AccountId: 011433970860
ContactId: 270d962a-ff66-4138-a8fe-a2489015c283
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 809739 ms
Total Talk Time (AGENT): 527810 ms
Total Talk Time (CUSTOMER): 204334 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/08/270d962a-ff66-4138-a8fe-a2489015c283_20250108T16:02_UTC.wav
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[AGENT][POSITIVE] Good morning thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I have a plan for you guys and I was wondering what is the easiest way for me to get a copy of what you guys have been paying on my medical bills because I think I have some providers that are charging that you guys are paying on but I'm also having to pay that bill.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so you're wanting to find out about how to see what claims we've received and explanation of benefits for those claims, is that correct? Yes, ma'am, I can help you with that. And who am I speaking with?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And Ms. [PII], do you spell [PII] or [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And your callback number?
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you. And your policy number, please?
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Let's see 02479853.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. One moment while I get your information pulled up mistakes and once I do, I will have to verify several things with you first for security. So just one moment please.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so first off, Miss [PII] and any information provided will be a verification of benefits and not a guarantee of payment.
[AGENT][NEUTRAL] So first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, your home mailing address?
[CUSTOMER][NEUTRAL] [PII] and that [PII].
[AGENT][NEUTRAL] Thank you. The phone number that we have on file for you is also the same as the one that you gave me, so that is your best contact number, is that correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][POSITIVE] Thank you and lastly your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. So first question, have you ever set up your profile, Miss [PII], in our portal? It's called the online service center.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So I did that this morning.
[AGENT][NEUTRAL] OK, so in the port now uh there's a user guide that not only tells you how to set up your profile but it tells you the different things that you can do within the portal as well because you do have access to your explanation of benefits for the claims that we have for you in your portal.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] So I can email you that user guide that gives you those steps if you would like for me to do that I'll be happy to.
[CUSTOMER][NEUTRAL] That would be fine.
[AGENT][NEUTRAL] OK, all right. Well, give me just one moment and I'll do that right now.
[AGENT][NEUTRAL] OK, so I have just sent that to you. The email that you're gonna get from me, um, Ms. [PII], is gonna come from [PII] [PII], and I did put APO in your subject line for you, but I can see according to your profile that we have 3 we've only, we only have 3 claims on this policy, so you should be able to print each of those explanation of benefits.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, so that is what I think. So I think that's part of my problem. So now my question is all for I've had this insurance since like April.
[AGENT][NEUTRAL] Again, from within the portal.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So my, so my main medical provider apparently has not been submitting them to you.
[AGENT][NEUTRAL] OK. Now,
[CUSTOMER][NEUTRAL] And I'm not entirely sure why, so what do I do about that?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, if they, if, if they can't, what do I do? or you know.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure. OK. So if for some reason, now I will, let me look at just a couple of things on your policy for you.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Because I can see that one of these claims that was processed was for an office visit.
[AGENT][NEUTRAL] And office visits are not covered under this policy.
[CUSTOMER][NEUTRAL] OK, that's fine.
[AGENT][NEUTRAL] OK, so um I could just easily see that um now any claim, if a provider will not file a claim, then you can actually submit the claim yourself to APL.
[AGENT][NEUTRAL] Those instructions that I sent to you explains how you can upload a claim to our portal. Now I didn't include the claim form, but I can give you our website where you can download the med link if you'll notice on your ID card it should say Medlink.
[CUSTOMER][NEUTRAL] Uh huh
[AGENT][NEUTRAL] Supplemental. OK, so that's the type of claim form that you're looking for, but you can go to our website section by going to [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] When that page pulls up at the top you will see a link that says claims and forms.
[CUSTOMER][NEUTRAL] Uh huh
[AGENT][NEUTRAL] Click there
[AGENT][NEUTRAL] Then you're just gonna scroll down the page and you'll come to a little box that says filter by product and it has a green drop down arrow in it.
[AGENT][NEUTRAL] If you click on that drop down it's gonna give you a list of the different forms you will see where it says med link.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Just click the word med link.
[AGENT][NEUTRAL] And once you do that out to the right of your screen you should see a blue button that says download form.
[AGENT][NEUTRAL] And click that.
[AGENT][NEUTRAL] And the claim form will open up the top of the first page has the instructions for what you would need to submit along with the claim form for our review.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, with APL, Miss [PII], there is not a timely filing limit like there is with, uh, you know, a lot of insurance companies. So it's, even if you found something, you know, if you still have found something next year that fell within your.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] You know, benefit period that's from [PII] forward you could still fall with us.
[CUSTOMER][NEUTRAL] OK, and then my, my other question is, um, what does it cover because that way like obviously office visits I won't bother to upload those.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. So now, again, in the portal, I'll be happy to go over your benefits, but you can also, there's a copy of your policy certificate that would explain, that gives you all of your benefit information in that portal as well, you just click on your policy number, then you'll see a little PDF icon.
[AGENT][NEUTRAL] If you click that, it'll download your policy, your full policy document.
[AGENT][NEUTRAL] So this plan, um, you know, just for a general overview.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] This does help you with your co-pays, deductibles and co-insurance amounts of covered services. Um, one moment it's still loading your information.
[AGENT][NEUTRAL] So on your outpatient benefits, if you go to emergency room, urgent care, now on your urgent care, you have a maximum of 3 urgent care visits per cover person per calendar year.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] But if you had to have any type of outpatient surgery, whether that's at a hospital outpatient setting or an outpatient surgery center, diagnostic testing, whether that's done at a hospital or a free-standing facility.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Those are types of things, um, if you went, mhm.
[CUSTOMER][NEUTRAL] So, so
[CUSTOMER][NEUTRAL] To summarize every colonoscopy that I had or endoscopy every um like scan or uh physical therapy, those kinds of things.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We can review those types of things. Now, your outpatient benefit maximum is $500 per covered person per occurrence for covered outpatient services.
[CUSTOMER][NEUTRAL] OK, so, so that means a max of for that type of thing but not a max for the year.
[AGENT][NEUTRAL] And what, what?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] No, you have a per-occurrence outpatient benefit. And in your poli I will read, I will explain the definition of what per recurrence means, but there is also in your policy certificate definitions for each term.
[AGENT][NEUTRAL] So a per occurrence means treatment for the same or related condition.
[AGENT][NEUTRAL] Unless separated by a period of 90 days.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Treatment for the same or related condition that's separated by 90 days or an unrelated condition will be considered a new per occurrence.
[CUSTOMER][POSITIVE] OK perfect.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] OK, I really appreciate that um.
[AGENT][POSITIVE] Absolutely.
[CUSTOMER][NEGATIVE] I think um essentially nothing that would have been pertinent to you guys actually got sent to you.
[AGENT][NEUTRAL] Oh goodness. Oh my. Well, hopefully, the providers will file for you, um, but if they want, like I said, the claim form, because you have to submit, one of the things you have to submit with each of your dates of service that you would be filing for is your primary insurance company's explanation of benefits. We always have to have that and we will have to have an itemized bill.
[AGENT][NEUTRAL] From the provider with listing, you know, the diagnostic code, diagnosis codes and all that. Again, don't write all that down. It's on the claim form.
[CUSTOMER][NEUTRAL] I understand.
[CUSTOMER][NEUTRAL] Um, so I will, um, yeah, so I think I can get all the detailed bills off of my portal link for the doctor's office, so it may just be that I have to call the insurance company and get them to.
[CUSTOMER][NEGATIVE] Explain to me how to get my EOBs because I don't think they mail them to me. I think they're online somewhere.
[AGENT][NEUTRAL] Oh, OK. So, yes, ma'am. And now on your, yes, and just make sure that on your bill, a lot of times with, on bills, they don't include diagnosis codes.
[CUSTOMER][MIXED] OK, but you need both of those.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So just make sure because that is, we have to know the, it may have, say, for example, if you had had an MRI it may list out the code for the MRI which is the CPT code, but we have to have the diagnosis code telling the why this was done.
[CUSTOMER][NEUTRAL] Uh huh
[CUSTOMER][NEUTRAL] Got it. OK, well, just so you know, uh, one of my major health is like a major health care center and so when I contacted them this morning asking them why I'm paying all these bills that I really thought would be like minimal, um, she was very confused by.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Um, and unable to answer my questions, they're actually researching it, so I'm kinda hoping that they will go back and file it for me and not me file it, but, but I just need the backup plan.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, if if if they for any reason don't, and like I said, the great thing with us is that there's not a timely filing limit.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] You know, um, so it can be filed with us at any point. Now, were you admitted at any point this past year and since the policy has gone into effect as an inpatient?
[AGENT][NEUTRAL] Or was everything that you had done outpatient?
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] No, everything I had done was outpatient and it was all last year.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so yes ma'am, I see the policy did go into effect for [PII] and as of now, the only three claims that have been received are the ones that you can see in in your portal.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it. OK, alright, so yeah, I have, I have several things apparently that didn't get reported, so I need to figure that out.
[AGENT][NEUTRAL] Mm. OK. OK. Well, is there anything else, Ms. [PII], that I can help you with at the moment?
[CUSTOMER][NEUTRAL] No, I think that's it. I just needed to kinda understand so I know where to go and what to do.
[AGENT][POSITIVE] OK. Well, if you have any other questions come up, please feel free to give us a call and we will be more than happy to help you.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] You are very welcome and thank you again for calling APL. I hope you have a wonderful day.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mm bye.
[AGENT][NEUTRAL] Bye bye.