AccountId: 011433970860
ContactId: 33260634-78b9-404f-a3cf-ff01b8b9d827
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 598289 ms
Total Talk Time (AGENT): 358630 ms
Total Talk Time (CUSTOMER): 191165 ms
Interruptions: 0
Overall Sentiment: AGENT=1.7, CUSTOMER=1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/33260634-78b9-404f-a3cf-ff01b8b9d827_20250121T21:17_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, [PII]. How are you doing today?
[AGENT][POSITIVE] Oh, I'm doing wonderful. How about yourself today?
[CUSTOMER][NEUTRAL] Uh, not too bad. Um, I'm calling because I actually am not as familiar with indemnity insurance, uh.
[CUSTOMER][NEUTRAL] And my wife has a surgery this Thursday, um, but to my understanding based on the coverage and benefits, uh, we would be able to apply.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I guess that insurance for her surgery or at least a portion of her stay or at least the admission and so I just wanted to give you guys a heads up and maybe just get some clarification on if there are any additional steps that I need to take between now and Thursday.
[AGENT][POSITIVE] OK, yeah, absolutely. I'd love to help you look at that today. Do you have the policy number handy?
[CUSTOMER][NEUTRAL] Uh, yes, I do.
[AGENT][POSITIVE] Oh, perfect.
[CUSTOMER][NEUTRAL] So, I think so.
[CUSTOMER][NEUTRAL] Yeah, uh, so the policy number is 025.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 812
[CUSTOMER][NEUTRAL] 22.
[CUSTOMER][NEUTRAL] And then I have a group number as well.
[AGENT][POSITIVE] Hopefully that policy number gets me exactly where I need to be.
[AGENT][NEUTRAL] And
[CUSTOMER][POSITIVE] Cool.
[AGENT][POSITIVE] Perfect. Could you verify for me, pretty please, uh, just your last name and your date of birth?
[CUSTOMER][NEUTRAL] Uh [PII] and then [PII].
[AGENT][NEUTRAL] Thank you. And I do just need to verify a couple other quick information bits with you before I can go over the policy, um, but could you verify for me your mailing address, please?
[CUSTOMER][NEUTRAL] Uh, yeah, [PII].
[AGENT][NEUTRAL] Thank you. And then the email address on file?
[CUSTOMER][NEUTRAL] Should be uh [PII]. If not, it'll be uh my first name. middle.last name at Hearts.
[AGENT][NEUTRAL] No, it was that first one and then.
[CUSTOMER][POSITIVE] OK, cool.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] So I'm just waiting for some of your policy documents to load on my side.
[AGENT][NEUTRAL] And let's see.
[AGENT][NEUTRAL] So, as far as submitting a claim or filing a claim, um.
[AGENT][NEUTRAL] The, have you used our online service center before, my friend?
[CUSTOMER][NEUTRAL] Uh, I have not, um, again, I just got this in the mail probably a week ago and hadn't really had the chance to open it until today. So if there's something I need to do online, uh, that's, that's fine. I just want to, normally I call insurance before there's kind of a surgery or a major appointment and so I figured the same would be true for.
[CUSTOMER][NEUTRAL] Uh, for calling you all.
[AGENT][NEUTRAL] No, I appreciate your, you know, being thorough here, um, so I'm just gonna email you out some information I think is gonna be helpful to you um one is just gonna be the user guide for setting up our online portal, um, that's gonna be your quickest, best way to file claims and submit them with us, um, and then you're gonna be able to view your claims in real time, view like the results of them, set up, you know, your payment, like how do you want that direct deposit through a check.
[AGENT][NEUTRAL] Um, and so that's gonna be really beneficial to you. I'm also gonna send you a copy of our claim form that's gonna tell you when you're submitting a claim with us, all the documents and information you need. So you're gonna need like your itemized bill from your um hospital or outpatient surgical facility wherever it is you go. Um, you'll want the bill, you'll want the diagnosis code. And so it's just gonna let you know what to submit and have you fill it out and send it in.
[AGENT][NEUTRAL] Um, and so I'll make sure you have a copy of that on hand, um, that way, especially as you're at the facilities you can ask for the right documentation, um, and then.
[AGENT][NEUTRAL] What I'm seeing on here is as far as your benefits, I don't have your full benefits, uh,
[AGENT][NEUTRAL] Policy information up, but I do see that you have, if you're admitted to the hospital, you do have a benefit there. um.
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] It looks like.
[AGENT][NEUTRAL] Um, if the surgery is because of an accident, you do have, um, outpatient, uh, or not outpatient, I'm sorry, but you do have accidental surgery benefits as well with us. Um,
[CUSTOMER][NEUTRAL] OK, but that's if it's in an accident, that's additionally. So if this is a um like follow-up surgery or if this is a surgery because of, you know, a complication or something like that, it's still covered to the extent that the, the benefits guide describes. Is that correct?
[AGENT][NEUTRAL] Um, it should be, but I'm not showing on here, uh, a surgical benefit aside from just the accidental surgical benefit. And granted, I don't have your full policy document like the 30, 40 pages to read through yet because it's, it hasn't been fully generated, um, but
[AGENT][POSITIVE] The benefits I'm looking at.
[AGENT][NEUTRAL] You have like a critical illness benefit.
[AGENT][NEUTRAL] Um, your outpatient accident treatment, outpatient.
[AGENT][NEUTRAL] Um, sorry, that's for physical therapy and outpatient accident treatment for the ER and outpatient accident treatment for urgent care for the physician's office, the critical illness, and then the outpatient accident surgery benefit in a facility or in a physician's office, is what I'm seeing listed as your covered benefits with this plan.
[CUSTOMER][NEUTRAL] OK. Um, got you. So if I see hospital admission benefit per day, there's
[CUSTOMER][NEUTRAL] I need to like read through the, the guide to see if there, that would be, there'd be any exceptions to that, because I see the accident surgery benefit.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] Yeah, so that hospital admission benefit, um, that one is I do see that as a listed benefit for you, um.
[AGENT][NEUTRAL] And it looks like that's just being admitted to the hospital, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Yeah, and then this, I would always recommend though, like I would send everything and any benefits payable or benefits payable, you know what I mean? Like I would just, I'd err on the side of sending all your charges and whatever you can get paid out for, like, you know, try to get those benefits paid to you.
[CUSTOMER][NEUTRAL] Uh, sure. Well, I
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Sounds good. Well then, uh, you said your name was [PII], right?
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] OK. [PII], I have one question then. Uh, I appreciate the information and I will look for your email. My question is, is there anything that I need to do on the front end? Do I need to bring any kind of documentation, uh, with my wife and I to her surgery tomorrow, or do I just simply need to show this card to one of her providers or someone that works underneath, uh, my wife's provider tomorrow or Thursday rather?
[AGENT][NEUTRAL] OK, yeah, so I mean it can go a couple different ways so if you want your provider can place a claim on this policy on your behalf. I do wanna let you know though that any benefits payable, um, especially where this is a lump sum benefit.
[AGENT][NEUTRAL] Um, goes to the provider where if you file the claim on your own behalf that lump sum benefit goes to yourself, um, and so I don't know you might just decide from there like what's your best course of action if you end up wanting to file the claim, um, do you know you said you're gonna be in a hospital setting or an outpatient office setting for the for the visit?
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] Um, so I think coverage is for both my wife and I, and she would be in a, uh, hospital setting, so.
[AGENT][NEUTRAL] OK, I'm gonna put the name of a form that you can ask for if you decide to file the claim, that's gonna have the diagnosis code and
[AGENT][NEUTRAL] Then other than that, the only thing is, again, if you decide to file, if you don't decide to file, the hospital will have all the information and you can just give them your policy information and let them try to file the claim. um if you wanna do it, you're gonna want a form that has the diagnosis code and I'm putting that in the email and then you're gonna want your itemized bill with procedure code and I'm gonna list that in your email too, OK?
[CUSTOMER][NEUTRAL] OK, thank you. So it definitely sounds like it, it's, uh, much, much to my benefit if I file the claim and so there's really nothing I need to do on the front end. It's more about just collecting the the appropriate documentation and then submitting that over to APL.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Yep, you bet you, and that claim form when you get to it, that first page is gonna let you know any documentation you might need. Um, the two things I'm listing in here will be things to help get you going, um, but always look at that, um, claim form, that very first page it will give you kind of directions like step by step what you need to fill out, what you need to get gather and send in, and then.
[AGENT][NEUTRAL] Um, we don't, yeah, we don't require pre-certification or anything like that, so you'll just take your documentation, submit it, and any benefits payable will be paid out to you.
[CUSTOMER][POSITIVE] OK, well thank you so much for the information and the help today. I appreciate your time.
[AGENT][POSITIVE] Oh, absolutely my pleasure. And is there anything else I can do to take care of you?
[CUSTOMER][POSITIVE] I think I'm squared away for today, but thank you so much. I'll call back.
[AGENT][POSITIVE] All right, my pleasure you take care and that email will be coming to you in just a moment, OK?
[CUSTOMER][POSITIVE] Sounds good. Thanks. Bye.
[AGENT][POSITIVE] My pleasure bye bye.