, a health screening.
[AGENT][NEUTRAL] Um, is like any type of wellness exam or test, so it can be a wellness test, a physical or any generally medically accepted screening test as an outpatient used to evaluate risk or promote prevention of a covered condition.
[AGENT][NEUTRAL] So the fact that on the claim they put that they were there for a wellness exam um we typically you know don't ask for verification but they did submit an after visit summary.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on the after visit summary, let me see, I believe it says wellness.
[AGENT][NEUTRAL] Specifically
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So yeah because like I reviewed the benefits used 02480506 for [PII] they've not used any of these, so this is a processing error so you can let them know that.
[AGENT][NEUTRAL] I wouldn't say that we're gonna pay it. I would just say that the claim is gonna be reviewed like.
[AGENT][NEUTRAL] Sent back for review.
[AGENT][NEUTRAL] Because of it, and then I'm, I'm fairly certain that this obviously is a payment because they haven't exhausted their benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Actually hang on let me.
[AGENT][NEUTRAL] Let me make sure this is not plan year.
[AGENT][NEUTRAL] Because that could be the difference.
[AGENT][NEUTRAL] Yeah, any one plan year.
[AGENT][NEUTRAL] That's the difference, OK, um.
[AGENT][NEUTRAL] I'm gonna read this remark code again.
[AGENT][NEUTRAL] Yeah, so.
[AGENT][NEUTRAL] Plan year is not January to December. Plan year is from their effective date to the day before the anniversary of the next effective date. So when you look at this policy, they were effective on [PII].
[AGENT][NEUTRAL] So, it would, you would have to look for benefits for this policy from [PII] and it shows that they have used the screening.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For that plan year, that's the difference. It's not calendar year.
[CUSTOMER][NEUTRAL] OK. So since, um,
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] The date of service was before the [PII] or I'm sorry [PII] of this year, then he's met it for the plan year.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Correct, and they there should be a definition for playing year in the policy. I can double check that really quick if if they're confused by that where you can kind of point them to that because under wellness benefits it will say total number of claims payable per plan year. There are no exception messages saying that this group or whatever um goes by calendar year and then um so that is under those benefits are under section 4.
[AGENT][NEUTRAL] And then which is page I can give you the page number in the policy it's page 7.
[AGENT][NEUTRAL] And then the definition for plan year is going to be found under section 10.
[AGENT][NEUTRAL] Page.
[AGENT][NEUTRAL] Where is it at?
[AGENT][NEUTRAL] Alphabetical order. [PII], keep on going. OK, page 19 and it says the time period commencing on the policy effective date and ending the day before the next policy anniversary and thereafter each 12 month period commencing on the anniversary. So basically from effective date to the day before the the following year's anniversary effective date.
[AGENT][NEUTRAL] So that would be that [PII] they've already used one for date of service [PII], so this plan year is exhausted.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] That's, that's the, that's the key word there.
[CUSTOMER][POSITIVE] All right, thank.
[CUSTOMER][POSITIVE] OK. All right, thank you so much.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] All right bye.
[AGENT][NEUTRAL] All right, bye-bye.