AccountId: 011433970860
ContactId: 1be1ca7b-db04-47ed-9d61-92637f49128b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 496480 ms
Total Talk Time (AGENT): 300243 ms
Total Talk Time (CUSTOMER): 154708 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/04/1be1ca7b-db04-47ed-9d61-92637f49128b_20250304T20:23_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. I'm with my husband, [PII], and he has this gap insurance through his work.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Um, we've got a couple, like he's been going to we don't know how it works or or or what it does. We never used it before.
[AGENT][POSITIVE] OK. Yes, I can assist you with your benefits. Um, first, let's see, could I get your name and a good callback number just in case we're disconnected?
[CUSTOMER][NEUTRAL] My name is [PII] and I spell the last name, [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the phone number would be [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK. Thank you, [PII]. Now, could I get your policy number? Um, it'll be the outpatient certificate number on the card.
[CUSTOMER][NEUTRAL] It's 166296.
[CUSTOMER][NEUTRAL] 3 ML 8.
[AGENT][NEUTRAL] OK. OK, and please verify your date of birth, [PII] and your mailing address and your email address.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And what else, my home address?
[AGENT][NEUTRAL] Yes, sir. Your home address and your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And my email is [PII].
[AGENT][NEUTRAL] OK. Yes, sir. And I'm showing that this is a policy for secondary gap insurance. What we do is cover the co-pay, the co-insurance, and deductible after your primary insurance um processes a claim for covered services. Um, I'm showing that you have.
[AGENT][NEUTRAL] Services for inpatient hospital. If you're ever admitted into the hospital, we'll cover up to 3000 per calendar year for, again, the co-pay, the co-insurance, and the deductible after your primary insurance processes a claim. Um, there's also coverage for outpatient hospital services, and that's services such as outpatient surgeries or urgent care facilities or ER visits, um.
[AGENT][NEUTRAL] We covered that. Let's see, yeah, under the outpatient benefit and that's covered up to 1500 per calendar year. Um, I'm showing that there's no coverage for services provided in the doctor's office unless you're going for a cancer treatment.
[CUSTOMER][NEUTRAL] OK. So, no, no type of doctor visits, no type of uh physical therapy, and it's good for going to the hospitals or the ER. Yeah, urgent care.
[AGENT][NEUTRAL] Um, well, actually,
[AGENT][NEUTRAL] Actually, um, physical therapy would be covered under the outpatient benefit. So, yeah, there is coverage for physical therapy and that's covered up to 1500 per calendar year.
[CUSTOMER][NEUTRAL] OK, so right now, as of even today, I want to go for my 2nd 3 uh therapeutic for my shoulders.
[CUSTOMER][NEGATIVE] Now I had to pay $60 each time.
[AGENT][NEUTRAL] OK. Yes.
[CUSTOMER][NEUTRAL] So do we submit the receipt to you?
[AGENT][NEUTRAL] Well, what we'll need is the EOB from your primary insurance company. So after your primary insurance processes the claim, we'll need the explanation of benefit because it shows how much we um need to pay. cause it'll show the charges that went towards the copay, the co-insurance or deductible, and we'll also need your diagnosis code.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So how do I know when my insurance company?
[CUSTOMER][NEUTRAL] Does that
[AGENT][NEUTRAL] Um, well, who's your primary insurance company?
[CUSTOMER][NEUTRAL] Blue Cross Blue Shield.
[AGENT][NEUTRAL] Yes ma'am well you will reach out to them and um verify if they have the claim on file for today's date of service and if they've processed it, if they have processed it, um, normally they can um show you how to log into your policy online to print it off and once you print off that information you can send it to us.
[AGENT][NEUTRAL] Or you can contact them. Mhm.
[CUSTOMER][NEUTRAL] Now if
[CUSTOMER][NEUTRAL] Am I better waiting until the end to do that or do I do that?
[CUSTOMER][NEUTRAL] Every couple of weeks,
[AGENT][NEUTRAL] Well, what I recommend is that you let your um physical therapist provider know about us. Do they know that you have a secondary gap insurance with us?
[CUSTOMER][NEUTRAL] No, they don't.
[AGENT][NEUTRAL] OK. Well, you would give them our information, um, give them your policy number and our phone number. Let them know that you have secondary gap insurance because normally the pro the provider files the claim themselves. And um once they um give us a call to verify your benefits, they'll know not to charge you and they'll file the claims um themselves.
[CUSTOMER][NEUTRAL] OK. So we have to give this to the, um, the physical therapist.
[AGENT][NEUTRAL] Mhm. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right. So, when I go back to physical therapy, I just show them this, this card that I got. Yes.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, sir, and they'll give us a call to verify your benefits.
[CUSTOMER][NEUTRAL] At
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] And then my insurance company will take it from there.
[AGENT][NEUTRAL] Um, well, the, the provider's office will take it from there. What they'll do is file a claim with your primary insurance company, and once they receive notification that your primary insurance company paid their portion, they'll file the claim with us. The um provider's office will file the claim with us.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, and, and, and do I keep paying my $60?
[CUSTOMER][NEUTRAL] Copayment every time I go there.
[AGENT][POSITIVE] Well, once they uh call us to verify that you have secondary gap insurance, they'll see that you, that they'll see that you have this insurance and they shouldn't charge you anymore. They shouldn't charge you until the full 1500 is um paid out for this year.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, so the money he's paid out.
[CUSTOMER][NEUTRAL] Would that be retroactive when you see that the money was paid already?
[AGENT][NEUTRAL] Um, well, the, the services that he's already paid for, he can, um, file those claims himself since he's already paid for those, and, um, once we receive that claim, we'll reimburse him.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and the claims, is that on the back to check claim status of you.
[CUSTOMER][NEUTRAL] I go to that website to do all that.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, you, you'll have to go to the website and set your policy up online. And once you set your policy up online and log into your policy, you'll see how to file a claim with us. And in order to file a claim, again, we'll need the EOB from the primary insurance company.
[AGENT][NEUTRAL] For today's date of service. And we'll also need the diagnosis code. The diagnosis code is, is not on the explanation of benefits. So you can get that information from your doctor and write it on there. And the diagnosis code is um is just the code for whatever is going on with your shoulder. I think you said that you were going to physical therapy for.
[CUSTOMER][NEUTRAL] Like that.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, yes, sir. They'll, they'll give you the code for that. You'll write it on the explanation of benefits and you'll submit that information to us online. And that's how you'll file your claim. And once we get that information, we'll process the payment and it'll be sent directly to you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright, you think we got it? OK, I think we got it.
[AGENT][NEUTRAL] OK. And if you guys have any more questions, please feel free to give us a call. We're here at [PII] central time.
[CUSTOMER][POSITIVE] Very good, thank you very much.
[AGENT][POSITIVE] OK, thank you guys again for calling APL. Have a great day. Mm bye.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Thank you