AccountId: 011433970860
ContactId: ffd1c2c9-3a8a-4789-8ef6-0a684ff4b5eb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 920520 ms
Total Talk Time (AGENT): 255015 ms
Total Talk Time (CUSTOMER): 303450 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/13/ffd1c2c9-3a8a-4789-8ef6-0a684ff4b5eb_20250513T14:50_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] at RJ Blanchard Benefit Services. We got permission from one of our clients for me to call and see about if y'all rejected one of the benefits on his accident claim.
[AGENT][NEUTRAL] OK, alright, so you're with the provider's office?
[CUSTOMER][NEUTRAL] I'm with the broker's office.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Um, do you have the policy number for the patient or a member?
[CUSTOMER][NEUTRAL] Policy number, let me get it for you.
[CUSTOMER][NEUTRAL] It's gonna be 244-97006.
[AGENT][NEUTRAL] OK, give me one moment.
[AGENT][NEUTRAL] And do you have a good callback number, [PII]?
[CUSTOMER][NEUTRAL] Yeah, it's gonna be [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And then, what is your email address, [PII]?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And do you have the member's name and date of birth?
[CUSTOMER][NEUTRAL] Yes ma'am, his name is [PII].
[CUSTOMER][NEUTRAL] And let me get his date of birth.
[CUSTOMER][NEUTRAL] His date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And what date of service is that for? Do you have the claim number?
[CUSTOMER][NEUTRAL] I have the claim number, it's gonna be 3,576,510.
[AGENT][NEGATIVE] It looks like we had denied it and sent a request for the form to be completed.
[AGENT][NEUTRAL] Um, let me see what we received originally. Let's see.
[AGENT][NEUTRAL] OK. I see the form.
[AGENT][NEUTRAL] OK, let me get you over to our claims department because I'm not sure I see the form here, so I'm not sure what's.
[AGENT][NEUTRAL] What they're needing. Um, is that OK? Can I transfer you over there?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, that's fine.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] Calling APL, this is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi, [PII], this is [PII] on the care team. I've got a broker on the line who I verified. They're wanting to check claim status on one of their, um, one of our members and, uh, so I, I'm not sure what's required on the claim. I was gonna see if you can help them.
[CUSTOMER][NEUTRAL] What's the policy number?
[AGENT][NEUTRAL] Policy number is 24497006.
[CUSTOMER][NEUTRAL] And who is the claim for?
[AGENT][NEUTRAL] The claims for [PII].
[CUSTOMER][NEUTRAL] OK, and they're just checking on the status of the claim?
[AGENT][NEUTRAL] Yeah, I, I, I see the denial reason for 3,576,510, but I don't understand what's required because I see the form.
[CUSTOMER][NEUTRAL] Let me pull it up, give me one moment.
[AGENT][NEUTRAL] Attached to the claim, so I don't know what we.
[CUSTOMER][NEUTRAL] See what we, what we got in.
[CUSTOMER][NEUTRAL] OK, so it looks like they needed the enclosed claim form completed on that one. So looks like we must have received it. There was a benefit issued under claim 3592793 for those dates.
[CUSTOMER][NEUTRAL] That was on that denial claim from date of service of [PII] up until.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII] that claim was processed. It looks like a benefit was issued for 1300.
[AGENT][POSITIVE] OK, OK, perfect. OK. Uh, she was calling on the denial, so I was looking at those. OK, perfect. Thank you so much.
[CUSTOMER][POSITIVE] Yeah, oh, you're welcome.
[AGENT][POSITIVE] Thank you, bye-bye.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] OK, sorry about that. It looks like we did get the information. So it, we had made a direct deposit of 1300 on [PII].
[AGENT][NEUTRAL] 25.
[CUSTOMER][NEUTRAL] So he said he received um a deposit, but he was wondering about the amputation cause he got his finger amputated due to this accident.
[AGENT][NEUTRAL] OK, um, let me see.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Trying to read these notes. Uh, one moment.
[AGENT][NEUTRAL] So his finger was completely amputated, right?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] What the definition is of amputation. If it was just the tip of his thumb, I don't know if that would qualify, so let me check.
[CUSTOMER][NEGATIVE] I'm pretty sure his whole thumb was removed, not the tip.
[AGENT][NEUTRAL] Um, well, the medical notes, they just tip.
[CUSTOMER][NEUTRAL] OK, well maybe it was just a tip.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] One finger or toe, see that.
[AGENT][NEUTRAL] Yeah, I bet it's because it says just the tip, um.
[AGENT][NEUTRAL] Said right tip amputation. So let me see. I'm sorry, let me get you back to claims again. I'm so sorry about that. I, when I looked at that claim number, it was denied, so that was what I was looking at. Hold on one moment, OK?
[CUSTOMER][NEUTRAL] It's OK.
[CUSTOMER][NEUTRAL] That's fine.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi, [PII], this is [PII] in the care team. I've got a broker's office again on the line, um, checking on a claim status, um, if you can help me with that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What's the policy?
[AGENT][NEUTRAL] Uh, policy is.
[AGENT][NEUTRAL] 244-97006.
[CUSTOMER][NEUTRAL] OK, and which claim are we looking at?
[AGENT][NEUTRAL] Uh, we're looking at the 359279-3.
[AGENT][NEUTRAL] He states he got his right thumb amputated, but when I look at the notes, it says tip of right thumb, so I'm thinking that's why he's not getting
[AGENT][NEUTRAL] The accident benefit, I wasn't quite sure.
[CUSTOMER][NEUTRAL] Probably let me see.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Uh, let me pull up the policy because I'm pretty sure that this policy states that um.
[AGENT][NEUTRAL] Well, I tried
[CUSTOMER][NEUTRAL] To be considered a full dismemberment, the joint, it has to be taken at the joint closest to the hand. So if you're just having that first.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEGATIVE] From the tip to that first joint it's not gonna qualify.
[AGENT][NEUTRAL] OK, we will play the, that's dislocation. OK, I didn't know what to, I looked up amputation, but I couldn't find anything on that.
[AGENT][NEUTRAL] And that's why I was
[CUSTOMER][NEUTRAL] OK, so single dismemberment, it's on page 10 if you're looking at on base, um, we will pay the single dismemberment benefit amount and the schedule benefits covered sustains the single dismemberment as a result must occur within 90 days.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and then when you look at finger and toe, um, still says that it has to occur within 90 days, but it doesn't actually define the dismemberment, so you have to go to the definitions to kind of see what qualifies.
[CUSTOMER][NEUTRAL] And that is going to be under.
[CUSTOMER][NEUTRAL] Definitions which start on page 26.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] When you look at dismemberment.
[CUSTOMER][NEUTRAL] Um, it's gonna be under single dismemberment because it looks like it has double and single.
[CUSTOMER][NEUTRAL] Defined separately so.
[AGENT][NEUTRAL] sustains the
[CUSTOMER][NEGATIVE] QRS OK, loss of hand, loss of food or loss of sight. Oh my gosh, now we have to go to those destinations. I hate when they do that. I just put it all up under one.
[CUSTOMER][NEUTRAL] OK, so let's see, loss of both hands, that's at the joint, feet, foot.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, it's not.
[CUSTOMER][NEGATIVE] Defining um there just finger and toe dismemberment. It is on there. It's on page 30, uh, close to the top. One or more finger, fingers or toe toes is removed or above the joint where it is attached to the hand or foot. So it has to be that joint closest. So if he is, it just had that tip, just had a bunch of bunch of black hats like flop by my house. It's weird.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, but if it was like basically just at that first joint and not at the joint closest to the hand, which I believe, you know, it's gonna be real, real, like it's gonna be essentially the entire thumb, um, or finger, whichever one it is, then it's not gonna qualify for the dismemberment benefit.
[AGENT][NEUTRAL] I
[AGENT][POSITIVE] OK, perfect. OK, that's what I was needing perfect I'll let her know thank you so much.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] You're so welcome.
[AGENT][POSITIVE] Thank you, bye-bye.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] OK, so sorry about that. OK, did get, I was trying to search in the policy and I couldn't find where it defined dismemberment it does though. It's on page 28 of their policy certificate.
[AGENT][NEUTRAL] And so it does define finger dismemberment. It has to be removed at or above the joint where it is attached to the hand. So that, so just the tip of the thumb would not qualify as an actual dismemberment.
[CUSTOMER][NEUTRAL] So, it says it was amputated through the interpolangeal joint.
[AGENT][NEUTRAL] Um, let me
[CUSTOMER][NEUTRAL] And
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] So that looks like it is the first joint.
[AGENT][NEGATIVE] Not near the hand.
[CUSTOMER][NEUTRAL] OK, so it has to be all the way to the hands.
[AGENT][POSITIVE] Correct, essentially, yeah, yeah, just that first joint, yeah. Sorry about that.
[CUSTOMER][NEUTRAL] Not just to a joint, OK.
[CUSTOMER][MIXED] It's OK. I just wanted to get the specifications of why it was rejected.
[AGENT][NEUTRAL] Yeah, and if you want to um reference page 28 on the policy certificate, that's where it defines that.
[CUSTOMER][NEUTRAL] So I can tell him.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I'll be sure to let him know.
[AGENT][NEUTRAL] OK. Anything else I can help with, [PII]?
[CUSTOMER][POSITIVE] Alright, that was all I needed.
[AGENT][POSITIVE] OK, thank you so much. Thank you so much for calling and I hope you have a great day.
[CUSTOMER][NEUTRAL] That's it.
[CUSTOMER][POSITIVE] Thank you bye bye.