AccountId: 011433970860
ContactId: 1553ae6e-fe60-45ed-a0ac-ada5a52fcd70
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 819099 ms
Total Talk Time (AGENT): 487320 ms
Total Talk Time (CUSTOMER): 203136 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/30/1553ae6e-fe60-45ed-a0ac-ada5a52fcd70_20250530T17:03_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, yes, I have a question about a couple of claims that I submitted.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, yeah, I can check on those plans for you. uh, what was your name?
[CUSTOMER][NEUTRAL] Pardon me, [PII].
[AGENT][POSITIVE] You're OK.
[AGENT][NEUTRAL] OK, and then [PII], can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] Um [PII].
[AGENT][NEUTRAL] OK, thank you and then do you have your policy number?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] 251-707-4
[AGENT][POSITIVE] Alrighty thank you one moment.
[AGENT][NEUTRAL] Alright and then just gonna verify some information really quick [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][POSITIVE] Perfect. Last thing I need is the email address that we've got on file for you. uh, looks like it is through an organization.
[CUSTOMER][POSITIVE] Um, best studies.
[AGENT][NEUTRAL] Yeah, that's it. OK, alright, thank you for verifying that. OK, give me just a moment let me get this pulled up.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Excuse me, I'm sorry. OK, so it does look like we are missing some information, so.
[AGENT][NEUTRAL] There were two for the date of service, um, [PII], those services are not going to be covered under this policy when performed in a doctor's office or clinic, so those are just not going to be covered. And then we've got uh [PII], that date of service looks like we're missing a diagnosis code so uh you can get that information from, I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Is that the ambulance?
[AGENT][NEUTRAL] Uh, let me see.
[AGENT][NEUTRAL] Just showing outpatient.
[CUSTOMER][NEUTRAL] I mean, it's the.
[AGENT][NEUTRAL] Let me see exactly what that is.
[CUSTOMER][NEUTRAL] The file ambulance that I'm looking at that I uploaded has has should have everything um on it.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, um, all I'm seeing is it says, uh, Montgomery County, so I imagine that's probably that service, um, and it is stating that we are missing the diagnosis code so.
[AGENT][NEUTRAL] Generally, uh, again, every provider the way that they operate are all very different, but most of the time that's not something they would just give you, um, so with the diagnosis code if you ask them for the itemized statement that shows diagnosis codes, uh, they should be able to send that to you and then as soon as you, I'm sorry.
[CUSTOMER][NEUTRAL] So that that was an ambulance ride.
[AGENT][NEUTRAL] Right, uh, you could still get that from that facility.
[CUSTOMER][NEUTRAL] OK. Then what about the stress test?
[AGENT][NEUTRAL] Yes, OK, I'm sorry, I do know it's very confusing. OK, and so for that one that was uh [PII], let's take a look here.
[AGENT][NEUTRAL] OK, so for this one we are also missing the diagnosis and also the explanation of benefits from your primary insurance essentially showing what they contributed to that treatment and again you can get all of that information from wherever it was that you received treatment.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] So, where, where, where can I find what, what you cover? Like what percentages or um cause the only thing.
[AGENT][NEUTRAL] Oh sure, give me just a moment.
[AGENT][NEUTRAL] You're fine. Um, I can get your actual policy pulled up here. I will say, um, it's not so much percentages as this is a secondary medical policy, of course, it's designed to help with uh co-pay, deductible and co-insurance after your primary insurance pays. And then from there you've got um.
[AGENT][NEUTRAL] Two separate buckets, uh, for example, of for inpatient benefits, which would be if you had to stay in the hospital for, you know, like over a day and then outpatient benefits, which generally speaking, any sort of treatment that, you know, doesn't require you being hospitalized for longer than a day. Um, both of them.
[AGENT][NEUTRAL] Pay on a per calendar year basis.
[AGENT][NEUTRAL] Um, let's take a look here. I'm getting your actual policy pulled up and I can send you a copy of your policy as well, uh, so you can have that for your reference.
[CUSTOMER][NEUTRAL] Well
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] I mean, I
[CUSTOMER][NEUTRAL] I'm, I'm
[CUSTOMER][NEUTRAL] I looked at it but I don't understand what's covered.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure, OK, so and it again very confusing it definitely can be as most of the policy is going to be um more or less definitions, um, that's what most of the policy is. There is one page that will be your best friend, let me find it.
[AGENT][NEUTRAL] There it is, so it's a schedule of benefits and it is let me see what page number this is oh well it's separate page one so it would be.
[AGENT][NEUTRAL] Kind of sandwich in the middle depending on how you're looking at it um but on the schedule of benefits it does go over inpatient benefits uh which is the max.
[CUSTOMER][NEUTRAL] What, what code is that?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] What page is that?
[AGENT][NEUTRAL] Are you looking at a physical copy or are you looking at a digital copy of your policy?
[CUSTOMER][NEUTRAL] Digital.
[AGENT][NEUTRAL] Digital, OK, so if you're looking digitally it should go in order uh now this one is for inpatient um if you wanted to look at the inpatient one I am on page 18 of 44.
[AGENT][NEUTRAL] And that's for your inpatient benefits that's just going to be the dollar amounts, um, and they're just kind of explaining, you know, there's no deductible or anything like that. Let me find the outpatient benefits.
[CUSTOMER][NEUTRAL] So,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I, I'm, I'm, I mean, I've never had gap insurance, so I, I'm very confused. So for instance,
[AGENT][POSITIVE] You're OK.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Well this one is quite a bit different as well.
[CUSTOMER][NEUTRAL] So for instance, if I have a specialist doctor that I go to, I pay $80 for my co-pay.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Of that $80 what do you cover?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, OK, so this particular policy does not cover office visits or treatment received in a physician's office environment.
[AGENT][NEUTRAL] This one under the outpatient benefits and which I've got that page number it's uh for outpatient that is page 3 excuse me, 34 of 44, and that one will cover or show the facilities that are covered under your outpatient benefit.
[AGENT][NEUTRAL] Excuse me.
[CUSTOMER][NEUTRAL] So it's a benefit maximum $6000 per cover person per calendar year.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And then it says deductibles, outpatient deductible is 0 covered.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, right, no 0 per covered person, um, so some of our plans do have their own deductible. This particular one does not. That simply means that there's no deductible that has to be met for this policy for that benefit to kick in.
[CUSTOMER][NEGATIVE] So it doesn't even make sense.
[CUSTOMER][NEGATIVE] Gotcha.
[AGENT][NEUTRAL] Yes, so directly underneath the deductibles where it says outpatient benefits and you see that big uh bulleted list, those are the covered facilities um that this policy would cover. So the emergency room urgent care, um, you see ambulance down there at the bottom, so that is covered, um, physical therapy facilities, it's just not going to be a doctor's office or clinic that's going to be covered under this policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] So if my my emergency room bill was $500 because that was my co-pay.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] What, what then is going to be covered from that $500?
[AGENT][NEUTRAL] Right, yeah, so it's that entire $6000 limit per calendar year, it would pay up to that maximum per calendar year towards any co-pays, deductibles or co-insurance, of course, after your major medical pays. So if none of that has been used, then you have that full $6000 it would pay that full $500 and up until that maximum has been met for the calendar year. Does that make sense?
[CUSTOMER][NEUTRAL] Got you, OK, yeah.
[CUSTOMER][NEUTRAL] OK, so
[AGENT][NEUTRAL] Oh, it is a bit different.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] So the emergency room bill, which is $500 I haven't submitted that one yet because I couldn't get my scanner to work. Um, but the ambulance bill, I just need um a procedure code.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Diagnosis code, um, now I will say just yes no you're you're on the right track though um so I will tell you for anything, any claims that you file for this policy, general rule of thumb we're going to need itemized statements that show diagnosis and procedure codes and then the primary EOB that's going to be the extent of what we need for any claims that you file with this policy.
[CUSTOMER][NEUTRAL] Or diagnosis but
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And all of that information you can get from wherever it was that you received treatment, they will have that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. But so like the ambulance, um,
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I mean they'll have a diagnosed or uh they'll have that code.
[AGENT][POSITIVE] Yes, absolutely.
[CUSTOMER][NEUTRAL] OK, so I mean.
[CUSTOMER][NEUTRAL] Because they just took me to the hospital.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Anything that you for why they picked you up, that's generally going to be what that diagnosis code is going to show.
[AGENT][NEUTRAL] And I will say as well if you ever run into any um providers or anyone that you speak to that they're kind of confused they're not sure um they're more than welcome to give us a call as well um we do talk to providers all the time. I would also say of course going forward I would always try to give them this information so that they might be able to file the claim for you.
[CUSTOMER][NEUTRAL] Got you. OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] So whatever my insurance is going to pay, let's just, let's just use round figures. Let's say I have a procedure done in the hospital and it cost me $1000.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The, the insurance, let's just say they pay $500 of that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then so this insurance is gonna cover the other $500.
[AGENT][NEUTRAL] Correct, up to that $6000 calendar year maximum, yes.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I think I'm, I think I'm getting it now.
[AGENT][NEUTRAL] I understand it took me a while to get it.
[CUSTOMER][NEUTRAL] OK. So
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah, um, so would a, um, if I had a, uh, an angiogram done, would that be covered?
[AGENT][NEUTRAL] It depends on the location really. um, for this kind of policy, that's really the biggest thing. So again, any treatment that's received in a physician's office or clinic, not going to be covered. Um, however, again, there's the urgent care if that was done there or in an outpatient hospital, um, that would be.
[CUSTOMER][NEUTRAL] OK, so how do you qualify if it's an outpatient hospital?
[CUSTOMER][NEUTRAL] Versus the doctor's office.
[AGENT][NEUTRAL] Sure, yeah, so uh that's a physician's office like you said, like a, um, I would think more clinic is probably going to be the best way to describe that a clinic or like you said, like a specialist, those are going to be considered, you know, physicians' offices and they're not going to be covered. However, if it's a, you know, a big actual hospital that's different, that is going to be covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Sorry, I know it's a bit confusing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK, all right, thank you very much.
[AGENT][NEUTRAL] Sure, did you have any other questions for me?
[CUSTOMER][NEUTRAL] Not this time.
[AGENT][POSITIVE] Alrighty well thanks for giving us a call. I hope you have a great weekend.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Thank you bye bye.
[CUSTOMER][NEUTRAL] Bye.