AccountId: 011433970860
ContactId: 2d213c8d-ed0d-4c47-8008-e63c1e1699f0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1001080 ms
Total Talk Time (AGENT): 625031 ms
Total Talk Time (CUSTOMER): 322926 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/03/2d213c8d-ed0d-4c47-8008-e63c1e1699f0_20250403T19:55_UTC.wav
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[AGENT][NEUTRAL] For contacting APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello?
[AGENT][POSITIVE] Thank you for thank you for contacting ATL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hey, [PII], OK, I can hear you now. Um, hi, uh, do you need my name and my um
[CUSTOMER][NEUTRAL] Group number or policy number or some type of number?
[AGENT][NEUTRAL] Yes, your policy number. Yes, please, if I could have that.
[CUSTOMER][NEUTRAL] Uh, policy number is 02570837.
[AGENT][NEUTRAL] Thank you. If I could verify your name, date of birth, and a phone number.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the phone number is [PII].
[AGENT][POSITIVE] I appreciate that, [PII]. How can I help you with your policy?
[CUSTOMER][NEUTRAL] She.
[CUSTOMER][NEUTRAL] OK, um, I have a, excuse me, I have a question, um, actually, well, I guess maybe a couple of questions, but, uh, I had, um.
[CUSTOMER][NEUTRAL] I had a procedure done.
[CUSTOMER][NEUTRAL] Um, on the [PII].
[CUSTOMER][NEUTRAL] And um at, at, at a hospital and uh they said that I, they don't, they don't uh do the gap paperwork or whatever. I don't, I don't remember the exact terminology they use, but they said that they don't do it that I have to do it directly with you guys.
[CUSTOMER][NEUTRAL] Um, so I'm what I'm asking, what I'm calling for is, uh, what do I need to submit?
[CUSTOMER][NEUTRAL] Um, in order to, um,
[AGENT][NEUTRAL] File a claim yourself?
[CUSTOMER][NEUTRAL] Send it I guess put it yes.
[AGENT][NEUTRAL] OK, yes, absolutely, we can help with that. So you had, first of all, you had an outpatient hospital procedure. Um, if this is for sickness or uh or an illness, sickness or accident, um, we pick up the deductible co-payment or co-insurance from your major medical up to 1 $1250. Now, what we would do, or, or the paperwork that you would need, um,
[AGENT][NEUTRAL] They have an an itemized bill that the facility would have given to you. They, they should have given you one. If not, they need to give you an itemized bill and one of the things that they will have on the itemized bill is, is the assessment or, or uh the reason that you had the procedure done.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And that is uh part of your medical, uh, um, paperwork that they, that they will give to you whenever you uh have any sort of thing done. uh, so that will be what is considered like a walkout paper or an itemized bill. So you will have that.
[AGENT][NEUTRAL] And then you have a major medical um insurance as well. Now, your, your major medical, I believe, is through uh Cigna, if that's correct?
[AGENT][NEUTRAL] Uh, and you'll have a you'll have an explanation of benefits from Cigna for that date of service, and on that explanation of benefits it will tell you the deductible, co-payment, or co-insurance that, that, um, we need to know so that we know what to pay out. So the uh documentation that you would need, uh, would be the itemized bill um along with the assessment, you know, the reason why you had the procedure done.
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] And then ya like um uh explanation of benefits showing how they um how they process the claim, what, what your deductible, co-payment or co-insurance is. Now, once you, you have those two documents.
[AGENT][NEUTRAL] Uh, there's several ways to file your claim. Probably the fastest one, is to go on our website which is [PII]. It's [PII], and then in our website may actually be on the back of your card. And when you get to that website, it it uh it says APL workforce benefits that work for you, and on the right hand side it says sign in.
[AGENT][NEUTRAL] And what this it will ask you to do if you don't already have a an account with us you'll you'll just have to create one and then you can download the the documents and submit them to them uh to uh them uh that way.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, otherwise, you can mail or fax those documents.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] If you would like.
[CUSTOMER][NEUTRAL] OK, so, so, [PII], let me ask you something, um, OK, so let me just repeat, uh, what, what you just said, um, not word for word, obviously I didn't remember every word for word, but basically what I need is the explanation of benefits from Cigna.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Correct?
[AGENT][POSITIVE] That's correct, yes.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] And then the other document I need is an itemized bill.
[CUSTOMER][NEUTRAL] With the reason for procedure.
[AGENT][NEUTRAL] Yes, it's called your assessment. It, it's a diagnosis code or an or an assessment. And um.
[CUSTOMER][NEUTRAL] And, and that would be.
[CUSTOMER][NEUTRAL] Sorry, and that would be through the hospital or through my doctor?
[AGENT][NEUTRAL] Well, the, the, um, the hospital, uh, will have an itemized bill. Um, if you're, you're probably going to be sending in, whenever you have something like that done, um, there's, there's several bills that you, that you will receive. You, you'll notice there's never just one bill. Um, there's the facility bill, there's your physician's bill, if you had anesthesia, there's the anesthesia's bill, um, anesthesiologist's bill. So, um,
[AGENT][NEUTRAL] What, uh, what is it that you're trying to submit? Are you trying to submit the, the facility bill for the, for the, the, the outpatient hospital facility or your physician's bill or?
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] OK, so let me, let me explain to you, I guess, um.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] So, uh, they had me, I, excuse me, pay a, a, a co-pay, I guess that's what it's called, before, um, they did anything.
[AGENT][NEUTRAL] And that was the facility that did that or or the uh.
[CUSTOMER][NEUTRAL] Right, um.
[AGENT][NEUTRAL] The doctor.
[CUSTOMER][NEUTRAL] Yeah, that was the hospital. That was the hospital.
[AGENT][NEUTRAL] The hospital. OK. OK. All right. Um, so the itemized bill, uh, from the hospital, you, you will contact the hospital for that. So the itemized bill for the hospital, you'll contact that. You might end up having to contact your doctor for the um assessment or the diagnosis code.
[AGENT][NEUTRAL] Uh, now, Cigna has an online, um,
[AGENT][NEUTRAL] Service center as well, where uh uh and, and probably your doctor's office does as well, um, where you will be able to contact your doctor um either online or, or you just will have to call his office. Do do you have, are you signed up with your doctor? Does, does he have like a um
[AGENT][NEUTRAL] Uh, an online, uh, service center that you can, you can actually talk to one of the nurses, one of the doctors, anything like that.
[CUSTOMER][NEUTRAL] Well, I, I, I, yes, but I mean, I have a doctor's appointment tomorrow, so I was, I was gonna, uh, go and, and ask them.
[AGENT][NEUTRAL] That you
[AGENT][POSITIVE] Oh, OK, awesome.
[AGENT][NEUTRAL] OK, yes.
[CUSTOMER][NEUTRAL] And that's why I'm calling today because I wanna.
[CUSTOMER][POSITIVE] I wanna make sure whatever I need from the doctor I can get it tomorrow since I have an appointment tomorrow.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, OK. Well, that's, that, that's even better. So when you, when you see your doctor tomorrow, um, explain to them that you're getting ready to turn in that bill, uh, you know, so you, to your insurance for that procedure, um, that you had. And uh they have what is called the walkout papers. They then they can give you a copy of that. Um, and on the walkout walkout papers, it tells, you know, why you were there, um, who you were seen by, and then it's called an assessment or a diagnosis code, and that should all be on there.
[AGENT][NEUTRAL] Now, now you'll have that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But what we're turning in now is the facility bill.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] If you have not already received.
[AGENT][NEUTRAL] A bill from them in the mail.
[AGENT][NEUTRAL] You can contact the billing department for that hospital and they can send you.
[AGENT][NEUTRAL] Uh, a copy of the itemized bill. So normally what they'll do is they'll go ahead and and send that to you that um they usually will mail it to you along with the, you know, you owe this much or something like that, but if they have not done that already.
[AGENT][NEUTRAL] Um, you can ask them for that. So we're gonna be asking for two different things. So actually, you're gonna have 3 different things now. So we're gonna get the, we're gonna get the, uh, the walkout papers or the, um, the, uh, assessment from the doctor, letting us know why we, we had to have that procedure on that particular day. We're gonna get something, a bill, I know this bill from the facility, letting us know how much the, the hospital bill was, the data service, that sort of thing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And then we're gonna get the Cigna EOB for that data service that shows the deductible co-payment or co-insurance that that.
[AGENT][NEUTRAL] Cigna has is put towards this, towards this procedure that we need to know um so that we'll know what to pay you.
[AGENT][NEUTRAL] Because
[CUSTOMER][NEUTRAL] OK, so, so what I paid the hospital before the procedure, that's, you guys don't cover that or you do cover that?
[AGENT][NEUTRAL] Well, it depends on um uh what we do on, this is an outpatient procedure, so what we do for outpatient services, we will pick up the deductible, co-payment or co-insurance, um, up to $1250. Now, I don't know how much they ask you for.
[AGENT][NEUTRAL] Um, but, but your, uh, secondary insurance or us will pick up the deductible, co-payment or co-insurance up to that amount, the $1250. Did they ask you for more than that, or?
[CUSTOMER][POSITIVE] Alright, I can tell you it's a lot more than that. Yes.
[AGENT][NEUTRAL] It wasn't? OK. And was this an outpatient service? Were you, were you in there overnight or?
[CUSTOMER][NEUTRAL] No, I, it was, I was, uh, it was outpatient. I was not overnight.
[AGENT][NEUTRAL] I, I understand. OK. Well, your, your secondary insurance um will pick up the, the deductible co-payment or co-insurance up to $1250 and that, that is what your, your secondary insurance will do.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK, uh, yeah, uh, um.
[CUSTOMER][NEUTRAL] That's not what I was told when I was sold this, but I know that's not your fault, um, OK.
[AGENT][NEUTRAL] So did, did they, they charge you much more than this? Is that what is?
[CUSTOMER][NEUTRAL] Um, alright,
[CUSTOMER][NEUTRAL] Yeah, it was like 4000 bucks.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and do you know what your deductible or uh deductible is from Cigna before they'll, they'll pay out anything, or is it, is it $4000 because.
[CUSTOMER][NEUTRAL] No, I
[CUSTOMER][NEUTRAL] I, I have to, I have to look and see. I don't know. I, I have, honestly, I don't know what it is.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Because normally, um, well, it just depends uh on, on what you're
[CUSTOMER][NEUTRAL] But um
[AGENT][NEUTRAL] On what your um deductible is. Uh, now, for the inpatient services, we pay up to $2500 but, but that's the maximum per individual that we pay for outpatient services.
[CUSTOMER][NEUTRAL] Right, OK, no, no, that's fine. I, I'm, I'm not, uh, I'm not calling, I'm not.
[AGENT][NEUTRAL] And usually, yeah, yeah. Oh no, I understand, yeah.
[AGENT][POSITIVE] Oh, no, I understand, absolutely.
[CUSTOMER][NEUTRAL] I'm not calling to, to.
[AGENT][NEUTRAL] Yeah, I
[CUSTOMER][NEUTRAL] argue anything. I just uh
[CUSTOMER][NEGATIVE] You know, again, uh, you're, you're telling me what it is and, and unfortunately I wasn't told this, um, and then now I.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I mean it is what it is, you know, no, it's, it's not your fault, yeah, whatsoever, um.
[AGENT][POSITIVE] Yeah, I'm very sorry.
[AGENT][POSITIVE] Well, now, um, when, when you do decide, when you do, um, uh, submit that, if you would like to submit your paperwork and then have one of us look it over, um, then we would be glad to do that. If you have any questions when you do get those documents that we can, um, you know, so that we can make sure that uh we can, we have all, everything, um, all our ducks in a row so that you can submit that to us. So if you have any questions when you're getting ready to do that, please let us know and we'll go over the paperwork and, and see what you've gotten. Yeah.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] I, I have another question for you and maybe you might not, maybe you might not know this, um, but you might not know the answer to this, but I, I just looked right now and in the signal, um, in my account or whatever.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And it shows the
[CUSTOMER][NEUTRAL] Uh, I guess on the medical claims it shows the hospital.
[CUSTOMER][NEUTRAL] Um, for that date, you know, the procedure, whatever, but it, it just says action required, it's not ready yet, says attempting to process your claim, um, and then I have another one from the actual doctor.
[AGENT][NEUTRAL] Oh, yes.
[CUSTOMER][NEUTRAL] That did the procedure.
[CUSTOMER][NEUTRAL] So is that two separate bills that I'm gonna get from them or you don't know?
[AGENT][NEUTRAL] Oh, no, it is, it is. Yeah, that's what, that's what um I meant earlier when I said that um whenever you have a procedure uh um then, let's just say that you have, I don't know, uh, some procedure done in the outpatient um uh surgery center.
[AGENT][NEUTRAL] Um, there's lots of bills, so you would have one bill. This is all completely separate, you have one bill from.
[AGENT][NEUTRAL] Each doctor who saw you.
[AGENT][NEUTRAL] You'll have bills, uh, sometimes separate bills from each anesthesiologist and then on top of that, you have the facility bill. So absolutely, they're gonna be different.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So, so there will be multiple bills that will be.
[CUSTOMER][NEUTRAL] But, but none of that
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] Yeah, there, there, there's usually multiple bills for each for each thing you have done.
[CUSTOMER][NEUTRAL] OK, but, but what I was gonna ask you, none of that obviously pertains to you, you guys just.
[CUSTOMER][NEUTRAL] Cover, you know, 1250 or for uh I believe that's the amount you said.
[AGENT][NEUTRAL] That's right. That's right. And you, regardless of whatever it is that you had done, um, that's, that is what we will do, but you can, you can send in, um, you know, it, it doesn't matter which bill you send in, um, that's the amount that, yes, that, that you're correct. That's exactly how much we will end up paying is that, is up to that $1250.
[CUSTOMER][NEUTRAL] And that's it.
[CUSTOMER][NEUTRAL] Regardless, OK.
[CUSTOMER][POSITIVE] OK, all right, no worries. um OK, so I will, um.
[CUSTOMER][NEUTRAL] I will
[CUSTOMER][NEUTRAL] Uh, get those documents and then, um.
[CUSTOMER][NEUTRAL] And then I'll uh is now is there a time frame?
[CUSTOMER][NEUTRAL] That I have uh to be able to get this info and and upload it on your website.
[AGENT][POSITIVE] No, not at all. Um, you can do that just at any time.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK, alright, well, I don't want it to, to take forever, you know, I, I'm, as soon as I get it I'm gonna.
[CUSTOMER][POSITIVE] I'll upload the stuff that uh that you're requesting. Alright, so just just to to to go over 11 last time just so I don't um miss anything you need the explanation of benefits from Cigna.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] And then you need the itemized bill from the hospital.
[CUSTOMER][NEUTRAL] And you need the.
[AGENT][NEUTRAL] Yes, sir, yeah.
[CUSTOMER][NEUTRAL] The assessment from the doctor, the walkout papers, so you need those three things.
[AGENT][NEUTRAL] Yes, um, and, and to make it easier, it's just, it's just, um, an anonymousvill, um, and then, uh, the explanation of benefits and then from your doctor, whatever, whatever reason, the, the diagnosis that you went, that you had to have that procedure for, you know, whatever it is that you had done. But yes, sir, that, that is exactly what you would need.
[CUSTOMER][NEUTRAL] Right, and the, the reason it would be with the, the assessment, right? It would be in there?
[AGENT][NEUTRAL] Yes. Yeah, that's what, yes, whenever you see the doctor, they're making an assessment, oh, this guy has tendonitis or this guy has whatever. Um, and that's, that's what we, uh, we need because we need to to know, you know, what, what procedure you went in for and why. Uh, and, and your major medical won't give that to us and neither will the hospital, so that's what we, we have to get that from you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Understood.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, excuse me, alright, well, um, I guess you answered all my questions.
[AGENT][POSITIVE] OK, well, if you do have any other questions like I said before when you're submitting, please let us know and we will be glad to to help as much as we can.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] OK, perfect. Thank you so much.
[AGENT][POSITIVE] OK, well thank you for contacting API. You have a good day.