AccountId: 011433970860
ContactId: 4e54bcdb-bb63-4f66-88c3-81b131580fe2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 560320 ms
Total Talk Time (AGENT): 206498 ms
Total Talk Time (CUSTOMER): 313057 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/27/4e54bcdb-bb63-4f66-88c3-81b131580fe2_20250127T19:35_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][POSITIVE] Good afternoon. Thank you for calling A.
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII] and I have a couple of questions about a policy that my employer has purchased.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It seems to me there's different coverages that I have been explained to you by different people. Um, I have a policy number. Do you need that?
[AGENT][NEUTRAL] Um, yes, [PII], may I have your a good contact number in case we're disconnected though?
[CUSTOMER][NEUTRAL] [PII] option 3.
[AGENT][NEUTRAL] Thank you for that. And may I have the um policy number?
[CUSTOMER][NEUTRAL] The policy number is 23804.
[AGENT][NEUTRAL] Is that the group number?
[CUSTOMER][NEUTRAL] No, it says policy number 23804. Uh there's a certificate number.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, the policy certificate number is the policy number. May I have that, please?
[CUSTOMER][NEUTRAL] OK, that's a certificate number, so that is 02440284.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] How confusing if it's the policy number, but the policy number is something different on the paper and then that's the certificate number. I don't know, weird.
[AGENT][NEUTRAL] Yeah, I didn't even know it said that. I'll, I'm gonna bring that, yeah, but that's true. I'm gonna bring that up. I, I didn't know that said that.
[CUSTOMER][NEUTRAL] Yeah, I'm like this is weird.
[AGENT][NEUTRAL] OK, I have you here. I just need you to verify your date of birth, mailing and email address on file.
[CUSTOMER][NEUTRAL] My date of birth is [PII]. My email is [PII].
[AGENT][NEUTRAL] Thank you, and your mailing address?
[CUSTOMER][NEUTRAL] My mailing address is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So you're wanting to go like over your policy coverage or you have particular questions?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I have a particular question. I'm sitting here looking at the supplemental limited benefit medical expense insurance plan description and um it's saying everything that is paid for and when it gets down to what it actually means, it doesn't say anything, um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm only getting paid for my deductible when I go to the doctors what's being reimbursed, but on my policy, it has an outpatient writer, an office treatment writer, a cancer writer, an independent lab writer. What is all that stuff, and it's being paid for.
[AGENT][NEUTRAL] All right, so you
[AGENT][NEUTRAL] So your policy has um the max, which is $5000 it'll pay towards in-hospital expenses and then $5000 it'll pay towards outpatient per calendar year. There is no deductible. Our policies pay towards the copays, deductible and co-insurance after your primary. So if primary charges you.
[CUSTOMER][NEGATIVE] That's not true. That's not true. I have, no, I pay all of my co-pays and you guys don't pay them. You can even go back and look at all of the benefits that I because other people are telling me, no, my co-pays are being paid. So I don't know if there's something wrong with my account, but none of my co-pays have been paid. As a matter of fact, I owe.
[AGENT][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] So if I could proceed?
[AGENT][NEUTRAL] It's of covered charges, of covered charges. So you do have several claims that were paid here, but if it's something where like office visits aren't covered or we're asking for the explanation of benefits like some of these denials, then that's different. But if the claim is paid out, that's what we're paying too. We only pay towards those three things.
[CUSTOMER][NEUTRAL] Yeah, go ahead.
[CUSTOMER][NEGATIVE] OK, so why am I paying, OK, there's, there's one right here that is dated [PII], a $50 co-pay to an urgent care. Um, my insurance primary paid everything except the $50 co-pay and you guys did not pay it. From what I've been told by
[AGENT][NEUTRAL] Would you like me to continue?
[CUSTOMER][NEGATIVE] It says on here you paid it, but I keep getting billed for it.
[AGENT][NEUTRAL] The date of service was [PII].
[CUSTOMER][NEGATIVE] Yes, I'm very confused.
[AGENT][NEUTRAL] We paid 50
[AGENT][NEGATIVE] We paid $50 to the provider. So if they're billing you, they, they should not be billing you. That's a double payment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the ones that
[AGENT][NEUTRAL] We pay directly to them.
[CUSTOMER][NEUTRAL] So the ones that I have that are bills that are stating maybe they might need to be reprocessed. I don't know because there's a $15 co-pay that I have a bill for on date of charge or date of um that is date of service [PII].
[AGENT][NEUTRAL] So for [PII], we don't have a claim on file, so they didn't file that with us.
[CUSTOMER][NEUTRAL] OK, so that needs to be refiled and I'm sorry that I'm doing this with you. I just, I just need to make, I just don't know what's going on. This one is dated, um, it's a co-pay for another urgent care date of service, [PII].
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] And it says even on my thing you guys paid 0.
[AGENT][NEUTRAL] We denied the claim, requesting the explanation of benefits from primary insurance that was sent to the um provider as well for a request.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I need to contact them.
[CUSTOMER][NEGATIVE] Isn't this awful that you have to do this?
[CUSTOMER][NEUTRAL] OK, then there is on date of service.
[CUSTOMER][NEUTRAL] [PII], no, that isn't the date of service, that is when the insurance paid.
[CUSTOMER][NEUTRAL] I think it might be [PII]. I'm not sure it just says it, it just says extended copay applied.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] [PII], the claim was denied um because office visits are not covered on the policy.
[CUSTOMER][NEUTRAL] OK, when we started the conversation, you told me office visits were covered under the policy.
[AGENT][NEUTRAL] I did not. I said that there was an office treatment rider, and I didn't even get to that point. You mentioned that, but the office treatment rider means, so sometimes the the the provider will charge a facility charge, and then all the treatment, if they charge you for the facility charge, like a place of service charge, those are not covered, but because you have the office treatment rider, any treatment done in the office can be covered.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Up to that $5000. So you do not have office visit setting coverage, but you do have treatment because of the office treatment rider.
[CUSTOMER][NEUTRAL] OK, so it just depends on how the how they um code the office visit.
[AGENT][POSITIVE] Right, that's correct.
[CUSTOMER][NEUTRAL] OK, OK, now there was on [PII], a balance of $418.79 for an epidural lumbar that was done in office.
[AGENT][NEUTRAL] OK, and there's no claim on file for [PII].
[CUSTOMER][NEUTRAL] Oh my gosh, OK, OK, so I need to have them resubmit these things correct?
[AGENT][POSITIVE] Yes, ma'am, that's correct.
[CUSTOMER][POSITIVE] OK. OK dokey, that's all that I wanted. I thank you for all of your information.
[AGENT][POSITIVE] You're welcome and thanks for calling APL. I hope you have a great day.
[CUSTOMER][NEUTRAL] OK, and I do have one more. I do have one more question about a date of service [PII].
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] And I'm not even seeing that on here either.
[AGENT][NEUTRAL] Yeah, for that one, I'm not showing a claim on file for that date.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I'm guessing maybe that um
[CUSTOMER][NEUTRAL] If they're not willing to submit to you guys because you're not a medical provider, I can do this myself.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You can, yes, you can file the claim.
[CUSTOMER][NEUTRAL] If I if I submit the EOBs, OK, OK, OK, and then just put myself as reimburser to be reimbursed.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Well, no, so once you file the claim, it'll, it'll come in as the insured submitted it and so it'll be paid out to you.
[CUSTOMER][POSITIVE] OK. OK dokey. I thank you.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Have a great day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye-bye.