AccountId: 011433970860
ContactId: 3ee2a905-34e1-48db-9d92-d08930cae1b2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1165260 ms
Total Talk Time (AGENT): 483765 ms
Total Talk Time (CUSTOMER): 490385 ms
Interruptions: 3
Overall Sentiment: AGENT=0.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/12/3ee2a905-34e1-48db-9d92-d08930cae1b2_20250212T15:02_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is. How may I help you?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Hi, um, my name is [PII], and sorry, hold on one second.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK. Sorry, I um just had a claim, um.
[CUSTOMER][NEUTRAL] I had it, um, I submitted it uh last week and I just got the notification that it was closed and it looks like everything has been denied. um, so I did get a couple of remark descriptions and I, I am going to appeal it, um, and it does say that I can, um.
[AGENT][NEUTRAL] Mhm, yes, ma'am.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Write to the office within 180 days, but I just wanted to confirm what the process is like, is there somewhere where I can print um uh like I don't know what else I need to do to like actually appeal the decision.
[AGENT][NEUTRAL] OK, um, so you can write to the office that you're going to need a letter written why you want to appeal the claim.
[AGENT][NEUTRAL] And then you're going to mail it to, I can give you the address.
[AGENT][NEUTRAL] It's APL, it's APL claims.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that's [PII].
[AGENT][NEUTRAL] And can you give me your um callback number Miss [PII] just in case our call is disconnected?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Uh, sure. It's [PII].
[AGENT][NEUTRAL] I'm gonna, I'm going to look up.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] OK, it's, it's [PII].
[AGENT][NEUTRAL] OK thank you and then what is your policy number? I wanna look at the claim and see what it says.
[CUSTOMER][NEUTRAL] Oh, sure. Sure. It's 02235729.
[AGENT][NEUTRAL] OK, let me look it up real quick.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and for security reasons, Ms. [PII], can you verify your date of birth for me?
[CUSTOMER][NEUTRAL] Sure, [PII].
[AGENT][POSITIVE] Thank you and then also your address, phone number and email address that we have on the policy for you.
[CUSTOMER][NEUTRAL] Sure, the address is [PII]. Uh, uh, what else did you need? The
[CUSTOMER][NEUTRAL] Email address is [PII].
[AGENT][NEUTRAL] Your email address, yeah.
[AGENT][NEUTRAL] OK and then the number that you gave me to call you back on if we're disconnected that's your cell phone number?
[CUSTOMER][NEUTRAL] Yes, the [PII] number, yes.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] Let's look here and see what's going on.
[AGENT][NEUTRAL] And do you have your claim number?
[CUSTOMER][NEUTRAL] Uh, yes, I do. It is 356-212-7.
[AGENT][NEUTRAL] OK, let me look at it, see if there's just sometimes it just might be something or a little extra something that you just need to send in so let me look and see if it says.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, it looks like a couple of them. uh, I need a diagnosis code, um.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] And then I was trying to, to go back through the, so I sent basically the same paperwork for each uh day of what I was trying to get covered um and it was from my United Healthcare cause that's my primary, and I just sent over the um the page that they usually send the explanation of benefits. So, um, I don't, I don't know why.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] It's um, the diagnosis could wouldn't be on those, um, because it was on the others and it looks like on, according to these remarks, um,
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] Oh wait, now I'm just noticing that they're, they're like doubled. um, so the Jennifer Pollock one that I don't know how that, that like snuck in there that's um everything was covered under my other insurance, so it's basically everything from [PII] and the [PII] and then the laboratory um core stuff. Um, so basically what I had done which
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Uh, from [PII], it was a, um, a, an ankle issue and
[CUSTOMER][NEUTRAL] The at the time I obviously gave them my two insurance cards, my United and APL and
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I mean, obviously they knew what my benefits were with APL as they were I guess submitting claims as I was getting everything done but I guess with APL um.
[CUSTOMER][NEUTRAL] This certain procedure was not covered because it's in a doctor's office, which
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It's crazy because I, I, there was nowhere else to get this actual procedure besides in the office, um, because it's, it's an outpatient type thing. Um, so I think
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] I don't know, like, I, I, at this point, I never would have gotten the procedure done if I had known that I couldn't get it done in the doctor's office, um, cause nobody ever made that clear to me.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Um, so that's basically what the issue is here.
[AGENT][NEUTRAL] OK, OK, I understand what you're saying, um, so let me go ahead and finish giving you that address to send the claims to.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, it's [PII] [PII] and that's in [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then the zip code is [PII] and you just need to send a letter stating why you want to appeal the claim, your reasoning for appealing the claim, and anything you have a document wise to back it up.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so there's no like specific form. I'm just writing like a word document of uh basically what I just told you but um more specific.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, yes, ma'am, and then, and then refer your claim, make sure you refer your claim number 3562127 on there so they know which claim you're appealing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, yeah, I figured I would just send like all of the um the paperwork that I have as well.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So, so, um, I don't know if you would be the one to ask. So, on the card that I received from APL, like the actual physical card, um, when I give it to the doctors, there's, I have on their in-hospital benefit number and the outpatient benefit number. And, you know, obviously they, they have both of those numbers. So,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] As the doctor's office is, you know, taking my insurance for, you know, each visit, are they, are, are they informed at the time that the procedure is not
[CUSTOMER][NEUTRAL] Uh, considered covered because it's in the doctor's office.
[AGENT][NEUTRAL] That all depends on if they call and verify your um benefits.
[CUSTOMER][NEUTRAL] OK, cause I, you know, obviously I gave them the card like at the beginning of all of this, um.
[CUSTOMER][NEUTRAL] So, I don't know if like they, they
[AGENT][NEUTRAL] And that should
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] That should also be in your policy that was mailed to you. You should be able to look at your policy and read that office visits are not covered under the policy, that the policy covers deductible copay and co-insurance when it's performed in a covered facility. So this secondary insurance only helps with deductible copay and co-insurance.
[CUSTOMER][NEUTRAL] OK, sorry, I don't, I don't know what that means, um.
[AGENT][NEUTRAL] So like if you had to pay a deductible or a co-pay with your primary insurance?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] So this, when you get the EOB from the primary insurance and it shows that you paid a deductible or a copay or co-insurance for a procedure that's covered, they send it to us what they pay depends on what we pay because go hand in hand together so.
[AGENT][NEUTRAL] When um when we get that EOB and we see that you have paid a deductible or co-pay or a co-insurance, then we look at your policy and see if the facility is a covered facility.
[AGENT][NEUTRAL] Uh, if you need me to send a copy of your policy to you, I can do that where you can read it and see what's covered and what's not covered. Do you have a copy?
[CUSTOMER][NEUTRAL] Um, I mean, I guess I, I don't, so then this, so.
[CUSTOMER][NEUTRAL] Basically,
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEGATIVE] Sorry, I, I was thinking of what I wanted to ask, but now it's like lost my train of thought. Um.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] So basically, because I already paid.
[CUSTOMER][NEUTRAL] So, OK, so sorry, this is my question. So because my primary insurance United is this specific doctor was covered under my insurance, but under APL that specific doctor under that umbrella may not actually be covered.
[AGENT][NEUTRAL] Correct. Because it doesn't go by doctor, it goes by the facilities like an ER urgent care center, MRI imaging center, and ambulatory center. It goes by facility that's covered.
[AGENT][NEUTRAL] On your policy how your policy is read.
[CUSTOMER][NEUTRAL] OK, so basically, it sounds like any type of like emergency type procedures is what APL covers.
[AGENT][NEUTRAL] Yeah, um, that's, and this is just to verify your coverage. It's not a guarantee of payment, but yes, if it's not in an office visit, then it, you can go to an ER urgent care center, MRI imaging center or an ambulatory center.
[AGENT][NEUTRAL] To have procedures done, um, since you don't have office visits on your policy.
[CUSTOMER][NEUTRAL] Oh, so
[AGENT][NEUTRAL] And you do
[CUSTOMER][NEUTRAL] I, I thought, I mean, I thought I was covered from what my work has told me, um.
[AGENT][NEUTRAL] You do?
[CUSTOMER][NEUTRAL] My employer is that we hand this card over for office visits as well, is what I was told.
[AGENT][NEUTRAL] Right, you have an out.
[CUSTOMER][NEUTRAL] I mean, if I had known that this.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] You have an outpatient benefit.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Per calendar year of $3000.
[AGENT][NEUTRAL] For a covered facility. So what, um, I'm gonna pull up your policy real quick.
[AGENT][NEUTRAL] And rate it.
[AGENT][NEUTRAL] Then I'm gonna make sure that you get a copy of it too. I'm gonna request a copy be mailed to your home address.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that, so that you have a copy of your policy and how it reads.
[AGENT][NEUTRAL] And you can see what
[AGENT][NEUTRAL] What facilities are covered and what facilities are not covered.
[AGENT][NEUTRAL] For your outpatient services.
[CUSTOMER][NEUTRAL] OK, and then my um another question I have, so when I was given this gap insurance, when I was given APL from my employer, um, we didn't have an option for different.
[CUSTOMER][NEUTRAL] Um, policies under APL, um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] We were never given any option of choosing anything. We were just given this as like an overall uh secondary insurance. So I was never aware that there were different um policies under it. So I
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] Right, and they, and your your um employer may only carry this.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] Secondary insurance with us. Uh, you might need to get with them and see if they have a better plan that um covers office visits. Just ask them and see.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Because it's all based on what your employer chooses.
[AGENT][NEUTRAL] Um, for the company.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So like this your policy says physician office, but it says physician office does not include a covered outpatient facility um and it's for treatment of sickness or injury.
[AGENT][NEUTRAL] But it, um, the physician office visits fee, the professional fee for the office visit when billed by a physician and incurred by a covered person in a physician's office. So it's.
[AGENT][NEUTRAL] Not
[AGENT][NEUTRAL] Covered for office visits.
[AGENT][NEUTRAL] Per your policy, the way your policy is written.
[AGENT][NEUTRAL] And like I said, you might want to go ahead and get with your employer, see if they have a plan that does cover office that's that can help, and you've got to understand this is your secondary insurance, your primary insurance, you know, takes on most what you incur as far as cost, and this is secondary, and ours helps with deductible copay or co-insurance.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, that makes more sense. Um, I mean, I was still going to appeal this only because, um, I mean, I just, I, I was unaware of any of this. I never would have gotten this these procedures done, um.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And you know, the doctors, they kept pushing and pushing like you need it, you need it, you need it. So I, you know.
[AGENT][POSITIVE] Oh, bless your heart. Yeah.
[CUSTOMER][POSITIVE] Obviously went forward with it. Um, OK, so I will.
[CUSTOMER][NEUTRAL] I'll wait for you. I'll um expect your email in the meantime just to explain everything and then um I will, I'll go ahead, I'll, um, write a letter and hopefully I don't know, we'll see what happens, but yeah, this is, this is, yeah, yeah, it's not what I was expecting with all of this stuff, so yeah.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][POSITIVE] Yes ma'am. Hey, it's worth a shot for sure.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Well, I'm going to, I'm actually gonna email your policy to you so you have it right away so that you can go ahead and refer to it while you're doing your paperwork, OK?
[CUSTOMER][POSITIVE] OK all right well thank you so much for your help, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK perfect thank you so much.
[AGENT][NEUTRAL] Um, can I put you on a brief hold while I do that so I make sure it goes through while you and I are on the phone together? OK. Thank you so much.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, OK.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Hi Miss [PII], this is [PII]. I did get that sent it looks like everything went OK.
[CUSTOMER][NEUTRAL] Hi.
[CUSTOMER][POSITIVE] OK, perfect.
[AGENT][POSITIVE] OK, and if you need anything else, please pick up the phone and call us and we'll help you all we can, OK?
[CUSTOMER][NEUTRAL] OK, and you said you emailed it to me, right?
[AGENT][POSITIVE] Yes ma'am, I emailed it to you that way you got it right away.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. All right. Thank you so much.
[AGENT][NEUTRAL] And we also, let me have you signed up for the online service center?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Um, I don't think you mean just like seeing everything online?
[AGENT][NEUTRAL] Right, um, it's a direct portal to your policy so when you send claims you can actually even send claims from the online service center and see a copy of your card and your policy you've signed up for that.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Oh yes, yes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Oh, OK, good, good deal.
[CUSTOMER][POSITIVE] Yes, yeah, I do. I did, yes. OK.
[AGENT][POSITIVE] OK, awesome.
[AGENT][NEUTRAL] OK. All right. Well, is there anything else I can help you with before we go?
[CUSTOMER][POSITIVE] Uh, no, that was all for now. Thanks so much for your help.
[AGENT][POSITIVE] You're very welcome, Miss [PII]. I hope you have a blessed day and thank you so much for calling APL.
[CUSTOMER][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] Bye-bye, ma'am.
[CUSTOMER][NEUTRAL] Bye