AccountId: 011433970860
ContactId: 3fd29221-aef4-4dc7-8198-63de3b253ef7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 601190 ms
Total Talk Time (AGENT): 387090 ms
Total Talk Time (CUSTOMER): 121074 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/21/3fd29221-aef4-4dc7-8198-63de3b253ef7_20250221T17:56_UTC.wav
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[AGENT][NEUTRAL] Good afternoon, thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, good afternoon, [PII]. My name is [PII] I'm calling in regards to a couple of questions.
[AGENT][NEUTRAL] OK, are you the insured or are you with the provider's office?
[CUSTOMER][NEUTRAL] No, I'm the insured.
[AGENT][NEUTRAL] OK, and I'm sorry, can you please give me your name again? There was some background noise that's um wasn't able to understand your name.
[CUSTOMER][NEUTRAL] Yeah, [PII] Last name is Guy spelled [PII]
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, and Mr. [PII], what is a good callback number for you please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you. And you have some questions?
[AGENT][NEUTRAL] Is that regarding your coverage or a claim or what type of questions?
[CUSTOMER][NEUTRAL] Yes, in regards
[CUSTOMER][NEUTRAL] In regards to claims and coverage, a bit of both.
[AGENT][NEUTRAL] Yes, I can help you with those. And so first off, what is the, uh, your policy number?
[CUSTOMER][NEUTRAL] Policy number is going to be.
[CUSTOMER][NEUTRAL] 2361422
[AGENT][NEUTRAL] OK, thank you. So give me a couple of moments to get your information pulled up first.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK, so first off, Mr. [PII], any information that I do provide for you today will be a verification of benefits and not a guarantee of payment. Also, I will need to verify several things with you first for security purposes. So if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][POSITIVE] Thank you, also your home mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Thank you. The phone number that is on file for you is the same as the one that you gave me, so that is your best contact number, is that correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][POSITIVE] Thank you and lastly your email address please?
[CUSTOMER][NEUTRAL] It should be my [PII] name, the [PII] [PII].
[AGENT][POSITIVE] OK, thank you so much for verifying everything. So, how can I help you today?
[CUSTOMER][NEUTRAL] I'm calling in regards to, let me see, I believe it's a claim I filed.
[AGENT][NEUTRAL] What is the date of service, Mr. [PII]? What date of service?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] The date of service was back in November. I'm sorry, I don't have the exact date. Give me one second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I believe it was the [PII].
[AGENT][NEUTRAL] OK, let me see if I can locate a claim for that data service.
[AGENT][NEUTRAL] OK, so, OK, I can see that we did receive a couple of different claims for the same data service and build them out.
[AGENT][NEUTRAL] OK, um, the most recent one that we received was denied as a duplicate. Let me look at the remarks on the one before that.
[AGENT][NEUTRAL] This is for West Kendall Baptist Hospital.
[CUSTOMER][POSITIVE] That's correct. It was an ER visit.
[AGENT][NEUTRAL] OK, so let me look at the remarks.
[AGENT][NEUTRAL] The claim number for reference is 3542219.
[CUSTOMER][NEUTRAL] OK, yeah, I see that one here.
[AGENT][NEUTRAL] OK, so, um, when you look at these remarks that I'm going to read to you, they are on your explanation of benefits in your portal on the second page of the explanation of benefits, but the first remark states in order to complete the processing of your claim, we need itemized statements of services provided listing the charges, diagnosis code and procedure codes.
[AGENT][NEUTRAL] The other code on there.
[AGENT][NEUTRAL] States we have received the primary explanation of benefits that were submitted with your claim. However, the explanation of benefits received does not list the amounts applied to the deductible, co-pay, or co-insurance. Please submit a more detailed explanation of benefits that shows these amounts for further consideration of your claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, would you be able to direct me as to where I can get that because I'm on the insurance plans, uh, website.
[AGENT][NEUTRAL] Because this
[AGENT][POSITIVE] Oh, I'm sorry.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] For your primary health care insurance?
[CUSTOMER][NEUTRAL] I mean, I just
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, you may have to reach them because every member, you know, I mean every provider or insurance company's portal is different.
[AGENT][NEUTRAL] You may have to reach out to them and tell them that the explanation of benefits, you know, that you have access to online does not show what your, the keywords in that remark that I read to you, Mr. [PII] is the amounts that are applied to the deductible, co-pay or co-insurance.
[AGENT][NEUTRAL] Because the supplemental policy that you have with us.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It is designed to help you with those amounts of covered services.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So that's why we have to have a detailed explanation of benefits showing the amounts that they applied to one of those three areas.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the other part, as far as the first remark I read, the itemized statement, that would come from your, the facility. You would have to reach out to the hospital and you can read them, you know, because we do have to have the diagnosis code, procedure codes and charges.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I will reach out to the facility directly in regards to that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then my insurance. And then I just wanted to verify one more thing. Um,
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] You did say that co-pays are covered if it's um within the means of the of that you guys cover for.
[CUSTOMER][NEUTRAL] Uh, does that include outpatient services done?
[AGENT][NEUTRAL] OK, so depending on me we would have to receive for covered outpatient services. Let me look like for example on your policy office visits are not covered.
[AGENT][NEUTRAL] This policy doesn't cover office visits. If you receive some type of treatment in the doctor's office, we could review the treatment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Under your outpatient benefit maximum.
[AGENT][NEUTRAL] Which is the $3000 per calendar year for covered outpatient services.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Or if you had lab work that was sent out to an independent lab facility, but a, an office visit itself is not covered.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, no, it was, um, I'm not sure what category it falls under, but it was for an ultrasound.
[AGENT][NEUTRAL] That is something that could be reviewed and we would need um I'm not looking at the documents that you submitted but do you know where to get if you're gonna be what I recommend first off, let me back up, what I recommend first off is always present your APL ID card along with your primary insurance card when you go for medical services because most providers will take care of filing both of your insurances.
[AGENT][NEUTRAL] In the event that they tell you that they don't file the supplemental, then of course, you can do it just like you did at this time. But it makes it a little easier for you if they will do it.
[AGENT][NEUTRAL] As far as you know getting all this documentation together.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] OK, perfect. I wasn't aware of that. Thank you so much for that information.
[AGENT][NEUTRAL] Yes, well, you're, yeah, you're welcome, but if you, um, do you know where to get the
[AGENT][NEUTRAL] Claim form for APL for this type of policy because it does have the instructions on it as well. OK.
[CUSTOMER][NEUTRAL] Yes, yes, I.
[AGENT][NEUTRAL] So on that Medli claim form on page one at the top, it gives instructions for completing the form and the additional documents that you need to submit.
[AGENT][NEUTRAL] So you know if you have to file claims in the future just use that as a checklist essentially to make sure that you you know have everything but once you do get this additional information that we need.
[AGENT][NEUTRAL] You can just log into your portal with APL into our online service center and you will just upload those documents like if you were uploading a new claim because the system will know that that was missing information that we needed um on on this claim there's no way to add to this claim OK? does that make sense?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] Yes, so you would just upload the files.
[CUSTOMER][NEUTRAL] Understood. OK.
[AGENT][NEUTRAL] Like you did before. OK.
[AGENT][NEUTRAL] Well, do you have any other questions, Mr. [PII], that I can answer for you or try to help you with?
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][POSITIVE] Um, no, I think that was all. Thank you so much for your help. I truly appreciate it.
[AGENT][POSITIVE] Well, you are certainly very welcome so thank you again for calling APL and I hope you have a wonderful weekend.
[CUSTOMER][POSITIVE] Thank you likewise.
[AGENT][POSITIVE] Yes sir, thank you.
[CUSTOMER][NEUTRAL] Mhm bye bye.
[AGENT][NEUTRAL] Bye bye.