AccountId: 011433970860
ContactId: fbc6ca6c-dbfb-4d70-b724-26b4132d1cd3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 456230 ms
Total Talk Time (AGENT): 104938 ms
Total Talk Time (CUSTOMER): 136904 ms
Interruptions: 2
Overall Sentiment: AGENT=0.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/fbc6ca6c-dbfb-4d70-b724-26b4132d1cd3_20250207T18:39_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] He had more
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling. I was just wondering as to why a claim wasn't paid.
[AGENT][NEUTRAL] OK. What's your name?
[CUSTOMER][NEUTRAL] Area.
[AGENT][NEUTRAL] And how do you spell your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what's the policy number and do you have the claim number? If so, if you can provide that?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Just uh
[CUSTOMER][NEUTRAL] Yeah, um, policy number is 02488639.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then the claim number is 3554154.
[AGENT][NEUTRAL] OK, what's a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. And what's the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is.
[CUSTOMER][NEUTRAL] [PII] and one second for the date.
[CUSTOMER][NEUTRAL] And then date of birth is.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that information and your question is that why was it denied?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] Well, not paid for.
[AGENT][NEUTRAL] And do you have a copy of the explanation of benefits?
[CUSTOMER][NEGATIVE] Yes, I do it just doesn't um doesn't provide.
[AGENT][NEUTRAL] Turn to the back of that and see if there's anything on the back.
[CUSTOMER][NEUTRAL] Um, it just says if you disagree with the, um, decisions made regarding the claim, you have the right to appeal the decision.
[AGENT][NEUTRAL] Yeah, so in the explanation that I'm looking at, it says that the benefits have been applied towards the $50 calendar year deductible.
[AGENT][NEUTRAL] And that appeal disclaimer on all of our ELBs so you don't show that remark on the ELB?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] That I just read.
[CUSTOMER][NEUTRAL] Um, I just see that it did deduct the $50.
[CUSTOMER][NEUTRAL] But then it just says that the patient's responsibility is 207.
[AGENT][NEUTRAL] OK. Give me a second.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, so there, there, there is a page 2.
[AGENT][NEUTRAL] To the um ELB and the the denial remark is on the back benefits have been applied towards the $50 calendar year deductible.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] For this one, the one you told me to call.
[CUSTOMER][NEUTRAL] From my side they're just saying that.
[CUSTOMER][NEUTRAL] not
[CUSTOMER][NEUTRAL] That's the only reason that they can you know.
[CUSTOMER][NEUTRAL] Doesn't mean they're only paying $50 for it?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes, this is [PII] with American Public Life.
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEGATIVE] Hi [PII], um, so yeah, because we just didn't understand how because on the EOB the insurance is not paying anything for it.
[CUSTOMER][NEUTRAL] So we just wanted to know why.
[AGENT][NEUTRAL] Give me 1 2nd.
[CUSTOMER][NEUTRAL] And she
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Just bear with me here. I'm still looking.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] U.
[AGENT][NEUTRAL] Alright, the calendar year maximum under this policy is 500 per calendar year. The benefit is exhausted. Mhm.
[CUSTOMER][NEUTRAL] 00, OK, can you tell me what the schedule they're using?
[AGENT][NEUTRAL] And it looks like
[AGENT][NEUTRAL] It's Carrington PPO and then also I think that there was another claim process for this state of service on [PII], so you're gonna be receiving that shortly and then it would it'll it'll indicate that the maximum calendar your benefit is exhausted.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK, and it will show it there.
[CUSTOMER][NEUTRAL] It's been reached, oh, OK, because we, yeah, because on this one it doesn't say anything, OK.
[AGENT][NEUTRAL] Uh, yeah, correct, I see that.
[CUSTOMER][POSITIVE] OK, sounds good.
[AGENT][NEUTRAL] So they went back in and right, so you should receive the updated explanation of benefits shortly. Anything else? And what's your name?
[CUSTOMER][POSITIVE] And you looked at it. Thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Spell it for me.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, [PII], any other questions?
[CUSTOMER][POSITIVE] No, that's it. Thank you.
[AGENT][POSITIVE] You're welcome thanks for calling APL have a good day.
[CUSTOMER][NEUTRAL] OK bye bye.