AccountId: 011433970860
ContactId: 12e14344-da01-4730-aca1-869092a4433b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 660409 ms
Total Talk Time (AGENT): 269063 ms
Total Talk Time (CUSTOMER): 367204 ms
Interruptions: 9
Overall Sentiment: AGENT=0.2, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/04/12e14344-da01-4730-aca1-869092a4433b_20250404T18:02_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, um, my name is [PII], um, I have, um, a couple questions for you.
[CUSTOMER][NEUTRAL] Um, I'm, we're, um, getting ready to.
[CUSTOMER][NEUTRAL] Sign up for our next year's um you know insurance or we're enrollment right now and my the benefits lady, she told me she said because I already have um a policy with y'all with the gap.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And she said that she wanted to because they're I'm trying to decide between two different plans. One of them has a $5000 out of pocket and the other one is $8500 out of pocket, and she said to call and just find out what do y'all pay out.
[CUSTOMER][NEUTRAL] Is what is the maximum? Is it the actual.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You know, out of pocket or is there like a limit?
[CUSTOMER][NEUTRAL] Does that make sense?
[AGENT][NEUTRAL] What's your policy number?
[CUSTOMER][NEUTRAL] Um, my gap policy is.
[CUSTOMER][NEUTRAL] 0244.
[CUSTOMER][NEUTRAL] 2159.
[AGENT][NEUTRAL] And could you verify your mailing address and your date of birth for me, [PII]?
[CUSTOMER][NEUTRAL] Yeah, it's [PII] and what was the other one date of birth? [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And verify, um.
[CUSTOMER][NEUTRAL] Sure
[AGENT][NEUTRAL] The email address that we have on file and then a good call back number just in case the call is disconnected.
[CUSTOMER][NEUTRAL] OK, well I'm, uh, my cell do you need my cell number or you want my office number that I'm on right now?
[AGENT][POSITIVE] Just any number just in case this call is disconnected I can call you back.
[CUSTOMER][NEUTRAL] OK, it's um [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And I don't know if you have my work or my um personal email but my email is [PII].
[AGENT][NEUTRAL] It's the one we have.
[CUSTOMER][NEUTRAL] And then my work email, OK, OK.
[AGENT][NEUTRAL] That's the one we have, the personal one. OK, so you was asking a question about your current policy which has the $750 per calendar day benefit amount versus the one that's $8500 per calendar year.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So once that 8500.
[CUSTOMER][NEUTRAL] Well, no, what.
[CUSTOMER][NEUTRAL] No, what I'm, what I was asking about is we're in enrollment right now and I, I'm gonna keep the gap insurance, but they told me to to call y'all and ask what was the maximum that you pay? Is it out of pocket? Is that the amount that you go up to or is it or is there a limit that y'all pay to because that's gonna determine which which plan insurance plan I go with.
[AGENT][NEUTRAL] OK, so this policy, your output.
[CUSTOMER][NEUTRAL] Because one of them, one of them, yeah.
[CUSTOMER][NEUTRAL] And I would have the same.
[AGENT][NEUTRAL] So, the current
[CUSTOMER][POSITIVE] Yeah, I would have the same as I have now on the gap, yes.
[AGENT][NEUTRAL] So your current policy pays outpatient per calendar day of $750 per calendar day.
[AGENT][NEUTRAL] And inpatient is $3500 per per calendar year.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And this is not a guarantee of benefits it's just a disclaimer of the policy's coverage. I'm not sure if that answers your question.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] No, no, I understand.
[CUSTOMER][NEUTRAL] Yeah, I think because what you're saying is that even if I had an insurance policy, a medical policy that had a $5000 out of pocket for me, you only will pay up to $3500.
[AGENT][NEUTRAL] It's for inpatient, $3500 for inpatient per calendar year and then outpatient, you have $750 per calendar day.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] OK, well, I do have another question for you, um, and this is gonna sound stupid. This is gonna really sound stupid, so last year it it.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] No, it's not, no question is stupid.
[CUSTOMER][NEUTRAL] And it last year in April when we signed up I got this policy and I guess at the time I read what it was and I was like oh yeah I'm gonna get that well by August when I actually had a um I had a couple of MRI's I had a back surgery and different things.
[CUSTOMER][NEUTRAL] I completely didn't I forgot that I even had this, so.
[AGENT][NEUTRAL] You can still submit them, your policy has been active since [PII], so there's no timely filing.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, so what do I need to do to file? Do I get like the like do I call the company where I got the MRI and say give me a copy of the bills and then I upload those bills to y'all?
[AGENT][NEUTRAL] So yeah, you would need an itemized bill from the facility where you receive the services from for those dates of services and you will also need to contact your primary insurance company and request the EOB which is your explanation of benefits for those dates of services.
[AGENT][NEUTRAL] So you can contact the the facility and ask them to request the um copy of your 1500 or UB depending on the location, maybe it's a facility. If it's a facility, it'd be called a UB but if it's a um office, doctor's office or office visit, then it'll be a 1500.
[CUSTOMER][NEUTRAL] OK, no, it was a facility. OK, so, um, that's for like [PII]. So is there a benefit that I get for like.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] It'll fall under your outpatient benefits.
[AGENT][NEUTRAL] Of the $75,750 per calendar day.
[CUSTOMER][NEUTRAL] So I well, right, but I was, but I.
[CUSTOMER][NEUTRAL] OK, but I would in August I actually was admitted in the hospital and I had surgery, so is there a payment on that?
[AGENT][NEUTRAL] So that you were in there for more than 18 hours?
[CUSTOMER][NEUTRAL] Potentially
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So that means it'll fall under your uh your inpatient benefits over the $3500 per calendar year.
[CUSTOMER][NEUTRAL] OK, so in that case I just need to get the.
[CUSTOMER][NEUTRAL] Itemized statement from the.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] From the facilities with the um diagnosis codes listed on them, yep, and your ELBs for those dates of services.
[CUSTOMER][NEUTRAL] Hospital
[CUSTOMER][NEUTRAL] So when you say the EOB that comes from my insurance, is that like the explanation?
[AGENT][NEUTRAL] Yes, that comes from your primary insurance company.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So explanation of benefits, right?
[AGENT][NEUTRAL] Yes, from your primary insurance company. I'm not sure who you, who you have benefits with.
[CUSTOMER][NEUTRAL] And.
[CUSTOMER][NEUTRAL] Of my, of my, yeah.
[CUSTOMER][NEUTRAL] United Healthcare, it's United Healthcare, so I print that out and then I include that with.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] This stuff
[AGENT][NEUTRAL] Yes, cause we're gonna need the itemized bill and we're definitely gonna need the ELB because we're gap insurance. We pay towards your deductible co-pay and co-insurance that your.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] That the primary didn't pay, but they put it towards your deductible co-pay or your co-insurance.
[CUSTOMER][NEUTRAL] Right, so I just need to make sure that you have my insurance, um, whatever my number is and all that kind of stuff for you know Healthcare we're actually changing the.
[AGENT][NEUTRAL] We need to just your EOB.
[CUSTOMER][NEUTRAL] OK, in in May we're changing to Cigna from United Healthcare, so I, I was trying to get all this together and get it to y'all as soon as possible, OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] There's no timely filing, so as long as the policy was active.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] You have more than enough time to.
[CUSTOMER][NEUTRAL] At the time
[AGENT][NEGATIVE] Mhm. Yeah, even if the policy was terminated, you still, even if it's terminated, but it was active at that time, then there's no timely found.
[CUSTOMER][NEUTRAL] OK, so what happens since.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] OK and so then my other question is um I know that and I didn't realize this because I, I totally did not know that I needed because I didn't even have my card from y'all until yesterday so to know what my.
[CUSTOMER][NEUTRAL] Group number and policy number and all that stuff was.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So and that may be my I mean I'm sure it's my fault because I'm sure I was supposed to do something and I didn't do it, but anyway, um.
[AGENT][NEUTRAL] Well, for future reference, when you go to your appointments, just provide them with your card since you have it now.
[CUSTOMER][NEUTRAL] Do uh
[CUSTOMER][NEUTRAL] Right, that's what I was gonna ask. So but that doesn't like if I go to the doctor and I'm just having like follow ups or whatever, that doesn't, it doesn't have anything to do with that. This is just like things like hospital MRI's, X-rays, those kind of.
[AGENT][NEUTRAL] Uh, so.
[AGENT][NEUTRAL] So, OK, so your outpatient benefits consist of diagnostic testing. You have a cancer treatment rider, gonna knock on wood.
[AGENT][NEUTRAL] You have a lab writer?
[AGENT][NEUTRAL] And you don't have office business so.
[CUSTOMER][NEUTRAL] You mean so if I have to have lab work done and I can and I can turn that really.
[AGENT][NEUTRAL] Mhm. It's covered. Yes, ma'am. Yup.
[CUSTOMER][NEUTRAL] Uh, so, OK, so some of these services I've already paid for and all that, so do y'all just send the money to me or you send it to them or how does that work?
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Yeah, the money would be sent to you because you submitted the claim, so long as you have the itemized bill and the EOB for those data services, then the payments, as long as you submitted the claim is gonna go to you. But I'm just letting you know the things that we would need so that way we won't be going when you get them and then you submit your stuff and then you don't have everything then we deny it.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And then some not saying you will, but a lot of our customers think that we don't wanna pay anything but we that's why we're here to pay things, but we can't pay them if you don't have all this if you if you did not submit the necessary documents for us to process the claim correctly.
[CUSTOMER][NEUTRAL] Now do I have to do them separately or like I got two MRIs I got a hospital thing. I got another hospital thing. I've got lab work, X-rays as long as I give you everything, I can just upload one document with all, I mean well one time and with all the documents there is that true, or do I need to do a claim for each each one?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes ma'am, that's correct.
[AGENT][NEUTRAL] No, you don't have to do them separately.
[AGENT][NEUTRAL] Yeah, because, because it's an insurer submitted claim, we're gonna bundle them all up anyway, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh OK, OK, and then just to make sure that I have whatever the medical codes or however it was coded that needs to be on there that was the.
[AGENT][NEUTRAL] Mhm. The ICD codes, yes.
[CUSTOMER][NEUTRAL] What did you call him?
[AGENT][NEUTRAL] ICDT codes, the diagnosis codes?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] ICD codes OK.
[CUSTOMER][NEUTRAL] Diagnosis codes.
[CUSTOMER][NEUTRAL] OK, well I wanna get all this in because.
[CUSTOMER][POSITIVE] I appreciate that OK so perfect thank you so much.
[AGENT][NEUTRAL] Is there anything else that I can assist you with today?
[CUSTOMER][POSITIVE] No, you've been a huge help thank you very much.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL and you have a great day.
[CUSTOMER][NEUTRAL] You have, you have
[CUSTOMER][POSITIVE] You too hon, thank you.
[AGENT][POSITIVE] Thanks. Goodbye.
[CUSTOMER][NEUTRAL] Alright bye bye.