AccountId: 011433970860
ContactId: 2528a62a-828d-4764-9794-56732fd8598d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 639739 ms
Total Talk Time (AGENT): 229376 ms
Total Talk Time (CUSTOMER): 300271 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/28/2528a62a-828d-4764-9794-56732fd8598d_20250228T23:15_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello ma'am. I'm sorry, I'm going to ask you an information about your claim on my account. Can I speak with you?
[AGENT][NEUTRAL] Yes, sir. I can help you with your claims. Can you please give me your name and your policy number?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII] and my policy number is 02212366ML7.
[AGENT][NEUTRAL] OK, let me look up your policy real quick.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII], what is your birthday?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you so much for verifying that and may I also get your address, phone number and email address?
[CUSTOMER][NEUTRAL] Oh my [PII], it's um [PII]. Email is uh my last name, [PII]. And the address is [PII].
[AGENT][NEUTRAL] Thank you, I appreciate you verifying that policy for me and you're needing claim information um, are you wanting to check the status of the claim?
[CUSTOMER][NEUTRAL] I would like to check a couple of claims because I don't see them my list of claims.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I would like to ask you if there is anything that maybe I don't see or not.
[AGENT][NEUTRAL] OK. All right. And, mhm, go ahead.
[CUSTOMER][NEUTRAL] Because uh
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, in my primary health insurance, there is a claim, for example, on [PII].
[CUSTOMER][NEUTRAL] And uh I don't see it in uh my uh my list of claims in your website.
[AGENT][NEUTRAL] OK. Do you know, um, the claim number or?
[AGENT][NEUTRAL] Or not.
[CUSTOMER][NEUTRAL] The claim number on my primary insurance?
[AGENT][NEUTRAL] Um, and you said it was for January, that was the date of service, [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let me look and these are for you, is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's for the year of [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, what was the name of the facility that you went to?
[CUSTOMER][NEUTRAL] NCH.
[CUSTOMER][NEUTRAL] Um, pro scan.
[CUSTOMER][NEUTRAL] Imagine
[AGENT][NEUTRAL] And that was the day that you went was [PII], is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, I'm not showing a claim has been submitted for that date of service.
[AGENT][NEUTRAL] So you'll need to get the um the facility that you went to, they need to submit the claim for you.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mm, um, OK, I understand.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] OK, that's, um, that's great. And so also I have uh something else I would like to ask you regard the I don't know I have the claim number on this one.
[AGENT][NEUTRAL] Yes sir, what is that?
[CUSTOMER][NEUTRAL] Is 356-2174?
[AGENT][NEUTRAL] OK, let me pull that one up.
[AGENT][NEUTRAL] OK. I've got it pulled up.
[AGENT][NEUTRAL] And what is your question?
[CUSTOMER][NEUTRAL] Yes, who are you?
[CUSTOMER][NEUTRAL] I don't understand what there is, uh, on the back because, uh, um, benefits are payable only if your major medical insurance provider.
[CUSTOMER][NEGATIVE] Provides benefits if this claim is later paid by your medical insurance based and the explanation of my insurance benefits were paid, what that exactly means? So you, you didn't cover this one.
[AGENT][NEUTRAL] Right, so your primary insurance needs to pay first.
[AGENT][NEUTRAL] And so if you send in the explanation of benefits where they paid.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] And what they paid, then we come after that. So this policy that you have helps with deductible, co-pay, and co-insurance.
[AGENT][NEUTRAL] So we need the explanation of benefits from the primary insurance showing that they paid.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, yeah, I understand that. And, uh, for example, if, uh, the, I mentioned is for all the claims is like that.
[CUSTOMER][NEGATIVE] Uh, if they, for example, if they, they, they, uh, they didn't pay because I didn't reach the deductible, you are supposed to cover it or not?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right, so, um, if it shows where the deductible co-pay or co-insurance was paid on the primary EOB then you can submit for us.
[AGENT][NEGATIVE] For that if it's not paid by the primary then it's not paid by us.
[CUSTOMER][NEUTRAL] Yeah, I know, I understand what you mean, but my question is, is the is the gap insurance, so your insured, the APL is not supposed to pay my deductible when I'm haven't reached yet the the entire deductible for my private insurance, so it's, it's covering this gap.
[AGENT][NEUTRAL] Right, only if your major medical insurance provides the benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So for example if my um uh primary insurance um in uh I I have like for example I have an amount bill of 2090 and then there is this plan discount of 1200.
[CUSTOMER][NEUTRAL] So that means um that my primary insurance didn't pay but apply a discount on this uh invoice. I have a total amount on my pocket of 878 that they can't cover because I haven't reached yet the deductible. What that means that you're gonna cover the 878.
[AGENT][NEUTRAL] No, on, on this claim, it's already been submitted, so the office visits are not covered by your policy.
[CUSTOMER][NEUTRAL] No, but it's not an office visit. This is like an um MRI.
[AGENT][NEUTRAL] OK, so there's 3 remarks on this claim. One is the office visits. The second one is the
[CUSTOMER][NEUTRAL] Oh, no, no, sorry, sorry, sorry, this is, this is, this is not the, the one that I'm talking about, but is, uh, is another one. Sorry, this is, I understood though about the, the one that I sent you the claim number is OK. I understood that because there is a co-payment that is in my pocket, but the second one was just, uh, a general question that I need to clarify it to myself because I'm not sure that I understood.
[AGENT][POSITIVE] OK, good.
[CUSTOMER][NEUTRAL] So in case I do like an MRI or an echocardiogram and the primary insurance is not covering because I haven't reached yet the uh deductible is are you in charge to cover the bill?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, up to now, on your, on your policy.
[AGENT][NEUTRAL] You have an outpatient benefit amount of.
[AGENT][NEUTRAL] Let me look at it real quick, $7150 so up to $7150 this and this is just to verify your benefits, it's not a guarantee of payment up to the $7150.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] This policy will help with deductible, co-pay, or co-insurance in a covered facility.
[CUSTOMER][NEUTRAL] OK, so if I'm, if I was in a in network facility you gonna pay the the balance uh um.
[CUSTOMER][NEUTRAL] Of the deductible, right?
[AGENT][NEUTRAL] Right, if the primary insurance pays first.
[CUSTOMER][NEUTRAL] OK, but if the insurance didn't pay because I haven't reached deductible, how we can, uh, clarify this point.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So, if the
[CUSTOMER][NEUTRAL] So my insurance will start to pay when I reach the deductible, but the deductible is not reached yet. So for this reason, I think that the gap insurance need to pay the gap.
[AGENT][NEUTRAL] OK, so the only thing you can do is, is send in the claim, um, with the explanation of benefits from your primary insurance and the itemized statement from your primary insurance and let the claims examiners examine the claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, OK, OK, um, yeah, OK, thank you so much.
[AGENT][POSITIVE] You're so welcome. I hope you have a wonderful weekend and we appreciate you calling APPL.
[CUSTOMER][POSITIVE] Yeah you too thank you so much.
[AGENT][NEUTRAL] All right, bye-bye, sir.
[CUSTOMER][POSITIVE] Thank you thank you bye bye.
[AGENT][POSITIVE] You take care. Bye bye.