AccountId: 011433970860
ContactId: f8a7ff3c-a4be-43a9-a170-877b4603b85f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1017880 ms
Total Talk Time (AGENT): 523403 ms
Total Talk Time (CUSTOMER): 391760 ms
Interruptions: 9
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/16/f8a7ff3c-a4be-43a9-a170-877b4603b85f_20250516T18:35_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEGATIVE] Yeah, um, I have a question about my claim that I believe was denied and I don't really understand.
[CUSTOMER][NEGATIVE] Uh, why it was denied. Is that something you can help me with?
[AGENT][NEUTRAL] OK, so you submitted a claim to us for for yourself that was denied and you're wanting to find out why, is that correct?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][POSITIVE] Yes ma'am, I can help you with that. And who am I speaking with?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you, Ms. [PII], what's a good callback number for you?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, and your policy number, please?
[CUSTOMER][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] Policy number is 02406268ML7.
[AGENT][NEUTRAL] OK, thank you. One moment while I get all of your information pulled up and then once I do, Miss [PII], I will have to verify information with you first for security and also any information that I provide for you will be a verification of benefits and not a guarantee of payment. So first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you and also your home mailing address.
[CUSTOMER][NEUTRAL] Um [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, so that is not what we have on file for you, Miss [PII].
[CUSTOMER][NEUTRAL] This is
[CUSTOMER][NEUTRAL] OK, I have the [PII] uh address is what the insurance claim was opened with, and this is gonna be the 3rd time that I've changed. If you can change it, this will be the 3rd time that I've had to change my address.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I, let's go ahead and verify the address that's on file. Let's finish verifying your information and then I'm gonna explain something to you about your address. So first off, go ahead and verify that address that is on file for you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] OK, would you just repeat the street number one more time for me?
[CUSTOMER][NEUTRAL] Yeah, uh, [PII], yeah.
[AGENT][NEUTRAL] OK, thank you. All right, the, uh-huh, OK, that's all I need. OK and then your phone number that is on file is the same as the one you gave me, so that is your best contact number that we should have, is that correct?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's it.
[AGENT][POSITIVE] Thank you and lastly your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you so I can see that the system has been changing your address back and the reason for that is because your employer is still submitting your the enrollment file information that has the [PII] address on it and so because of that, the sys that is overriding the changes that we have made.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So until they, I will be happy to go ahead and change it for you again um back to what your current or correct address is but until they get it changed, it's going to continue to.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] To change back.
[CUSTOMER][NEUTRAL] Kick it back.
[AGENT][POSITIVE] Mhm, it is. So I'll be happy though.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] you know what, it's my
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I'm gonna say it's my son's address. So it's probably like if stuff goes there, he'll give it to me. It's just not coming straight to my address. So.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Again, I can see where it has been changed several times and I can also see where the system is um automatically changing it back because we're receiving your information.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] From your employer through the enrollment file with the 13835 so it's up to you if you if you want me to change it or if you want to if that's entirely up to you but uh if you do want it permanently changed, yes ma'am, you will need to get with your employer and let them know to update it.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, I understand that.
[CUSTOMER][NEUTRAL] Yeah, I understand that.
[CUSTOMER][NEUTRAL] I'll do that.
[AGENT][NEUTRAL] OK, so do you want me to change it?
[CUSTOMER][POSITIVE] Sure, I'll do that. Thank you.
[AGENT][POSITIVE] Yes, ma'am, you're welcome.
[CUSTOMER][NEUTRAL] You know what, let me change it with my employer first.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then I'll call back and have it changed.
[AGENT][NEUTRAL] OK. All right then.
[AGENT][NEUTRAL] Alright, so what is the date of service, Miss [PII], that you're calling about and the bill amount?
[CUSTOMER][NEUTRAL] Um, it is, uh, [PII].
[AGENT][NEUTRAL] OK, of this year.
[CUSTOMER][NEUTRAL] Um, and I have the insure the, uh, claim number if that would be helpful.
[AGENT][NEUTRAL] It's the, is the year, it will, but is it for this year? Is it for 2025, 224, 2025? OK.
[CUSTOMER][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And what is the total bill amount on your claim?
[AGENT][NEUTRAL] Ms. [PII].
[CUSTOMER][NEUTRAL] For the gap insurance or for the entire?
[CUSTOMER][NEUTRAL] The entire claim is like 127,000.
[CUSTOMER][NEUTRAL] Something close to that.
[CUSTOMER][NEUTRAL] And my, um, my portion that, uh, I guess it would be the deductible with 6000.
[CUSTOMER][NEUTRAL] And then, or 6000 plus or minus. And then the um
[AGENT][NEUTRAL] OK, so the total bill amount was how, but what was the big, the big amount?
[CUSTOMER][NEUTRAL] Uh, if you need the exact amount, I can look that up, but it was like 127,000.
[AGENT][NEUTRAL] Do you have that?
[AGENT][NEUTRAL] Well, we have
[AGENT][NEUTRAL] It looks like we have received this claim from you multiple times. So that's why I'm need which claim number are you specifically wanting me in?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] To look at.
[CUSTOMER][NEUTRAL] 360-1581
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK. And that's the one that was most recently reviewed. And yes, ma'am, that one has been denied. Give me a moment to get the remarks pulled up.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you can also see these remarks as well in your portal. Uh, your explanation of benefits will be in there. This claim just went through, well, it should be in there today. You should be able to see this explanation of benefits by now and the remarks will be on page 2 of your claim form.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So there were multiple dates of service on this claim, so there are multiple different denial reasons. Um, one of them for a data service of [PII] states that benefits are payable under this 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] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, now what, what part is.
[CUSTOMER][NEUTRAL] Is I'm not sure what part of the claim is not eligible.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me look at some of these other remarks first because.
[AGENT][NEUTRAL] OK, so I can see on here it shows that this service was provided in a residential treatment facility.
[AGENT][NEUTRAL] And a residential treatment facility is not a covered facility as outlined in your policy certificate. Therefore, benefits are not payable.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. It's
[CUSTOMER][NEUTRAL] For uh men for a mental or emotional disorder.
[CUSTOMER][NEGATIVE] Um, and it's, it's impatient. There's, I don't know how it's.
[CUSTOMER][NEUTRAL] How, uh, this.
[CUSTOMER][NEUTRAL] Specific place is being
[CUSTOMER][NEUTRAL] Put into it that uh category of a residential.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Treatment facility. It's a an inpatient.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Uh, medical, mental, and emotional disorder, uh, treatment place.
[AGENT][NEUTRAL] Now, according to the medical information, again, yes, ma'am, it's it's showing that this is a residential treatment facility. That's how this facility is classified. Now, you can always file an appeal, Ms. [PII].
[CUSTOMER][NEUTRAL] So I'm not sure why.
[AGENT][NEUTRAL] And you have 180 days from the date of the decision to submit your appeal in writing to us.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you can include any information that you would like to do that, the claim, the appeal.
[CUSTOMER][NEUTRAL] OK. How
[AGENT][NEUTRAL] Can be mailed, it can be faxed, um, it could be uploaded, but you need to make sure that it's clearly marked as an appeal.
[AGENT][NEUTRAL] So that it's not denied as a duplicate claim. No, ma'am. We cannot accept any form of claims information via email due to security.
[CUSTOMER][NEUTRAL] OK. So can I email it?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It either has to be.
[CUSTOMER][NEUTRAL] OK, so fas.
[AGENT][NEUTRAL] Mhm. Mailed or uploaded to your portal.
[CUSTOMER][NEUTRAL] What is the mailing address?
[AGENT][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] [PII]. Mhm.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Well, no.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the uh zip code is [PII].
[AGENT][NEUTRAL] [PII] and again please put attention appeals department.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] So if I address that in my appeal, that's the only issue that I need to address.
[AGENT][NEUTRAL] If you are welcome to include anything. You can include, um, you know, your claim number obviously that you're requesting the appeal for and if there's any additional information that you want to provide, you can do that as well.
[AGENT][NEUTRAL] But there's not a specific.
[CUSTOMER][NEUTRAL] OK, as for what I'm asking.
[AGENT][NEUTRAL] Now there's not a specific form or anything for an appeal.
[CUSTOMER][NEUTRAL] OK, what I'm asking is the issue is they're not categorizing.
[CUSTOMER][NEUTRAL] This
[CUSTOMER][POSITIVE] Uh, impatience.
[CUSTOMER][NEUTRAL] Uh, hospital, they're, they're not categorizing it. That's the issue I need to address that it has not been categorized as something that would be covered. So that's the information I need to give, or is there anything else that they're uh questioning about the claim?
[AGENT][NEUTRAL] No, ma'am. It's the place of service is not covered.
[AGENT][NEUTRAL] Under your policy. Yes, ma'am. That is how it's showing. And again, you can see the remarks that I went over with you on that explanation of benefits in your portal because I can see you are set up on the portal.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I am. You know what, sometimes I can get to that, and then sometimes I'm not able to get to it. I'll click on the uh claim number and nothing comes up.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sometimes, if you, sometimes if you click, if it's something that's just recently, like within a day been processed, you may not see it yet because it takes a little more time. Like um I think you're also opted in.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] 41 2nd.
[AGENT][NEUTRAL] So you receive text alerts when your claims have been processed. So you're gonna receive that text alert before you will actually be able to see it in your portal because it typically has to go through our overnight processing and then by that next afternoon, you should be able to see it then.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. So if I, just so I understand, if I go into the portal, I click on the number, it should show me the reasons why it was, there should be access to that of the information.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, ma'am, because, mhm.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, if I'm not able to see that now.
[CUSTOMER][NEUTRAL] What would, how do I, uh, correct that?
[AGENT][NEUTRAL] So you're saying that you can't see it?
[CUSTOMER][NEUTRAL] Cause I just checked just now.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And one is also gonna be mailed. One is also being mailed to you?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] They will always go in the mail as well as in the portal.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] But I'm not sure at the moment why you can't see that yet.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Because it should download a copy of it. I'm able.
[AGENT][NEUTRAL] To see it, let's see, let's see. Yeah, I, I'm able to see that your EOB is there.
[CUSTOMER][NEUTRAL] Do you, um,
[AGENT][NEUTRAL] Now are you on a computer or on your phone?
[CUSTOMER][NEUTRAL] Do you have any way of
[CUSTOMER][NEUTRAL] I'm on the app in my phone.
[AGENT][NEUTRAL] That's OK, so that's why you're not gonna be able to see that from a phone. You're gonna have to log in from a computer, Miss [PII], in order to be able to see that.
[CUSTOMER][NEUTRAL] OK. So since you can see it, can you tell me when I make the appeal, what issues do I have to address? One is gonna be the facility type. And then is there anything else that I need to uh address?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh let's see.
[AGENT][NEUTRAL] The denial remark on here is showing that it's your place of service, which is showing as a residential treatment facility is not a covered place of service under your supplemental policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So that's what I need to address.
[AGENT][NEUTRAL] And therefore, right, and therefore any additional anything else related to it is not covered either since it's not a covered place of service.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK. Um, is it the fact that
[CUSTOMER][MIXED] OK. I'll take care of it. Thank you. I can tell you're very upset and you're being very unprofessional this way. So, what is your name?
[AGENT][POSITIVE] Oh, no, ma'am. I'm so sorry. No, ma'am, I'm.
[AGENT][POSITIVE] No, ma'am. I'm not at all. I'm so sorry. My name is [PII], but I am so sorry. Again, Miss [PII], my name is [PII] and I'm not exasperated.
[CUSTOMER][NEUTRAL] What is your name?
[CUSTOMER][POSITIVE] Thank you, [PII].