AccountId: 011433970860
ContactId: 3810ae5f-da2d-40e9-88ab-24f1636962ee
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1227920 ms
Total Talk Time (AGENT): 765794 ms
Total Talk Time (CUSTOMER): 424202 ms
Interruptions: 3
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/3810ae5f-da2d-40e9-88ab-24f1636962ee_20250219T14:01_UTC.wav
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[AGENT][POSITIVE] Thank you for contacting ATL. My name is [PII]. How may I help you?
[CUSTOMER][NEGATIVE] Hi, um, I have, uh, we, I have a gap insurance. Well, our company set up a gap insurance with you guys, but I never received a package. I never received a card in the mail. I never received any information, and I completely forgotten that we even have this until somebody mentioned it to me at the office the other day and he said, why are you paying so much and.
[CUSTOMER][NEGATIVE] And differences and co-pays. I said, you know what do you mean you have to? And he said, no, but we have a gap insurance to cover that. So, the reason why I never knew about this is because I never received anything in the mail, and I remember calling and asking somebody to send it to me. They said they would they'll send it and I still never received it. Um, so,
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] I need that information, like I need everything, like maybe a packet or something sent out to me with the cards because I didn't even have a card or anything. Um, and, and number 2, I wanted to know now if I could be reimbursed for the procedures that I had done like months ago that I had to pay for out of my own pocket, which I could have been reimbursed for.
[AGENT][NEUTRAL] OK, well, let's look at your policy first, and I'm sorry you didn't get those cards. Um, could you spell your, your last name for me, please?
[CUSTOMER][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you and your uh and your first name, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you, um, really, let me see if I can't find this.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] And if I could verify your date of birth uh and a phone number, I would, I really appreciate it.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] My birthday is [PII], and the phone number is [PII].
[AGENT][POSITIVE] OK, thank you so much. Let's see what we have here.
[AGENT][NEUTRAL] OK. So it looks like we tried to email the policy back in July. So let's see if we have what we have is your address. Um, what, what is your uh current address, please?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] OK, great.
[AGENT][NEUTRAL] And there's also a uh email address that is associated with this, a Gmail address. If you could verify that for me, please?
[CUSTOMER][NEUTRAL] Uh, I have two. It's either [PII] or [PII].
[AGENT][NEUTRAL] OK, yes, I think that's probably the one that we'll use. So what I'm going to do is I'm going to uh email you um your card to begin with, uh, and then I'll, um, uh, since we do have the correct address, I'm not sure why we don't have you, uh, why you weren't able to get that, but, um, I will go ahead and and send that to you. Now, um, let's go over your policy. So your
[CUSTOMER][NEUTRAL] You have the correct uh zip code [PII]. Did I mention that? [PII].
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] OK, now what is your apartment number again, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the zip code that I have is [PII]. Is that correct?
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK. And well, I think maybe I'll, I'll just make sure that the zip code is correct because that's um that could be, uh, excuse me, not the zip code, but the apartment is correct. That might, that might be the reason why we, uh, we didn't get that, um, to you. Uh, but let's look at your, uh, benefits, um.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] What was the zip code that you had?
[AGENT][NEUTRAL] Well, no, that's the zip code that I had. I don't know whether, I don't know whether we have your apartment number down. I'm not able to see that. So what I'm going to do is I'm gonna verify that we have your apartment is [PII]. Um, so your your policy went into effect on November, excuse me, I apologize, [PII], um.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yes please.
[AGENT][NEUTRAL] And what you have, um,
[AGENT][NEUTRAL] Uh, or benefits for inpatient, outpatient services, treatment within the physician's office, um, up to $4250 for outpatient services. Um, let's see what you have for inpatient services. I'm just gonna check here.
[AGENT][NEUTRAL] Uh, the inpatient services are also up to $4250. So what you can do, uh, when you get the card, uh, it that I'm going to email to you, um, today, you can go on our website. Now you'll notice that when you look this up, you'll see that the card has a has a website listed on it. It's [PII] and you can go in on that site.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And create an account. It just takes a few moments to do that. Basically all you're doing is creating a user name and a password and you will see uh when you do that that there's a place for you to start a claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you can start the claim, uh, you can, uh, the, the procedures that you had, uh, previously, um, you can go ahead and, uh, uh, send those to us. Just, just download the documents and you can send those to us, and then, um, what you're going to be sending will be the uh uh bills that you've received, the uh itemized bills that you received from the doctor's office. There's also
[AGENT][NEUTRAL] An explanation of benefits because we're your secondary insurance. There's an explanation of benefits for each data service from your primary insurance. Now, I'm showing your primary insurance is being um Florida Blue, is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, so for each data service you will have a uh a companion EOB.
[AGENT][NEUTRAL] Um, from Florida Blue. So let's just say, uh, on [PII] you went to the ER, um, you would have handed them your Florida Blue card. Uh, there will be, um, an explanation of benefits that will show how um uh that claim was processed through Florida Blue, and it will show your deductible, co-payment or co-insurance. So we need to itemize bills plus for each data service we need.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] That explanation of benefits from Florida Blue, which tells us what the deductible, co-payment or co-insurance is that we need to pay.
[AGENT][NEUTRAL] And with each one of those that you send in, we need to know why you had those services. So let's just say at the first of the year, [PII], you went to the ER, uh, you have your, uh, Florida Blue um explanation of benefits on that you would write, uh, for this data service, um, uh, these charges are for the flu, um, or, or, uh, I sprained my ankle, just something like that. You just need to let us know what those services were for, um.
[AGENT][NEUTRAL] So that we can look up the diagnosis code and finish filing the claim. Now, um,
[AGENT][NEUTRAL] Florida Blue will have that information, but, but they don't, they don't need to share it with us because we're your secondary insurance. And that's why we need to know that information from you. So we'll have your, your itemized bill, your explanation of benefits, and then the reason for the visit. Um, just, and you can just write it down and then what you can do is it, uh, you'll notice when you, when you build your, your uh account, it, there's a place for, uh, where it actually says start a claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And um you will just uh begin downloading documents and send them to us. Now, we normally take 3 to 6 business days to process those.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And uh then the, the, uh, you'll also notice when you're filing that claim, there's a place for a direct deposit, uh, we can either directly deposit your benefits to you or we can mail you a check, whichever you prefer.
[CUSTOMER][NEUTRAL] OK, so now basically to retrack what you just said, I go on the website that's on the card that you're gonna send me now by email and I have to go on the file a claim. I have to download, so I go to my um Florida Blue website and download my statements from there.
[AGENT][NEUTRAL] Yes, you can do that. Yes, um, they, they would have sent them to you um at the time, um, so you'll you'll either have them already or you can go in to, to uh the Florida Blue um website and um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What right.
[AGENT][NEUTRAL] And download them for each, for each, yeah, or, or you can call them and they will mail them to you. Um, by law we, we have to provide you with an EOB uh for each um event that your card is used.
[CUSTOMER][NEUTRAL] Download down
[CUSTOMER][NEUTRAL] What does EOB stand for?
[AGENT][NEUTRAL] Explanation of benefits.
[CUSTOMER][NEUTRAL] Explanation of benefits, yeah.
[AGENT][NEUTRAL] Mhm. Yes, so, so it's what it does is it um it tells you how your insurance company processed your claim. So for example, um for that ER visit that we were talking that emergency room visit we're talking about, um, let's just say that you were charged $5000 for it, um, it will show, uh, it will show the total charges. It will show how much of that bill was allowed by Florida Blue.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then it will show what they've broken down into what they will pay and what you will owe.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And that's what that deductible, co-payment or co-insurance is.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Now, let me, let me ask you a question. From what you can see from your end, um, has, has myA insurance ever been used in the past year? cause I don't know, I don't recall if I maybe given the numbers to anyone before or any visits, you know, and is it covered.
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] Yes, absolutely.
[CUSTOMER][NEUTRAL] Can you see from your?
[AGENT][NEUTRAL] Absolutely. So let's just look at those really quickly. Uh, the last one that I have is from December. Um,
[AGENT][NEUTRAL] It looks like uh there was um
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Uh, well, maybe this might be an ER visit. Let me just check.
[AGENT][NEUTRAL] From uh
[CUSTOMER][NEUTRAL] I had an ER visit, but I don't remember when it was.
[AGENT][NEUTRAL] Yes
[AGENT][NEUTRAL] There was one on [PII].
[AGENT][NEUTRAL] And it looks like um the reason for that was uh chest pain.
[AGENT][NEUTRAL] Um, now, we were.
[CUSTOMER][NEUTRAL] Oh, that's it.
[AGENT][NEUTRAL] Right. And so we, we were contacted by the physicians who, who's, uh, who saw you and the Florida Blue, uh, the Florida Blue EOB or explanation of benefits that they sent us didn't show a deductible co-payment or co-insurance. So what we did was we asked them to send us that. Um, they, they didn't send us the, uh, deductible co-payment or co-insurance. So we asked them to send us that.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, and once they do, we will finish processing that claim and, and, uh, we send them an explanation of benefits saying, hey, you know, you need to let us know that, uh, uh.
[AGENT][NEUTRAL] You know this is what has happened. Now, for that same data service, [PII].
[AGENT][NEUTRAL] The hospital
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Send us a bill for the, so like you went to the ER uh on [PII]. So, from that one visit, there are multiple charges.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] So there's the, there's a facility charge just to be just to use the facility charge. For every single physician that you see, there's a charge for every single um uh uh supply that they use, there will be a charge. So that first charge that I told you about was for the physician services for a physician to actually see you when you were in the AR.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm mhm.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Now the one that we received and paid for [PII] was the facility bill. So when United Health, uh the uh emergency room sent us a bill for $2,027 we paid that and that looks like that was paid um back in uh.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Let's see, it looks like we paid that back in August, uh, when they, when they sent that out to us. So we received that bill on [PII], we processed it on the [PII], and that was for, um, uh, let's see what that was, that was $2000 yeah, $2,027 so that was paid. That was for [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So, let me ask you a question. When you tell me my, my limit is 4500, that means 4500 a month, uh, a year, and then like, like, so the 2000 whatever was taken from that, right? And then I have whatever left for cleaning.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] A year.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right, it's, it's actually $4250 4250 dollars.
[AGENT][NEUTRAL] So for last year, that's correct. So for last, last year.
[CUSTOMER][NEUTRAL] A year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, we received claims for you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] In the amount of 2000.
[AGENT][NEUTRAL] Uh, $50.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, um, so your, uh, your policy with us, um, let's see that, what was that? So 2000.
[CUSTOMER][NEUTRAL] 4250, so I have 2200 left for last year.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] So now if I send you like let's say um $1500 that that I paid out of my pocket from last year, I could still be reimbursed for it because I still had 2 $2200 with me.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] Yes, yes, as long as, well, as long as the, as long as the, uh, provider hasn't already sent in a claim.
[AGENT][NEUTRAL] Then yes. Um, now the other claim that you, uh, there are two other claims.
[AGENT][NEUTRAL] One is for uh uh Miami uh medicine cardiac uh services.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That was for [PII].
[CUSTOMER][NEUTRAL] From the same visit.
[AGENT][NEUTRAL] Uh, yes, [PII], uh, not [PII], I guess she went the very next day.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] They uh charged $13 and, and uh we paid that. And then the final visit that we have, all these things were submitted in June, in August I should say.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah, it was the same visit, probably.
[AGENT][NEUTRAL] Yeah, there's also one for radiology for $14. Um, I guess you had a yeah.
[CUSTOMER][NEUTRAL] Yeah, same visit.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] As long as we're not talking about those bills, then yes, if there's any other bill that's out there.
[AGENT][POSITIVE] Yes, we can certainly help with that.
[CUSTOMER][NEGATIVE] Mhm. So, so what's out there is not exactly a bill, it's what I paid out of my pocket for a co-pay.
[CUSTOMER][NEUTRAL] So I had, for example, I had a biopsy.
[CUSTOMER][NEUTRAL] For my thyroid. Um
[CUSTOMER][NEUTRAL] And I had to pay like, I think it was $500. I paid that out of my pocket.
[CUSTOMER][NEUTRAL] So, how do I get that reimbursed? And I also had um for, for the same, same thing, I had to go before the biopsy. I had to do an ultrasound for my thyroid. So the ultrasound, I paid 150 out of my pocket and then the procedure, the biopsy procedure, I paid 500 out of my pocket.
[CUSTOMER][NEUTRAL] But the only proof I have of that is my receipts, like my credit card receipt. So how would I go about getting that?
[AGENT][NEUTRAL] Well, you also
[AGENT][NEUTRAL] You should also have an EOB from uh [PII], from Florida Blue.
[CUSTOMER][NEUTRAL] So, OK, so I can go to [PII] and try to download the EOB from there and then just submit it with my, the receipts that I paid. Is that how?
[AGENT][POSITIVE] That's correct, yes.
[AGENT][NEUTRAL] Yes, so any, any time that.
[CUSTOMER][NEUTRAL] OK, let me try to look.
[AGENT][NEUTRAL] Yeah, so, um, so you would have your, you would have your receipts and um then you would, you would have that, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, you'd have that, uh, uh, Florida blue, um,
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] EOB.
[AGENT][NEUTRAL] Yes, yeah, so that's what you would use for that type of thing.
[CUSTOMER][NEUTRAL] OK, so I'll, I'll try to do that and if I have any questions I'll call again. In the meantime you're gonna send me the email with my card and then you're gonna send me a hard copy like a an actual physical card by mail, right with like the whole package. OK.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] Yes, that is correct. Yeah, so I'm gonna, I'm sending that to you now. You should be getting it, uh, it will be, uh, the reference will be APL card.
[AGENT][NEUTRAL] And um you should be receiving that and then I'm going to go ahead and have another policy sent to you uh and uh make sure that we have your apartment number on there because that's the only reason I can think of that you didn't get it back in July. Um, but while you're, while we're on the phone, um, uh, if I could give you your policy number, if you don't mind writing it down, you're gonna, you're gonna get it in just a moment anyway, but if I could give it to you so that you could write it down.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I think I
[CUSTOMER][NEUTRAL] Is it the 02481980?
[AGENT][POSITIVE] 80. That's it, yes, yes. So that's, yeah. That's great. Well, um, so I will go ahead and send you another one, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so hard.
[CUSTOMER][NEUTRAL] I have one more question. Now, if I, you said the my limit is 4200 inpatient and 4200 outpatient?
[AGENT][POSITIVE] That's correct, yes.
[CUSTOMER][NEUTRAL] So what's the difference between the inpatient and the outpatient?
[AGENT][NEUTRAL] Well, the inpatient is when you go into the hospital for 18 hours or more.
[CUSTOMER][NEUTRAL] Oh, OK, OK, and outpatient is like that one night emergency room visit.
[AGENT][NEUTRAL] Yes, so if you were in there um for uh um
[AGENT][NEUTRAL] I don't know how, how long, how long you were in there, um.
[CUSTOMER][NEGATIVE] That I was only there for like one hour. All these bills came for one hour.
[CUSTOMER][NEUTRAL] Um, but basically what you're saying is if it was, if it was there for like inpatient for 3 days, it will only cover up to $4200 and I'll probably get a bill for like $50,000.
[AGENT][NEUTRAL] Yeah, the
[AGENT][NEUTRAL] But uh, yes, it's actually for your deductible co-payment or co-insurance. So it, remember, uh, Blue Cross and Blue Shield, you do have a deductible with Blue Cross and Blue Shield, but once they, once you meet that, then that's what we do is we're, we're the gap between um what Blue Cross and Blue Shield will pay and, and helping you meet your deductible. So if you did have, let's say you did have a $50,000 bill, um, remember that, um, that, uh, part of that will go towards your deductible, co-payment or co-insurance.
[CUSTOMER][NEUTRAL] Well that
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] But then once we, we pay that part, um, Blue Cross and Blue Shield will then kick in.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it's, it's not as bad as it's, it'll be bad enough, of course, receiving that kind of a bill, but, but then at that point, you have two insurances paying for it, so that's, that usually helps somewhat.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Now, if I, one more question, if I go to, like, for example, I had a doctor's visit, televisit this morning and um they said the co-pay was $55 I said, OK, I have gap insurance to cover the co-pay. She said, oh, we don't, we're not with them.
[AGENT][NEUTRAL] Not the copay.
[AGENT][NEUTRAL] Yeah, yeah, the office visit co-pay is not, yeah, the office visit co-pay is not covered. Now, treatment within the physician's office is that the office visit co-pay is not.
[CUSTOMER][NEUTRAL] Oh, not the.
[CUSTOMER][NEUTRAL] Oh, it's not. I thought it is.
[AGENT][NEUTRAL] Um, no, no, ma'am. I'm sorry, that's, those are not covered.
[CUSTOMER][NEUTRAL] Oh, OK. All right.
[CUSTOMER][NEUTRAL] OK, good to know. So it's just the treatment, not the, not the, not the co-pays.
[AGENT][POSITIVE] That's right.
[CUSTOMER][NEUTRAL] OK. All right. Um, that's all I think.
[AGENT][NEUTRAL] OK, well, let me go ahead and send you your card and if you have any questions, uh, just let us know.
[CUSTOMER][POSITIVE] Thank you so much. I appreciate all your help and time.
[AGENT][NEUTRAL] OK. Mhm.
[AGENT][POSITIVE] Thanks for contacting ATO have a good day.