AccountId: 011433970860
ContactId: 14fb5a2a-a8c6-4c29-9a3e-bb6773fe83b3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 798559 ms
Total Talk Time (AGENT): 397675 ms
Total Talk Time (CUSTOMER): 198659 ms
Interruptions: 2
Overall Sentiment: AGENT=0.6, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/21/14fb5a2a-a8c6-4c29-9a3e-bb6773fe83b3_20250521T18:26_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], how are you? I'm calling because I have a few questions. My husband has a um a policy, an APL policy.
[CUSTOMER][NEUTRAL] And um I, I, I have a few questions about his policy.
[AGENT][POSITIVE] Sure, I can help you with that.
[CUSTOMER][NEUTRAL] I'm wondering if you can help me with that please thank you.
[AGENT][NEUTRAL] OK, um, what's your name and a good callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, my name's [PII].
[CUSTOMER][NEUTRAL] Last name [PII] and a good number is [PII].
[AGENT][NEUTRAL] OK, and do you have the policy number with you?
[CUSTOMER][NEUTRAL] No, I don't.
[AGENT][NEUTRAL] OK, that's OK.
[AGENT][NEUTRAL] Same last name? I can look it up that way.
[CUSTOMER][NEUTRAL] Yes it is.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] [PII], correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes. And his first, and his first name is [PII].
[AGENT][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] Give me just a moment while I pull that up, OK?
[CUSTOMER][POSITIVE] Yes, thank you.
[AGENT][NEUTRAL] I apologize my computer is running just a little slow. Give me just a moment, OK?
[CUSTOMER][POSITIVE] No worries, take your time. Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Do you know what kind of policy it was?
[CUSTOMER][NEUTRAL] Um, gap insurance.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Does that make sense?
[AGENT][POSITIVE] Yes, ma'am, that, that helps. Thank you.
[CUSTOMER][NEUTRAL] I can look up the number. I have a picture of the card on my phone.
[AGENT][NEUTRAL] Um, I think I found it. Give me, give me just a moment and make sure.
[AGENT][NEUTRAL] And what is his date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And can I get you to verify the mailing address and phone number?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] And then the phone number it's [PII].
[AGENT][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] What questions do you have?
[CUSTOMER][NEUTRAL] I'm gonna put you on speaker because we're in the cars and I want him to hear also.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hi, can you hear me?
[AGENT][NEUTRAL] I can hear you a little bit.
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] OK, um, so my question has to do like how does the coverage work because we get a lot of denials. I'm wondering what, what, um.
[CUSTOMER][NEUTRAL] What is it because it says it denies because it's and it and makes a comment that um office visits are not covered, so what is covered?
[CUSTOMER][NEUTRAL] How do we use this insurance?
[AGENT][NEUTRAL] So this
[AGENT][NEUTRAL] OK, so this is a secondary gap policy, meaning that um it, it has to have the major medical um explanation of benefits in the claim. If the major medical denies the claim, then this policy will also deny a claim.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] And let me see.
[AGENT][NEUTRAL] What actual benefits you have.
[AGENT][POSITIVE] And I can help you through that.
[AGENT][POSITIVE] So this insurance does help with co-insurance, co-pay, and deductible.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Because this is a secondary insurance and it's just gap. So let me pull up your policy and I can go over a few things with you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Give me just a moment.
[AGENT][NEUTRAL] You were correct. There's not an office visit.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Benefit on this claim, but there is an office treatment writer that is a little different. That's if treatment was provided in a physician's office. Um, it's a little different than just an office visit.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, I do want to remind you that this is just a verification of benefits and not a guarantee of payment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, it looks like you have in hospitals benefit maximum of up to $6000 per covered person per calendar year, with a maximum of 1 of $18,000 per calendar year for all covered persons combined.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, you have a $0 deductible with this policy.
[AGENT][POSITIVE] It looks like you also have benefits for treatment for mental and emotional disorders and an ambulance benefit.
[CUSTOMER][POSITIVE] Thank you
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] With a maximum of 30 days per treatment, per covered person, per calendar year.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] So that's a maximum of 30 days.
[AGENT][NEUTRAL] Let me see what else we have.
[AGENT][NEUTRAL] I also see the office treatment writer like I mentioned earlier.
[AGENT][NEUTRAL] There's a cancer outpatient treatment writer as well.
[AGENT][NEUTRAL] You have a lab facility writer, so that's if you need to get labs done at an independent facility, um, not in the medical um provider's office. And then you also have what we call a DME or a durable medical equipment writer.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Are there any specific questions after what I I just mentioned?
[CUSTOMER][POSITIVE] Nice
[CUSTOMER][NEUTRAL] Yes, um, the, um, the lab one, so like for example if we because I know we we we.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] So along with proof of equipment, take, yes, can you hear me?
[AGENT][NEUTRAL] Um, it, it cut off briefly for a moment, so can you, I heard the word lab and that was it, so sorry.
[CUSTOMER][NEUTRAL] Don't me. Um, so how would, like, for example, you've got quest diagnostic bills.
[CUSTOMER][NEUTRAL] Um, so we would just pay sets I would.
[CUSTOMER][NEUTRAL] And then I could and then I would just submit reimbursement to you guys.
[AGENT][NEUTRAL] You can do that or you can ask the the hospital can file a claim for you or you can file the claim. Um, I am seeing that you have an outpatient benefit because that would be outpatient. So you do have an outpatient benefit maximum of up to $4000 per covered person per calendar year.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] With a maximum of $12,000 for all covered persons. Um, again, $0 deductible, $0 deductible for the emergency room.
[AGENT][NEUTRAL] I am showing diagnostic testing in a hospital with a maximum of up to 30 days per treatment.
[AGENT][NEUTRAL] And then you were asking about labs specifically, correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So it looks like for this one, your benefit is that we will pay the out of pocket amounts for diagnostic testing in an independent lab facility.
[AGENT][NEUTRAL] And it's limited to the outpatient maximum that I gave you earlier of the up to $4000.
[CUSTOMER][NEUTRAL] It makes sense. Do you have any questions? No, that means we gotta get, yeah, because they're like an external, even though a lot of times quest will be like.
[CUSTOMER][NEUTRAL] They're in like their own separate office in that building.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You want to have a quest diagnostics downstairs so it's separate from the office.
[AGENT][NEUTRAL] If you're if you're concerned, I would, I would go ahead and have them call and verify benefits with us as well. Um, a lot of hospitals do that before you're seen anyways, um, to play it safe. I, I, I would ask your doctor to verify with us ahead of time of your benefits, um.
[CUSTOMER][NEUTRAL] OK, so OK.
[AGENT][NEUTRAL] We do cover Quest. It's just, uh, it can be it can be tricky depending on, like you said, if it's independent or not, um, but either you can file that claim or or they should be able to file the claim for you as well. It just depends on how you would like which route you'd like to go, um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Let me check something.
[AGENT][NEUTRAL] If you want, you can set up an online account with us using the information that you that we have on file and you are able to submit claims electronically once you set up that um online portal account. Would you like me to send you all a help guide for how to start that?
[CUSTOMER][POSITIVE] Oh, nice.
[CUSTOMER][NEUTRAL] No, I already created an account.
[AGENT][NEUTRAL] Oh, you already created account you should OK.
[CUSTOMER][NEUTRAL] I think yeah.
[AGENT][NEUTRAL] OK, you should be able to file claims through there too, and you'll be able to check the status of those claims as well. And sometime I will say sometimes when they get denied it's just because we're needing a piece of information. So if you see that denial, just look at the reasoning why. Sometimes we need the, uh, a lot of times it's because we we're waiting for the primary insurances um explanation of benefits, or you might see it as EOB.
[CUSTOMER][NEUTRAL] I didn't know we
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Makes sense. Thank you.
[AGENT][NEUTRAL] And I will say we do not have timely filing, so it it takes you a while to get some of that information back from your hospitals or your doctors. We don't have timely filing, so as long as it's within the active policy dates, you should be able to file a claim and we will honor that.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] Thank
[CUSTOMER][NEUTRAL] OK, and just to confirm, do you see that who's covered? Is it, is it it's [PII] and our children, [PII] and [PII]?
[CUSTOMER][NEUTRAL] That's what the active policy is for.
[AGENT][NEUTRAL] Let me check.
[AGENT][NEUTRAL] OK, I am showing 3 people on this account, so, uh, you said [PII] the primary and then who were the other two?
[CUSTOMER][NEUTRAL] I just wanna see if I'm if.
[CUSTOMER][NEUTRAL] [PII] and [PII], our children.
[AGENT][NEUTRAL] Yes, ma'am, they are on this and they are active on this policy.
[CUSTOMER][NEUTRAL] OK, now quick question um.
[CUSTOMER][NEUTRAL] Do you guys do um policy individual policies for people so like my husband gets it through his job.
[CUSTOMER][NEUTRAL] And so, and I'm not included in the policy because I don't have [PII], I don't have their insurance. Is there a way for me to get my own individual policy or doesn't work like that?
[AGENT][NEUTRAL] Uh, we mainly work with employers. Um, if he, if he, uh, would like you to be on his policy, he will need to go through his employer to add you and he should be able to add you and it becomes family instead of, uh, right now it's single parent, so it's him and, uh, dependents. um, if he'd like to add you and turn this coverage into family coverage, he would need to go through his um employer for that.
[CUSTOMER][POSITIVE] OK, that sounds good. Thank you so much for helping and answering my questions.
[AGENT][NEUTRAL] Oh, anytime and if you ever h[PII] any more questions about what's covered or if you have any questions about claims, just give us a call back, OK?
[CUSTOMER][NEUTRAL] about.
[CUSTOMER][POSITIVE] Will do, thank you.
[AGENT][POSITIVE] Great, thank you so much for calling APL. Have a great day.
[CUSTOMER][POSITIVE] You too, take care. Bye.
[AGENT][NEUTRAL] Alright bye.