AccountId: 011433970860
ContactId: 49e7320f-c0ac-488b-8617-17fe1b8e068b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 604820 ms
Total Talk Time (AGENT): 389782 ms
Total Talk Time (CUSTOMER): 200522 ms
Interruptions: 4
Overall Sentiment: AGENT=0.7, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/49e7320f-c0ac-488b-8617-17fe1b8e068b_20250219T14:50_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] For contacting ATL, my name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. How are you today?
[AGENT][NEUTRAL] I'm fine. How are you?
[CUSTOMER][NEUTRAL] Good, I'm calling regarding my gap insurance.
[AGENT][POSITIVE] Yes, how may I help you?
[CUSTOMER][NEUTRAL] Um, yeah, my, my, my, um, medical insurance goes from [PII].
[CUSTOMER][NEUTRAL] And um and I had a claim on [PII] for an X-ray and it went to my deductible, but it was denied by APL so I'm just calling to inquire about it.
[AGENT][NEUTRAL] Yes, so let's look that up, [PII]. What is your policy number, please?
[CUSTOMER][NEUTRAL] Let's see.
[AGENT][NEUTRAL] You might begin with a 01 or is this, yeah.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Yeah, I'm just like there's two numbers here 0184.
[CUSTOMER][NEUTRAL] 114
[CUSTOMER][NEUTRAL] 9 NL
[CUSTOMER][NEUTRAL] I guess 8
[AGENT][NEUTRAL] OK, thank you. If I could verify your date of birth and a phone number, please.
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][POSITIVE] Thank you so much. Let's see what we have here.
[AGENT][NEUTRAL] And what uh you
[CUSTOMER][NEGATIVE] And I go, I go to the website and you click on the claim numbers and and it it wants to download it doesn't, you can't open anything is that normal?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Oh, OK. Uh, yes, yeah, you have to download the, so you can open up the entire thing. uh, what was the date of service that we're looking for, uh, [PII]?
[CUSTOMER][NEUTRAL] December it was either [PII] or [PII].
[AGENT][NEUTRAL] OK, let's look at that.
[AGENT][NEUTRAL] So, first of all, um,
[AGENT][NEUTRAL] For outpatient services, your policy will pick up the deductible, co-payment or co-insurance up to $1000.
[AGENT][NEUTRAL] Uh, that's per calendar year, so let's see what we have here.
[CUSTOMER][NEUTRAL] Yeah and I'm not sure this is this is um designated as inpatient or outpatient because it was at Cleveland Clinic.
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] So this is uh [PII]. It's what we're looking at.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] I'm trying to find it OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, when I look at my card, my card's old, but it says the effective date is [PII], and that matches my effective date on my Cigna insurance.
[AGENT][NEUTRAL] Absolutely. So, as I mentioned before, for the calendar year [PII], you have $1000 in which we will pick up the deductible, co-payment or co-insurance for your major medical. Now, on [PII], we have a data service for that date and it looks like that was um an outpatient, or excuse me, uh.
[AGENT][NEUTRAL] We have a uh event for.
[CUSTOMER][NEUTRAL] OK, let's, let's first, let's, let's first talk about the date.
[AGENT][POSITIVE] Yes, of course.
[CUSTOMER][NEUTRAL] Now my, my, my Cigna insurance starts over again on [PII].
[CUSTOMER][NEUTRAL] And I think I just heard you say that APL starts over again on, on um [PII], is that true? OK, that, that, that's the problem then the insurances aren't in sync.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] [PII]. That's right. That is correct.
[AGENT][NEUTRAL] So it's uh on some of these, um, yeah.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Now is that something we choose or is that something that's assigned because it doesn't make sense for our um insurance person.
[AGENT][NEUTRAL] It's
[CUSTOMER][NEUTRAL] To have 22 dates that don't match when when it when we're talking about deductibles.
[AGENT][NEUTRAL] Right, um, normally the way that this is, uh, this is set up is with the um.
[AGENT][NEUTRAL] The group, uh, individual, um, the person who, uh, um,
[AGENT][NEUTRAL] Sets up your insurance to begin with.
[AGENT][NEUTRAL] It's, it's usually set up with a, with a person, yeah, so whenever they uh begin negotiating um terms, uh, that's usually what uh what has happened is that, is that they will uh negotiate that, that amount or or and the dates, um.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, so it sounds like something was over something was overlooked when it comes to the dates, right?
[AGENT][NEUTRAL] When it will start and when it will end.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] If, if my sign that policy starts on [PII] and my EPL policy starts on [PII], we've got a month that we have a month difference.
[CUSTOMER][NEUTRAL] And that it sounds like that's what the issue is.
[AGENT][NEUTRAL] Well, that would be something that they would negotiate as a group, so that would be something that that group of.
[CUSTOMER][NEUTRAL] Right, but you're you're looking, you're looking at our policy and our policy goes from [PII], correct? as far as APL is concerned.
[AGENT][POSITIVE] That is correct. For, for us, yes.
[CUSTOMER][NEUTRAL] OK, OK, now saying that.
[AGENT][NEUTRAL] And so I don't know why they, why they have that that gap. I don't know why they have that gap because we do, we also have what we call um uh policy years. So there are some groups where they, the policy will begin in the middle of the fiscal year um like uh um I don't know from as you say [PII] [PII] through, you know, to to next [PII], um, we do have the plan year.
[AGENT][NEUTRAL] Policies, but those have to be elected by
[AGENT][NEUTRAL] The group as a whole.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and so what uh the group as a whole, um, has elected or whoever it is who, who manages that with your company, um, they have elected for the uh for the um uh plan or excuse me, the, the policy year which is [PII].
[AGENT][NEUTRAL] The plan year policies, uh, you can also get a plan year policy with the same benefits. Um, it's just that uh you, you have to, you have to do that when you're negotiating the, the, uh, the, the gap insurance and that would be with your company. So whenever uh they do renew as a group, and they can also request that if they want to.
[CUSTOMER][NEUTRAL] OK, because it sounds like we started that way because my card is dated [PII] and it has an effective date of [PII], so somewhere along the way something happened.
[AGENT][NEUTRAL] Well, your, your, your card, um, unless they, they change.
[AGENT][NEUTRAL] Um, benefits. Let's just say, uh, uh, we, we started, um, issuing benefits for your group on [PII]. You'll keep the same card.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Until as a group.
[AGENT][NEUTRAL] You change
[AGENT][NEUTRAL] Gap policies. So right now we have a, a policy for you ending in 1149 that began [PII]. Um, once, uh, as a, let's just say as a group, um, beginning in [PII] they decide to go with the plan year rather than the, the, uh, a fiscal year rather than the policy, uh, [PII]. Let's just say that your group decides.
[CUSTOMER][NEUTRAL] OK, so that was just that was just that was just decided this year then?
[CUSTOMER][NEUTRAL] Last year wasn't like that.
[AGENT][NEUTRAL] No, I'm not saying, I'm not saying that they have been decided, [PII]. I'm just saying that if they decided if they, if they did, this is hypothetical. So let's just say that if they did that, then it would change.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, because, OK, because it sounds like the, because it sounds like my problem is my plans aren't matching.
[AGENT][NEUTRAL] That would be
[CUSTOMER][NEGATIVE] Because I was denied coverage.
[AGENT][NEUTRAL] So I'm gonna, I will have the um uh I am going to have, I'm going to send the uh um claims back uh to um
[AGENT][NEUTRAL] Uh, so that we can have this, uh, looked at, um, but it, it, it does look like that's, that is, uh, that may possibly be an issue if you were, if there is that gap there, but that is something that they would have to resolve at the, at the, uh, um, at the group level rather than us being able to do it as an individual, unfortunately, because it is group gap insurance. But the December, uh, let's see, what are we looking at? It was [PII].
[CUSTOMER][NEUTRAL] Yeah, cause our whole company is the same.
[AGENT][NEUTRAL] Exactly. So what I'm gonna do is I'm gonna go ahead and send this claim, the one for [PII], um, for Cleveland Clinic, Florida. I'd like to send that back to um uh and see uh if there's any way that that can be paid, but, um, that is what has happened here is that uh is that as a, as a group.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] It was uh it was sent out. Now, is there any, uh, do we have any other uh issues, um, besides that?
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] No, that's the only that's the only issue.
[AGENT][NEUTRAL] OK, so this is, let's see, I'm gonna get that claim number ending in 3264 and yes, yeah, I'm sorry about the system being that way it it forces you to open up the entire um thing rather than and they are working on that uh for what it's worth we are updating our system and they are trying to make it more user friendly and and one of the things that they were looking at is is uh being able to actually um you know look at the claim uh.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, because I don't like I don't like to open that up on my on my um work computer.
[AGENT][NEUTRAL] Right, no, I understand that. Yeah, you don't want other people to see your stuff, so, um.
[CUSTOMER][NEUTRAL] Cause yeah.
[CUSTOMER][NEGATIVE] Well, not only that, I, I don't want it to be saved into the into the work computer.
[AGENT][NEUTRAL] And yes, of course, absolutely, um, well, let me go ahead and and as I said, they are, they are looking at that. I think that's, that is an issue that uh that is cropped up for many people, um, and we'll, uh, but they, but, uh, let me see what I can do about these particular claims first um before we ever get started on this. Um, so, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, I'm sorry about that but uh yes, let me go ahead and see if I can get this one reviewed um.
[AGENT][NEUTRAL] At least.
[CUSTOMER][POSITIVE] Perfect.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, because that'll be that's the only issue for the year because that's the only time I went to the doctor's in December.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So everything else will fall into the sync.
[AGENT][POSITIVE] OK, great. OK. Well, um let me go ahead and do that and thank you for bringing this to our attention and we'll just see what we can do about getting this resolved.
[CUSTOMER][POSITIVE] OK. Thank you very much. Have a great day.
[AGENT][POSITIVE] OK, thanks for contacting AP have a good day.