AccountId: 011433970860
ContactId: 0d5cb749-2817-4f56-b186-c2114ef6a141
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 505109 ms
Total Talk Time (AGENT): 233313 ms
Total Talk Time (CUSTOMER): 237228 ms
Interruptions: 3
Overall Sentiment: AGENT=0, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/25/0d5cb749-2817-4f56-b186-c2114ef6a141_20250325T21:31_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling ATL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yes, I wanted to uh double check on a couple of things please about uh haven't done gap in a long time just trying to kind of get myself reoriented. What is the, how far back, how far back can we go?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It depends.
[CUSTOMER][NEUTRAL] As far as the calendar wise.
[AGENT][NEUTRAL] It depends on, on the policy. So I need to be looking at the policy. Um, may I have your name and a callback number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] My name is [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you. And do you have the policy number, Mr. [PII]?
[CUSTOMER][NEUTRAL] Uh, no, not in front of me. I have to print out some stuff. I don't know.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I look and see if it's in my wallet here.
[CUSTOMER][NEUTRAL] Is there another way you can look me up because I'm not.
[AGENT][NEUTRAL] I'm trying by your name. Um, how do you spell your last name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And that's [PII], correct? [PII]
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Here's my dental.
[CUSTOMER][NEUTRAL] I'm still looking here.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Um, let's see. Let me try this one. let me have your date of birth for security.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, I found you. And may I have the mailing address and email address on file?
[CUSTOMER][NEUTRAL] It's [PII], and uh email is [PII].
[AGENT][NEUTRAL] Mm, we have a [PII] [PII] [PII]. Is that OK?
[CUSTOMER][NEUTRAL] Oh well maybe it's yeah that's where I work so maybe it's uh it's probably that that's right, yeah, yeah, because it's uh I'm getting this through my school policy so yeah it'd be [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, thank you. I know. All right, so you started the policy with us on [PII]. Uh, so to submit claims you can go as far back as that day, [PII].
[CUSTOMER][NEUTRAL] OK, OK, OK.
[CUSTOMER][NEUTRAL] And go
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] A 2.
[CUSTOMER][POSITIVE] 1 [PII]. OK, fantastic um.
[CUSTOMER][NEUTRAL] For these, for these things, if I remember correctly, you need, you need something from the doctor that shows the code, is that correct? the diagnostic code, is that what it's called?
[AGENT][NEUTRAL] Uh, correct, yes. Uh, we need an itemized bill with the diagnosis code or diagnostic code.
[AGENT][NEUTRAL] And we need a copy of the explanation of benefits from the primary insurance.
[AGENT][NEUTRAL] And we need the claim form.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] On in a claim form, OK, and I need to do a form for each one, right?
[AGENT][NEUTRAL] No, just one claim form and just add as many claims as you would like to that form.
[CUSTOMER][NEUTRAL] Oh, OK, OK, all right, um, the other part of my confusion is, for example,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] If or my question is.
[CUSTOMER][NEUTRAL] If I have, uh, like my wife had some nasal surgery.
[CUSTOMER][NEUTRAL] OK, they ordered an MRI to go with that. From what I'm reading on the paperwork, is that all considered.
[CUSTOMER][NEUTRAL] Maximum benefit $500 per occurrence.
[CUSTOMER][NEUTRAL] The MRI and the surgery side, is that what that's saying?
[AGENT][NEUTRAL] Mr. [PII], you said your wife?
[CUSTOMER][NEUTRAL] Yeah, I'm just using that as an example. I'm sorry, I'm using that as an example.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] OK, yeah, because I'm like you're the only one here, OK.
[CUSTOMER][NEUTRAL] Yeah, I'm sorry, I'm sorry. No, sorry.
[CUSTOMER][NEUTRAL] Can't read my mind. What's your, what's wrong with you? No, no, I'm sorry. So I was issuing that for an example. The, uh, maximum out outpatient benefits is like $500 per occurrence.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, um, per our current, mhm, go ahead.
[CUSTOMER][NEUTRAL] So is the MRI?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so percurre means.
[CUSTOMER][NEUTRAL] So does that mean?
[AGENT][NEUTRAL] If it's related to the same treatment or condition, it's every 90 days. So, if the MRI and the surgery took place um within those 90 days and they're due to the same sickness, then it's just $500 for that occurrence. Now, if um they did the MRI and then then they decided to do the surgery 90 days after, then you have $500 each 90 days.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Thank you, so it's 90 days, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So related, they are related and within 90 days, that would be a one occurrence.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And the reason I'm asking is it some of this stuff is so challenging to get all the paperwork. I didn't want to be spinning my wheels on something that uh, turns out it doesn't do me any good. OK, any other thoughts that you have for somebody that's trying to get back into this again as far as uh.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You know, things that, that usually wind up making a claim, you get kicked back or whatever, any thoughts off the top of your head.
[AGENT][NEUTRAL] The only thing I can tell you is that the claim form needs to be fully filled out, including the authorization form, which is really important. Um, also, um, the explanation of benefits, the explanation of benefits needs to show the amount applied towards the deductible, co-payment and co-insurance. So it's a fully explanation of benefits.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] OK, OK, OK, so you can see what, what, what money basically I paid out of pocket right? because this is all, this is all towards the pocket, correct?
[AGENT][NEUTRAL] It is out of pocket, but it's gonna be applied towards the deductible, co-payment, and co-insurance. That's what we help with. We help with the deductibles, co-payment, and co-insurance. So if the explanation of benefits only says um
[AGENT][NEGATIVE] Out of pocket amount or patient's responsibility, 200, then that's not what we need. It needs to say 200 was applied towards the deductible and that is the member's responsibility.
[AGENT][NEUTRAL] So it is a detailed explanation of benefits, OK? Um.
[CUSTOMER][POSITIVE] OK, great.
[CUSTOMER][NEUTRAL] OK. Uh-huh.
[AGENT][NEUTRAL] And, and for the itemized bill, um, it just needs to be a fully itemized bill, meaning that it's gonna have the information of the doctor. It's gonna have the diagnosis codes, procedure codes, which is gonna tell us um the service render and the reason of that service and the charge amounts.
[AGENT][NEUTRAL] That matches the explanation of benefits.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, uh, OK, I think I got that and then, uh, in my policy, the uh 25 for doctor visits part, um, for doctors visits per year.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, is there a time limit on that one also? I mean, I'm not trying to go back 10 years. I'm just saying is, is in the last year or two acceptable for that?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, yes, there, there's no timely filing limit for any of it. So if you have not received anything from um that writer, which is an office visit writer, um, you can submit claims. So, um, if you have 4, yeah, for, for a year, you can just submit that one. Like, you don't have to just get all of them, just have that 4 that you need to charge or get back refunded.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Right, right, right, OK, alright, thank you very much. I appreciate it. uh, I appreciate your time on that. Uh, I went to the web and I got stuff, but I still like to hear a person's voice just to be sure I didn't misread or misunderstand something. So thank you very much.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yeah. Mhm. No problem.
[AGENT][POSITIVE] Uh-huh. You're welcome. Is there anything else I may help you with today? You need any history or anything like that?
[CUSTOMER][NEUTRAL] Like if you wanna do the paperwork for me that would help, but no, I'm teasing.
[AGENT][NEGATIVE] Unfortunately, we need your signature.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEGATIVE] We cannot do it over the phone.
[CUSTOMER][POSITIVE] Yeah, it's no, it's been good. I appreciate it. Thank you very much.
[AGENT][POSITIVE] You're welcome. Have a good afternoon, Mr. [PII].
[CUSTOMER][POSITIVE] All right thank you bye bye.
[AGENT][NEUTRAL] Bye bye.