AccountId: 011433970860
ContactId: 3f713c42-e9aa-45c3-9214-5cc123413e81
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1159890 ms
Total Talk Time (AGENT): 395759 ms
Total Talk Time (CUSTOMER): 351938 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/06/3f713c42-e9aa-45c3-9214-5cc123413e81_20250606T20:37_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], um, I'm calling, uh, because I had two questions. One, I received an EOB and just wanted to verify that this was sent directly to the provider, um, and then two, I had, I wanted to see about other services that I might be able to get reimbursed on.
[AGENT][NEUTRAL] OK. Do you have your policy number?
[CUSTOMER][NEUTRAL] Um, yeah, let me see.
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] Um, OK, so policy number is 02554490.
[AGENT][NEUTRAL] OK. Can I get your first and last name and date of birth?
[CUSTOMER][NEUTRAL] Um, yes, [PII], [PII].
[AGENT][NEUTRAL] And can you verify your address and your email address for me?
[CUSTOMER][NEUTRAL] Yes, address is [PII].
[AGENT][POSITIVE] And you have a good callback number in case we're disconnected?
[CUSTOMER][NEUTRAL] Um, yes, um, call back [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And was it a claim for yourself?
[CUSTOMER][NEUTRAL] Um, yeah, I'm, I'm for myself and also for my husband because we have several claims that we're trying to see um how we can go about getting the, the money back and for my kids actually.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, which, which one did you wanna start with? I look, it looks like I've got one for you on file. Um, we paid the provider.
[CUSTOMER][NEUTRAL] OK, I'll
[AGENT][NEUTRAL] It's for 216-2025.
[CUSTOMER][NEUTRAL] Was that the emergency room?
[AGENT][POSITIVE] Um, yes, that's correct.
[CUSTOMER][NEUTRAL] OK, and it was 3 and you paid 350, right?
[AGENT][POSITIVE] Yes, that's right.
[CUSTOMER][NEUTRAL] OK, so let me, my policy started 101, right?
[AGENT][NEUTRAL] Um, let me
[CUSTOMER][NEUTRAL] Mm.
[AGENT][POSITIVE] Yes, that's right.
[CUSTOMER][NEUTRAL] I just wanna see if I have any other.
[CUSTOMER][NEUTRAL] OK, I just wanna see if I have anything else that I can obviously get uh money back on, so let me just look at my claims really quick, um, like what, what kind of services, what kind of services do I get reimbursed on uh emergency room, urgent care?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Any anything else or?
[AGENT][NEUTRAL] Yeah, let me pull up your policy. Give me one moment.
[CUSTOMER][NEUTRAL] OK um.
[CUSTOMER][NEUTRAL] 2026
[AGENT][NEUTRAL] Um, anything I quote is not a guarantee of payment. It's a basic outline of your policy.
[AGENT][NEUTRAL] Um, let me see.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So you have a calendar year maximum for outpatient benefits of 7900 that we we can reimburse on after primary pays. That's gonna be for like emergency room, um, urgent care facility charges, surgery charges in an outpatient facility, um, diagnostic testing in a hospital or MRI facility.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, physical therapy facility, ambulance.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, there's also you.
[CUSTOMER][NEUTRAL] Uh, physical, physical therapy is also included, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, got it. Um, ambulance, OK.
[AGENT][NEUTRAL] And then, um,
[AGENT][POSITIVE] Also have a benefit that pays $25 for physician office visit co-pays and $50 for specialists.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So you have, I have PCP and specialist?
[AGENT][NEUTRAL] Yes, it'll it'll reimburse that back if that's what's left over from your primary. Um, that is a maximum of 4 visits for each of those, and then a total of 8 for all people covered under the plan for each of those.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so, I'm sorry, can you, can you repeat that again?
[AGENT][NEUTRAL] So you have a benefit payable of $25 a max of 4 visits per covered person per calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then 8 visits for all covered persons combined, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Or is all.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yeah, and then specialists.
[CUSTOMER][NEUTRAL] Is that just PCP or is that specialist separate?
[AGENT][NEUTRAL] That's uh that's just PCP Specialist is separate.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That's up to $50 per visit with the same maximums.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, perfect.
[AGENT][NEUTRAL] And then, let's see, lastly, any treatments rendered in in the office, so like if you got injections or X-rays in the doctor's office or anything rendered in the office, that's also um can be reimbursed under this 7900, so.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Um, OK.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Let me see how I can filter mine out myself. OK, so and it started [PII], right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me see if it, that's me, just me, OK, cause my husband had surgery too and
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] What do I need to do to submit?
[CUSTOMER][NEUTRAL] Claims or what do I need to do to submit a reimbursement request?
[AGENT][NEUTRAL] Um, so the easiest way to do it would be through our online portal, um, which you would have to set up. I don't have an email on file for you, so if without that, you won't be able to set up the account.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Are you interested in setting that up?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. Um, let me get here.
[AGENT][NEUTRAL] Um, what email would you like to put on file?
[CUSTOMER][NEUTRAL] I'm, I wanna put my my personal.
[CUSTOMER][NEUTRAL] Which is [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, [PII]
[AGENT][NEUTRAL] [PII], correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] To set up your account, um, you would go to [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] [PII]. OK.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] And then
[CUSTOMER][NEUTRAL] OK, let's look it up.
[CUSTOMER][NEUTRAL] And.
[CUSTOMER][NEUTRAL] OK, it's getting me in though.
[CUSTOMER][NEUTRAL] OK, [PII] got it log in or create your.
[AGENT][NEUTRAL] Create your OSC account.
[CUSTOMER][NEUTRAL] O
[CUSTOMER][NEUTRAL] OK. Um, insured?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Alright lovely [PII].
[CUSTOMER][NEUTRAL] Social security number?
[AGENT][NEUTRAL] And it'll be your full social, no um dashes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Error, no, no user was found.
[AGENT][NEUTRAL] OK, hold on just a second.
[CUSTOMER][NEUTRAL] Sometimes my, sometimes my last name gives problems, but
[AGENT][NEUTRAL] Make sure this took your.
[AGENT][NEUTRAL] Email address. Hold on just a second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] OK, now try it. I don't know why it didn't retain your email address. It should work now.
[CUSTOMER][POSITIVE] OK perfect
[CUSTOMER][NEUTRAL] Continue.
[CUSTOMER][NEUTRAL] Alright, and verification code.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And it's verification code.
[CUSTOMER][NEUTRAL] OK, I'm just waiting for the verification code.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yeah, it'll do one verification code and then once you get in and create your password, it'll ask you to log in again and it'll ask for another verification or send you another verification code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] American public life.
[CUSTOMER][NEUTRAL] verify.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Your account, your account has been created. OK, so then, alright, so I guess it's asking me just to log in again.
[CUSTOMER][NEUTRAL] OK, every, every time I log in it's gonna ask me for a code. Is it safe to say that or?
[AGENT][POSITIVE] It is, yes, yeah, we just wanna be secure, so.
[CUSTOMER][NEUTRAL] OK, got it. I get it.
[CUSTOMER][NEUTRAL] OK, hold on.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] OK, here it goes.
[CUSTOMER][NEUTRAL] 352441.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, so I it looks like I'm in.
[AGENT][NEUTRAL] OK. Um, so you'll see on, you see on the left-hand side dashboard my policy resource center help.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so you'll click on dashboard.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then on the right hand side you should see starting starting your claim.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] Start your claim. OK.
[AGENT][NEUTRAL] And then you'll pick traditional claim.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 1 2nd.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Wait, so on on dashboard?
[CUSTOMER][NEUTRAL] Start your claim, right? OK. Additional claim.
[AGENT][NEUTRAL] OK, and then this is the process you'll do to upload, you'll need your primary explanation of benefits for any date of service that you're submitting for, and then you'll need.
[CUSTOMER][NEUTRAL] Then next, next, oh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Claim information. So you're gonna need, you know, we have to see like the diagnosis code, um, what procedures took place.
[CUSTOMER][NEUTRAL] That's that's usually on the EOB though, right?
[AGENT][NEUTRAL] Not usually, no, it's not. Um.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Sometimes the procedures will be on there, but the diagnosis usually is not.
[AGENT][NEUTRAL] Um, so if you have access to one, you, you can call your providers and see if they can give you that information. Another option you can look into is if you have your own online portal for the providers that you've seen, like MyChart or whatever their online portal is for the hospitals you've gone to, sometimes that will have that information in it, um, and you can like take a screenshot and upload those documents.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] So it is important to, number one, have the primary EOB.
[AGENT][NEUTRAL] Whoever your primary insurance is, and then #2, showing what services were rendered, what was the diagnosis, and charges, etc. so.
[AGENT][NEUTRAL] We have to have all those pieces.
[CUSTOMER][NEUTRAL] Um, OK, so not, so not CPT code.
[AGENT][NEUTRAL] Yeah, so CPT codes, um, diagnosis codes, um, and like I said, the EOBs from your primary, who, who's your primary, the Aetna, United Healthcare, or?
[CUSTOMER][NEUTRAL] I, I see here.
[CUSTOMER][NEGATIVE] Uh, no.
[AGENT][NEUTRAL] And uh, yeah, sometimes they'll have the CPT codes on there, but they a lot of times won't have the diagnosis, um, so.
[AGENT][NEUTRAL] That might be the missing piece, so.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Well let's see, I just um.
[CUSTOMER][NEUTRAL] Uh, this was [PII], but you told me [PII], right? So here I have another emergency room visit.
[CUSTOMER][NEUTRAL] On [PII] and I would have to send you the EOB right which.
[CUSTOMER][NEUTRAL] Here has service day CPT code.
[CUSTOMER][NEUTRAL] OK, got it. So I need to get these from, OK.
[CUSTOMER][NEUTRAL] And diagnosis cold, OK.
[CUSTOMER][NEUTRAL] All right, and then I put it here.
[AGENT][NEUTRAL] Yeah, you don't have to fill out anything, just upload your documents and then we'll process them according to your policy, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I get um 70,900 per calendar year, right?
[AGENT][NEUTRAL] That's correct, per person. Uh-huh.
[CUSTOMER][NEUTRAL] Um, uh, they've come here. So I have a question on physical therapy cause my husband does physical therapy pretty often and I see this one that we received here is for physical therapy. So does this mean for [PII] that you guys paid them $60?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let me see. And let me correct, uh, so you do get 7900 per person. It's a max of 15,800 for all covered persons.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it is just, yes.
[CUSTOMER][NEUTRAL] Per year.
[AGENT][NEUTRAL] Let me look at his claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what date was that again? I'm sorry.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Uh, say that again?
[AGENT][NEUTRAL] Uh, what date was that?
[AGENT][NEUTRAL] That he was
[CUSTOMER][NEUTRAL] It says here [PII].
[AGENT][NEUTRAL] 36, OK.
[AGENT][NEUTRAL] Yes, we paid 60 to the provider. Yes.
[CUSTOMER][NEUTRAL] OK, so if he paid that he's supposed to get reimbursed from them.
[AGENT][NEUTRAL] So if that was if, so was that, yes, if he paid that as well, uh, well, you'd have to check with them on getting reimbursed back, but in theory, if your primary insurance only had a balance, yeah, if they only had a balance left of $60 owed and you paid $60 and we paid $60 then yes, there's an overpayment due back to you.
[CUSTOMER][NEUTRAL] Yeah, yeah, because that's what they charge.
[CUSTOMER][NEUTRAL] How
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK and so moving forward, um.
[CUSTOMER][NEUTRAL] Moving forward, he they can bill you guys and then you guys call right?
[AGENT][NEUTRAL] Yeah, so they can bill us and then.
[CUSTOMER][NEUTRAL] I'm sorry, and then you have
[AGENT][NEUTRAL] They shouldn't charge him because they'll be able to call and we'll tell them what we will pay.
[CUSTOMER][POSITIVE] OK perfect thank you.
[AGENT][NEUTRAL] OK. Is there anything else I can help with today, [PII]?
[CUSTOMER][POSITIVE] No, that's it. Thank you so much.
[AGENT][POSITIVE] OK, well, thanks for calling APL. I hope you have a good weekend.
[CUSTOMER][POSITIVE] Thanks. You too.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][NEUTRAL] OK, bye.