AccountId: 011433970860
ContactId: 05fe690c-4561-40ca-8695-0dad230d2ea4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 951400 ms
Total Talk Time (AGENT): 429365 ms
Total Talk Time (CUSTOMER): 416101 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/07/05fe690c-4561-40ca-8695-0dad230d2ea4_20250407T14:29_UTC.wav
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[AGENT][POSITIVE] Thank you for calling ATL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, good morning. I'm calling because I wanted to get some information um regarding the plan that I have, um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Would you prefer my, oh wait, where is it? My name or I have a group number?
[AGENT][NEUTRAL] OK, if you can give me your name and your policy number or your um certification number that's on the card?
[CUSTOMER][NEUTRAL] Oh yes, that I do see. So my name is [PII].
[CUSTOMER][NEUTRAL] And then it it gives me 2, it has an in-hospital benefit cert number and then it has an outpatient benefit number. Which one would you like?
[AGENT][NEUTRAL] Either one would be fine.
[CUSTOMER][NEUTRAL] OK. So the first one is 02069775, the letter M as in Michael, L as in Larry, 7.
[AGENT][NEUTRAL] OK, thank you very much for that information. OK, Ms. [PII], we'll need to verify your policy. Can you please give me your date of birth?
[CUSTOMER][NEUTRAL] Uh yes, it's [PII].
[AGENT][NEUTRAL] And then I'll also need your address, phone number, and email address that we have on the policy for you.
[CUSTOMER][NEUTRAL] Sure. Address is [PII]. Phone number is [PII] and email should be [PII].
[AGENT][NEUTRAL] Thank you, Ms. [PII] and if our call is disconnected, can I call you back on the number you just verified for me?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. All right, so I do show that a claim was sent in this morning in the online service center.
[CUSTOMER][NEUTRAL] Uh, yes, I did that in response to the letter I received.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, what did the letter state that you received?
[CUSTOMER][NEUTRAL] Um, it was telling me that I had to send back the, uh, like a detailed of what was, um, the invoice, the services invoiced.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, ma'am. OK.
[CUSTOMER][NEUTRAL] So I called the urgent care and I told them that, that I needed, I read it to them like it was on the letter and they sent me that in the mail.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] Awesome. OK, good deal.
[AGENT][NEUTRAL] Alright, so that's we did receive that today. Are you just looking for benefit information like.
[AGENT][NEUTRAL] What your policy covers or?
[CUSTOMER][NEUTRAL] Um, I guess in a way I just wanted to get a better understanding of what my policy covers cause I know I'm sending in this claim now and I know it takes a few days to process, so I understand there's not an answer for that one right now, but I wanted to just also understand when I purchased, when I got this this insurance, right, um, when I was doing the open enrollment.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] I, I believe I understood that it covered other things. For example, um, if I do like my yearly visits with my primary for like my wellness check, um, and I wanted to verify that and if that was the case, I wanted to understand how do I file a claim for those visits.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] What this policy is, and this is just to verify your benefits, it's not a guarantee of payment. It's a supplemental insurance policy that helps with deductible, co-pay, and co-insurance.
[AGENT][NEUTRAL] So every year,
[AGENT][NEUTRAL] A benefit account and if you go into the hospital for like inpatient more on 18 hours.
[AGENT][POSITIVE] The amount of $2500 that helps.
[AGENT][NEUTRAL] Deductible, your co-pay or your co-insurance. If you go outpatient to an outpatient facility.
[AGENT][NEUTRAL] Uh, that's covered under your policy, you have a benefit amount of $1500 to go towards deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Sorry, go ahead.
[AGENT][NEUTRAL] In the online I noticed that you're signed up in the online service center you can get a copy of your policy there in the online service center.
[AGENT][NEUTRAL] Um, I'm gonna check it real quick for you to see about, uh, wellness.
[AGENT][NEUTRAL] So the facility, it goes by facility, a covered facility, um.
[AGENT][NEUTRAL] Let me look at something real quick for you.
[AGENT][NEUTRAL] OK, so you have um benefits in outpatient facility which is an ER urgent care center, MRI imaging center or an ambulatory center that covers the treatment, but your policy does not cover the physician's office visit fee.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, let's see, and it's for, uh,
[AGENT][NEUTRAL] Sickness or injury. Your policy is for sickness or injury.
[CUSTOMER][NEGATIVE] OK, so, I, to me, it sounds like I should qualify for something cause that's literally what happened. An injury which ended up me at an urgent care.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Oh, OK, yes ma'am, definitely send in, send in a claim for that because that is a covered facility on your policy.
[CUSTOMER][NEUTRAL] Yeah, I sent, I guess like my discharge paperwork originally, and then then I got the letter telling me to send a detailed bill of what they did to me with the codes, and then that's what I emailed this morning.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, good. And the reason why we ask for that because it goes hand in hand with your major medical insurance. So we have to see what the major medical insurance paid.
[AGENT][NEUTRAL] On their part of the claim, so we know what to pay on our part of the claim, so that's why they ask for that.
[CUSTOMER][NEUTRAL] OK. All right. So I guess I'll give it the days to process. And then you had mentioned about MRI. I'm also gonna get an MRI done this coming Thursday. Once I have that done, um, what, uh, paperwork should I be sending in to file a claim for that?
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK, so every time you file a claim, you'll need your explanation of benefits from your primary insurance.
[AGENT][NEUTRAL] And you'll need your itemized statement with your procedure codes and diagnosis codes.
[AGENT][NEUTRAL] If the facility doesn't file the claim for you, sometimes when you give them both cards they'll file the claim for you, uh, but in the case if they don't, you'll always need your explanation of benefits and your itemized statement along with your claim form that you like you filled out in the online service center.
[AGENT][NEUTRAL] Always those 3 documents.
[CUSTOMER][NEUTRAL] Um, OK, yeah, I haven't gotten anything other than the order to go get it done.
[AGENT][NEUTRAL] Yes
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So I guess I'll find out um.
[CUSTOMER][NEUTRAL] I know the explanation of benefits. I have to call [PII] to, I'm sorry, not [PII], I have to call my health insurance to ask them to mail me that. And then what was the first thing that you mentioned the
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] So,
[AGENT][NEUTRAL] The
[CUSTOMER][NEUTRAL] B.
[AGENT][NEUTRAL] The the explanation of benefits comes from your primary insurance and the itemized statement comes from the facility that you go to.
[CUSTOMER][NEUTRAL] Oh, OK. Sorry, that's what I didn't write down so that I can um ask him for it when I go.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] And it may also be a case since since you're just now getting scheduled if they want to call and verify this policy and show that it does help with your deductible co-pay and co-insurance, um, they can do that also.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right. Um, OK.
[CUSTOMER][NEUTRAL] So, OK, so I guess to just understand what I had asked about were for wellness visit, that is not a covered, um, uh, a covered visit or a covered um type of benefit.
[AGENT][NEUTRAL] The office visit itself is not covered.
[AGENT][NEUTRAL] Now, the treatment in the office is something that you could probably file a claim on depending on what your primary pays.
[CUSTOMER][NEUTRAL] OK, so I go back to getting those two documents, the explanation of benefits and the itemized statement?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] All right, I'm just trying to understand how I can take advantage of having this insurance, um, because I just, you know, I don't know what to file a claim for. Um, like, you know, I did my physical, I went to the doctors, um, but now I'm also dealing with this injury, so I wanna try to see what I.
[AGENT][NEUTRAL] Of course.
[CUSTOMER][NEUTRAL] Basically what I can, you know, get back from it because
[AGENT][NEUTRAL] Right. Exactly. Yes, ma'am.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I guess one last question. um, does it have anything on my benefits related to physical therapy?
[AGENT][NEUTRAL] Let me check that for you real quick.
[CUSTOMER][NEUTRAL] That's another thing that I'm doing now for 3 times a week for 4 weeks. Um.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK. So, it does cover um physical therapy, the treatment of a physical dysfunction or injury uh in an office center or clinic in which a licensed physical therapist provides physical therapy.
[CUSTOMER][NEUTRAL] OK, so I'm, I'm doing that. I just started this week. Um, how do I go about filing a claim for that? Do I wait for the therapy to be done?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You can do it as it's being done if you want to do that um you can do it as it's being done or if you wait until it's all done and send it all at one time that's fine too because we do not have a timely filing limit as long as you're covered on the data service you can send a claim in at any time.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, yeah, considering I'm gonna be doing 12 of them, I guess the best thing I can do is just keep all the receipts and then I, at the end of it, I still have to get that explanation of benefits correct and then and what an itemized statement from the facility where I'm getting the therapy.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Yes, that's correct. You've got it.
[CUSTOMER][NEUTRAL] OK, I'm just trying to understand the right way so that I can collect the paperwork as I go, um, and then that way I don't have to, you know, be uploading something every week if it makes sense that I upload everything together at once.
[AGENT][POSITIVE] Yeah. No, you're doing good.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] All right, and it does it doesn't tell you what I like what it is a benefit like monetary wise that is what reviewed when I send everything in?
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Are you still there?
[CUSTOMER][NEUTRAL] I hear you now. I lost you for a minute.
[AGENT][POSITIVE] OK. Oh, yeah. I, I am very sorry about that. Um, yes, that my
[AGENT][NEUTRAL] Program that I was working in just decided to close itself but it's OK I'll open it back up again.
[AGENT][NEUTRAL] Uh, so the benefit amount is the amount I gave you at the beginning of the call that you get every single year. Um, once that benefit amount is exhausted.
[AGENT][NEUTRAL] Then it, you know, the policy will not pay any more other than the amount that.
[AGENT][NEUTRAL] Is given to you annually.
[CUSTOMER][NEUTRAL] OK, I think you had said 1500 or something like that.
[AGENT][NEUTRAL] Right. Let me look real quick.
[CUSTOMER][NEGATIVE] I mean, right now I'm paying $15 each visit, which I don't see it.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right.
[CUSTOMER][MIXED] Um, you know, 15 times 12, whatever that is, um, I don't think I'm gonna exceed it, but at least I'm gonna try to take advantage of whatever it is that I have benefits so if I can get it back, that'd be great.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right. Yes, ma'am, and that amount was $1500 annually.
[CUSTOMER][NEUTRAL] OK. All right, and I think I have one last question. um, does my package, I, I, I think the answer is no, but I'd rather ask, have anything uh related to like uh medical equipment rental?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Uh, yes, it does.
[CUSTOMER][NEUTRAL] So if I have a receipt for renting um a scooter, uh, that I had to use for a month, I can file a claim for that?
[AGENT][NEUTRAL] It has
[AGENT][NEUTRAL] Right, you have a durable medical equipment rider on your policy.
[CUSTOMER][NEUTRAL] OK, uh, I don't have an explanation of benefits on that one because I had to pay for it myself. I just have a receipt uh for what I paid for from the facility. Am I OK to scan that and upload it into the system?
[AGENT][NEUTRAL] You can, you can try to send it in, um, you didn't file it on your primary insurance?
[CUSTOMER][NEUTRAL] I'm sorry, I'm sorry. Can you repeat that again?
[AGENT][NEUTRAL] Uh, you didn't file it on your primary insurance, is that what you're saying? You only have a receipt where you purchased it?
[CUSTOMER][NEUTRAL] I, I have not. Yeah, I have not yet. I just went to the
[AGENT][NEUTRAL] OK. You can try.
[AGENT][NEUTRAL] You can go ahead and send it in and try. Um, thank you. But like I said, this policy works hand in hand with your primary insurance. You can send it in and you can see if you can try to get some reimbursement for it, um, but like
[CUSTOMER][NEUTRAL] Laing.
[AGENT][NEUTRAL] Normally, we always have to have that explanation of benefits from the primary insurance.
[CUSTOMER][NEUTRAL] OK, that's fine. I'll make that call first and then I'll deal with them and then whatever is the outcome I'll then go back to you guys.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, sounds good.
[CUSTOMER][POSITIVE] All right. Well, thank you so much. You've been very helpful.
[AGENT][POSITIVE] You're very welcome, Ms. [PII]. Is there anything else I can help you with before we go?
[CUSTOMER][NEUTRAL] I don't think so right now, but I have you guys' number saved.
[AGENT][POSITIVE] OK, well, always feel free to pick up the phone and we'll help you all we can, OK?
[CUSTOMER][POSITIVE] All right. Thank you. You have a great day.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.
[AGENT][NEUTRAL] Bye bye.