AccountId: 011433970860
ContactId: 10b1c4d2-43a5-4bf1-a354-827cf59329fe
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 622580 ms
Total Talk Time (AGENT): 374631 ms
Total Talk Time (CUSTOMER): 182292 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/19/10b1c4d2-43a5-4bf1-a354-827cf59329fe_20250519T14:19_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, yes. Um, I'd like to, uh, find out why something was not being covered from my surgery.
[AGENT][NEUTRAL] OK, yeah, I can check on that claim and we can get clarification regarding that um what was your name? I'm sorry.
[CUSTOMER][NEUTRAL] My, my first name is [PII]. Last name [PII].
[AGENT][NEUTRAL] OK, [PII], can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] Sure, [PII].
[CUSTOMER][NEUTRAL] 5399.
[AGENT][NEUTRAL] OK, thank you. Do you have your policy number?
[CUSTOMER][NEUTRAL] Yes, it is 0554490.
[AGENT][NEUTRAL] OK, uh, so that's not gonna be one of our policy numbers [PII], um, it doesn't have a letter in the, uh, beginning like that. Uh, let's see, I could start using your social unless you have that claim number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure, I could give you my social. It's uh [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 58
[CUSTOMER][NEUTRAL] 873 4
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] Oh, you know what, it's not a Z, it's a 2, the policy number.
[AGENT][NEUTRAL] Ah, that'll.
[AGENT][NEUTRAL] OK, OK, um.
[CUSTOMER][NEUTRAL] To.
[AGENT][NEGATIVE] No, no, that's all, that's what threw me off, um.
[CUSTOMER][NEUTRAL] Sorry.
[AGENT][NEUTRAL] OK, uh, would you mind reading that policy number back to me?
[CUSTOMER][NEUTRAL] 02554490
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] There we are, OK, alright, I'm just gonna verify some information really quick, uh, [PII], can I get your date of birth please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and then can I get your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Perfect, thank you for verifying all of that. OK, so the claim we're looking at [PII], this was for you correct? or was it for somebody else under the policy?
[CUSTOMER][NEUTRAL] Co
[CUSTOMER][NEUTRAL] No, for me.
[AGENT][NEUTRAL] It is for you, OK, give me just a moment. Do you happen to know the claim number or the date of service?
[CUSTOMER][NEUTRAL] I do have the claim number. It is 35, 0 sorry, I have 2 actually.
[AGENT][POSITIVE] Oh perfect.
[AGENT][POSITIVE] No, no, no, you're OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I have um 3,581,640.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then I have another claim number that's 3581633.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, got it, thank you one moment I'll take a look at those.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, so the claim number ending in 633, that one is not going to be covered as a durable medical equipment or DME is not covered under this policy, so that was something that was just simply not covered.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So my brace is not covered under the policy.
[AGENT][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] Correct. Under this uh secondary medical. And let me take a look at this other one.
[AGENT][NEUTRAL] OK, so the other one that you gave me ending in 640, uh, we were unable to pay a benefit as according to the information we received, your primary insurance provided full benefits, so there was no benefits payable.
[CUSTOMER][NEUTRAL] So my primary
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Covered it fully.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] And is there a reason why the brace isn't um
[CUSTOMER][NEUTRAL] Covered
[AGENT][NEUTRAL] It's durable medical equipment is what that would have been considered. That's just simply not a coverage under this particular policy. Some of ours do offer that this particular one just does not have that as a covered benefit.
[CUSTOMER][NEUTRAL] Got it, got it. OK, um.
[CUSTOMER][NEUTRAL] And then, so then my surgery should be free and clear except for that $650 balance?
[AGENT][NEUTRAL] Um, let's see, hang on just a minute, let me get your actual benefits pulled up here.
[AGENT][NEUTRAL] Is that the remaining after your major medical paid? Was that you said 650?
[CUSTOMER][NEUTRAL] I believe so. And then emer is, is the emergency is the emergency room covered?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, um, so under your, um, outpatient benefits, so the way that this policy works is.
[AGENT][NEUTRAL] It's designed to help with co-pay, deductible and co-insurance after your primary medical pays, and you have two separate benefit buckets essentially one is going to be for inpatient procedures, the other is going to be for outpatient. So essentially the big difference with that is anything is going to be considered outpatient if you weren't hospitalized for about longer than a day that's going to be that general rule of thumb. So the outpatient benefit is.
[AGENT][NEUTRAL] $7900 per calendar year and again it would pay all of uh deductible co-pay coinsurance up to that limit per calendar year. Does that make sense?
[CUSTOMER][NEUTRAL] Yes. Now, those claims do, like, like I had, I paid, I paid those deductibles out of pocket. My emergency room, my, now, is that something where I go ahead and I submit those claims to you all and we get reimbursed?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh.
[AGENT][POSITIVE] Absolutely.
[AGENT][POSITIVE] Absolutely, um, I would go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] OK, do I have to
[CUSTOMER][NEUTRAL] No, I'm sorry. Do I have to get each single claim, like for every single time I went to the emergency room? How, how would I do that?
[AGENT][NEUTRAL] I absolutely would, um, just, you know, that's something that you could potentially get uh some money back for um going forward, of course I would say wherever you go for any sort of medical treatment to give them this information as well as your primary so that they could try to file the claim for you so you won't have to worry about it um but yeah so if you do you have access to a desktop or a laptop computer [PII]?
[CUSTOMER][NEUTRAL] Um, not, not in front of me, not right now.
[AGENT][NEUTRAL] No, no, no, it doesn't have to be at the moment. I just meant in general.
[CUSTOMER][POSITIVE] Oh yes, yes, yes, I do.
[AGENT][NEUTRAL] OK perfect so the reason I ask is that the quickest and easiest way to get claim information to us is going to be through our online portal so if you were to create an account um if you haven't already well or uh [PII] I guess, um, there's gonna be a spot there where you can just simply upload claim information and it gets to us very quick, um, and whenever you're ready I can let you know exactly what we need for those claims if you'd like to write it down.
[CUSTOMER][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] Yes, I have a paper and pen ready.
[AGENT][POSITIVE] Awesome, OK, so we would need the itemized statements.
[CUSTOMER][NEUTRAL] Itemized statements. This is for each claim, correct?
[AGENT][NEUTRAL] That show
[AGENT][NEUTRAL] Correct, um, so itemized statements that show diagnosis and procedure codes.
[CUSTOMER][NEUTRAL] no s is and procedure codes. And this is something where I would call the hospital for them to give me.
[AGENT][NEUTRAL] Yes, sir.
[AGENT][NEUTRAL] Absolutely um so we would need that and then we would also need the explanation of benefits from your primary insurance and again the facility or provider wherever you went for treatment, they will have that information so if you were to call them you would just ask them for this specific information for whatever dates of service you went for treatment.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] Got it. OK, um.
[AGENT][NEUTRAL] And from there um it's whatever how however is easier for you but I will say if you just had you know a bunch at once for several dates of service or anything like that um you can upload all of that information under the same claim, so you would only need to fill out one claim form.
[AGENT][NEUTRAL] I know there's some confusion regarding that.
[CUSTOMER][NEUTRAL] Got it and then just bunch them all together.
[AGENT][NEUTRAL] Right, right, and that's perfectly fine. I will say that our website, it, it can have um a limit as to how much can be so if there's a lot, you know, there, you know, it might make you separate them, but that's perfectly fine as well.
[CUSTOMER][POSITIVE] OK. I'll try that then and uh I'll get that started and um hopefully uh get the ball rolling then.
[AGENT][POSITIVE] Absolutely and if y'all have any questions um feel free to give us a call so we can help you out and I know it can be pretty confusing.
[CUSTOMER][POSITIVE] I appreciate it thank you.
[AGENT][POSITIVE] Absolutely yeah thanks for giving us a call. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You too. Oh, and, and, uh, I'm sorry, the website where I could create the portal.
[AGENT][NEUTRAL] Oh yes.
[AGENT][POSITIVE] Oh yes, um, are you ready for it now?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so that's going to be it's the word secured with an [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Secured. [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII] secured. [PII] yes and now [PII] might need to give us a call um as she's the policy holder because uh the information that entered whenever you do create an account uh does have to match what we have in our system and I'm not showing that we have an email address for her so if she could give us a call um and give us a good email that we can enter that would be what y'all would use to create the account.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] Can, can I give you any uh her email or no?
[AGENT][NEGATIVE] It would have to come from her as she's the policy holder unfortunately.
[CUSTOMER][POSITIVE] OK, got it, got it. All right. No problem. All right. Thank you very much.
[AGENT][NEUTRAL] Alright, you're welcome did you have any other questions for me at the moment?
[CUSTOMER][POSITIVE] Have a great day.
[CUSTOMER][NEUTRAL] No, that's, that's basically it. That's, that, that should be all.
[AGENT][POSITIVE] All right, thanks for giving us a call have a great day.
[CUSTOMER][NEUTRAL] Uh, you too. Bye-bye.
[AGENT][NEUTRAL] Bye bye.