AccountId: 011433970860
ContactId: 033cbb39-0895-4ffc-84fb-ce324833bdd3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 695320 ms
Total Talk Time (AGENT): 325663 ms
Total Talk Time (CUSTOMER): 224546 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/2025/05/21/033cbb39-0895-4ffc-84fb-ce324833bdd3_20250521T15:38_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Um, I'm calling about a claim that was recently submitted for [PII].
[CUSTOMER][NEUTRAL] [PII] birth date [PII].
[CUSTOMER][POSITIVE] And he's right here so he can verify that I'm able to speak with you.
[AGENT][NEUTRAL] OK, I'm happy to check on a claim. Uh, do we have a policy number?
[CUSTOMER][NEUTRAL] Hi
[CUSTOMER][NEUTRAL] Yep, 02499.
[CUSTOMER][NEUTRAL] 224
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Alright, and then I'll need to verify please the address and email address.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] I sent you, [PII]. Our email is [PII].
[AGENT][POSITIVE] All right, thank you so much. OK.
[AGENT][NEUTRAL] So it looks like there was a recent claim submitted on [PII] and then it was processed on [PII], is that the one that we're calling on?
[CUSTOMER][NEGATIVE] Yes. So we received a $50 check. I'm not even sure what that's for, but all the other explanations, I guess I'm not sure what in the heck does his monthly premium cover if it doesn't cover a preventative physical where he went into the doctor, they drew blood, told him he had type 2 diabetes and cholesterol issues. He had to go for a recheck for the diabetes. The Quest Diagnostics wasn't covered. Uh, nothing seems to be covered. I'm not even sure.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] If you're reimbursing us his co-pays, if that was what the $50 is for, I don't know what we're paying a monthly premium for. The man has to go for a colonoscopy. What will be the price for that? Because that's preventative. So, I, I don't know, I'm getting close to wanting to just cancel this policy because it's not covering anything.
[AGENT][POSITIVE] Yeah, I'm sorry for the frustration on it, so.
[AGENT][NEUTRAL] It looks like there were some portions of it that look like we're saying no diagnosis code was provided.
[AGENT][NEUTRAL] Um, so we needed, it looked like an itemized bill with a diagnosis code.
[AGENT][POSITIVE] It looks like well
[CUSTOMER][NEUTRAL] OK, well that would.
[AGENT][NEUTRAL] Go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] Can you go back to a line of clinics? Yes, I, I get that, that the codes are a lot of the problems a lot of the times, which I don't have control over, right? That's the clinic itself. Can you go guys go back to the line of clinic and tell them, or is that something I have to do?
[AGENT][NEUTRAL] Well, I mean, I feel like the provider should be filing the claims on your, on his behalf for the services.
[CUSTOMER][NEUTRAL] Well, and they did, and it seems like it took forever for anything paperwork wise to come to us until the clinic itself sent us a bill, which showed pretty, I don't know if you have all the paperwork there, pretty much showed that APL didn't cover anything. So, if it's a code issue, then I will get on that clinic. I mean,
[CUSTOMER][NEUTRAL] Um, what would they need to code it as?
[AGENT][NEUTRAL] So, we need, it looks like the itemized bill with the diagnosis code. Um, the diagnosis code is what is needed.
[CUSTOMER][NEUTRAL] OK, that's weird because what does the itemized bill show? It doesn't have a diagnostic code.
[AGENT][NEUTRAL] Well, there, there's a difference, yeah, there's a difference between a procedure code and a diagnosis code. A procedure code is a code that is given for the things that were done. So, there's a code for taking blood, a code for all of those things. Diagnosis code is what was the end result of all those procedure codes.
[CUSTOMER][NEUTRAL] I mean, I, I sent all the records of what.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And are you saying if you had that we uh OK go ahead.
[AGENT][NEUTRAL] So
[AGENT][NEGATIVE] So I'm saying that that was right. I'm saying that that's part of the denial. Now, the plan itself doesn't have a wellness screening benefit. Um, I don't know if he was aware of this when he signed up for it, but it's a limited medical benefit plan. It's not a major medical.
[CUSTOMER][NEUTRAL] OK, diagnosis closed and uh.
[CUSTOMER][NEUTRAL] It's.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So there's a huge difference.
[CUSTOMER][NEGATIVE] Well, that is deceiving.
[CUSTOMER][NEUTRAL] Yeah, well, I know that we were told that there would be no deductible, uh, it's no deductible plan, but uh
[CUSTOMER][NEUTRAL] So why, so how much more does he have to pay to have wellness exam stuff covered?
[AGENT][NEUTRAL] So the plan only covers 10 amount of visits, only pays so much towards whatever you're having done. It's not a percentage like a major medical, which most people are familiar with where you're paying just a percentage of the cost. So, we don't have any idea what a doctor or facility is gonna charge you for a service. That's something set out by that doctor or facility.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] His plan itself pays for hospital admission, physician's office, things of that nature. For example, the physician's office visit, you're allowed 3 a calendar year, 3 visits total, and it's gonna pay $50 towards the visit. That's what the $50 was. If the doctor charges $400 for the visit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] It's up to them to decide what your responsibility would be from the difference of that.
[CUSTOMER][POSITIVE] All right. OK, we're good.
[AGENT][NEGATIVE] So that's why there is no deductible, there is no co-pay, there is no any of that because it's just paying the set amount. It's not gonna pay anything over that.
[CUSTOMER][NEUTRAL] So basically it's paying $150 a year, 3 hospitals, 3 doctors visits at $50 a visit.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] I'm paying $300 a month for you guys to pay out 150. The rest is up to me.
[AGENT][NEUTRAL] That's what the plan pays towards the physician's office visit, yes.
[CUSTOMER][NEUTRAL] It's what you just
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So I have to get insurance.
[AGENT][NEUTRAL] So if you would like me to send you the policy certificate, so you can look at the schedule, the benefits to see what's on it, I'm happy to do that. Um, it lays it out as far as the benefit name, the benefit amount, it's all listed in there if you would like a copy.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Yeah, that would be good. Yeah, we never got that.
[AGENT][NEUTRAL] So is it OK if I send that to your email?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, that's fine.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so, uh, policy certificates on its way to the email address on the policy, so you guys should have that in a few moments.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, the scheduled benefit scheduled page of benefits, um, like I said, is where you will see the breakdown of the coverage in regards to the claim that was submitted, the only thing that was needed was the itemized bill with the diagnosis code for one of the denials. It does look like.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] But
[AGENT][NEGATIVE] The rest of it is looking as far as there was nothing additional payable. They were just not covered.
[AGENT][POSITIVE] Benefits on the plan.
[CUSTOMER][NEUTRAL] OK, so there's nothing further that I can do to get any of what I submitted covered?
[AGENT][NEUTRAL] The only thing that you could do is go back to um let me see that's one.
[CUSTOMER][NEUTRAL] And also he recently saw a neurologist regarding migraine headaches. I imagine we're gonna be paying out of pocket for that too.
[AGENT][NEUTRAL] Let me see what this procedure code was.
[CUSTOMER][NEUTRAL] Where
[AGENT][NEUTRAL] OK, so the only other thing that you could, you can submit would be um from Alina Health.
[AGENT][NEUTRAL] Um, if you get the itemized bill with a diagnosis code on it, you could submit that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Because that was one of the denials for a portion of the office visit and that would pay the $50.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] That was the only thing else listed in this claim that looks like would be available for reconsideration, and the date of service was on [PII].
[CUSTOMER][NEUTRAL] OK. All right.
[CUSTOMER][POSITIVE] I, I think I know what that is. All right, thank you.
[AGENT][NEUTRAL] You're welcome. Is there anything else that you'd like me to check on or?
[CUSTOMER][NEUTRAL] Um, and did anybody submit a, uh, another claim from, from a [PII] visit?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Right, of this year.
[AGENT][NEUTRAL] I mean
[AGENT][NEUTRAL] No, I don't see anything. Just this one claim has been submitted towards this policy. There are not any other claims.
[CUSTOMER][POSITIVE] OK. All right. Thank you. I appreciate your help.
[AGENT][POSITIVE] You're very welcome. I hope you have a nice rest of your day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] You too. Thank you. Bye-bye.
[AGENT][NEUTRAL] Mhm