AccountId: 011433970860
ContactId: 517d394d-68e5-4b80-bf38-540f1a0b94f5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 554619 ms
Total Talk Time (AGENT): 360695 ms
Total Talk Time (CUSTOMER): 140275 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/04/517d394d-68e5-4b80-bf38-540f1a0b94f5_20250404T13:08_UTC.wav
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[AGENT][POSITIVE] Thank you for contacting ATO. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] Yes, hi, good morning, [PII]. Um
[CUSTOMER][NEUTRAL] I have a question.
[CUSTOMER][NEUTRAL] I went to see um a doctor yesterday.
[CUSTOMER][NEUTRAL] And they say they don't take um the gap insurance or in this case it would be um you know uh APL um because they're totally out of that book with all gap insurance.
[CUSTOMER][NEUTRAL] But they were, they said that because of the financial problem I'm having that they would go ahead and submit the claim. Would that claim be paid?
[AGENT][NEUTRAL] Well, let's look at your policy and find out. Um, what is your policy number? We, we can go over your benefits, we can see uh what's going on with that. If you have your policy number there with you?
[CUSTOMER][NEUTRAL] Actually I have a group number.
[AGENT][NEUTRAL] OK, and, and what is that?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] That is 14793.
[AGENT][NEUTRAL] 14793. OK. Excuse me just a moment, please. We'll just see if we can get that going.
[AGENT][NEUTRAL] 14793.
[AGENT][POSITIVE] Thank you. And how do you spell your last name, please?
[CUSTOMER][NEUTRAL] Uh [PII].
[AGENT][NEUTRAL] And I just need to have a date of birth, please, ma'am, and uh a phone number.
[CUSTOMER][NEUTRAL] Uh, date of birth, [PII]. Phone number [PII].
[AGENT][NEUTRAL] Great, thank you. So your policy um uh went into effect on July 1, 2021. It is active. So your uh benefits include in and out of hospital, um.
[AGENT][NEUTRAL] Treatment within a cancer, uh, facility, uh durable medical, excuse me, not durable medical, but lab, independent labs. Uh, where was this place of service? Where, where did you go yesterday that uh we need to look at?
[CUSTOMER][NEUTRAL] Well, it's um it's a cardiologist's office.
[CUSTOMER][NEUTRAL] And uh they do a, I think it's called a heart, uh, cardio pet, I believe it is.
[CUSTOMER][NEGATIVE] Um, they actually rent out the facility and the, you know, they have their own texts that do it, so they, I was told that they, um, did not accept the gap as a matter of fact, they need to have an echo, and I have to pay that out of pocket as far as my co-pay because again they said they didn't pay, uh, that they were totally out of network with all of, um.
[CUSTOMER][NEUTRAL] You know, with all gap insurance.
[AGENT][NEUTRAL] Sure. I, no, I get it. Um, the, the, uh, now the gap insurance is normally, uh, the, the thing about that is that we follow your, your major medical, so it in
[AGENT][NEUTRAL] Whenever you, um, whenever you have something like that, and normally what, uh, there, it's not, there's no network, let me put it that way. So, uh, we, what we do is we look at the network that you're, um, that you're in with your major medical, but let's, let's go over what uh your what your benefits are. Now,
[AGENT][NEUTRAL] Um, for this group gap insurance, uh, what you are covered for is, um, inpatient hospital and outpatient hospital, the ER, urgent care, anything like that. It's going to depend on how the cardiologist, uh, um, files the claim.
[AGENT][NEUTRAL] Now, if they file it as a physician's office.
[AGENT][NEUTRAL] That is, is a, is a private office. It's not gonna be covered under your policy because your policy covers hospitals. It covers inpatient hospital, the urgent care, outpatient surgery, um, uh, imaging within an outpatient, uh, facility.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But it does not cover the private uh physician. So if you went to your, to your um uh
[AGENT][NEUTRAL] Your primary care physician and, and like had an office visit co-pay or they got, you got a shot or something, those things are not gonna be covered uh because anything within a private physician's office is not covered. So it's going to depend on how the cardiologist um bills it. Uh, now, if they did something like a stress test, if they, if they have an office that they rent out, sometimes they will, they will, uh,
[AGENT][NEUTRAL] Um, bill that as being an outpatient facility. In other words, not something that they did in their private practice, but something they did in their outpatient facility. Now if they do that, if they bill it in that way, then you are covered under your outpatient hospital benefits which are $5500 per calendar year.
[AGENT][NEUTRAL] If
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Just say that and, and this is, this is in, if, if everything goes the way, you know, you know, it, it, we would like it to, uh, you would be in-network with your, with your uh primary uh insurance. Uh, there would be a deductible, co-payment or co-insurance, and then, and then we would, um, you know, we could, we could uh look at at paying that. Um.
[AGENT][NEUTRAL] If they bill it as a private.
[AGENT][NEUTRAL] Uh, physician's office. It's not gonna be covered. It may very well be covered under your major medical, but it would not be covered under your gap insurance. So, so we never have any sort of um of uh a network. What we do is we, we always follow your major medical. Um if there's a deductible, co-payment or co-insurance, uh, that is what we're going to follow, um, but, uh,
[AGENT][NEUTRAL] You know, I, I, if there, if it's in the hospital, we would cover it if it's in the physician's office, we wouldn't.
[CUSTOMER][NEUTRAL] OK, so with this, for example, the echo I have um scheduled.
[AGENT][NEUTRAL] With, with.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Um, it'll be done in office. I just don't know how they would bill it. Um, so if they, they bill it under an office visit, I know I have my copay of $85 for my specialist.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] They're also saying that I have to pay the $85 for that echo, so based on how they do it.
[CUSTOMER][NEUTRAL] Um, it would be covered or not.
[AGENT][NEUTRAL] Well, it sounds like, it sounds like it will not be covered by your gap insurance because it sounds like they're doing it as a private uh physician's office. It's the way that it sounds like, um.
[AGENT][NEUTRAL] You can always ask them when you're in the office, is this going to be, you know, do you bill as an outpatient hospital facility or do you bill as a, as a, uh, um, it's, there, there're two if they bill as a, as a physician's office, then, then it's not gonna be covered. So you can actually ask them, are you going, you know, when you send this into my major medical, do you bill as a outpatient facility or as a private uh physician's office? Um,
[AGENT][NEUTRAL] But it sounds like uh that it's not going to be covered because it just sounds like it's going to be in a physician's office, that that that's the way that they're going to bill it. And, and these, and the policy that you have with us is meant for outpatient hospital, um, but I would ask them, you know, it never hurts to ask to find out how they're going to bill it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, now, if it turns out that they do not bill it and that they are billing it as an outpatient hospital facility, um, there are ways that you can file the claim yourself if they don't, if they don't, uh, have the means to file the, the, uh, additional insurance themselves, um, but I would find out first whether, uh, how they're going to bill it and whether, um, it's gonna be uh considered an out an outpatient facility or a private physician's office.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, as long as it's still under either an outpatient or inpatient facility and not a medical office, it should be covered.
[AGENT][NEUTRAL] Uh, yes, it would be covered under that $5500 that is, uh, your, your benefits with us.
[AGENT][NEUTRAL] Now, if you, if you're getting ready to do something like imaging or something like that, um, you know, that's, that's why we would want to ask because sometimes they do build that as outpatient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, let me find out how they're gonna do it.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, of course, and then, and then if they, um, and then.
[CUSTOMER][NEUTRAL] And expo yeah.
[AGENT][NEUTRAL] Now, if you are, uh, if they do bill it as outpatient hospital and, and, um, you do decide to uh file the claim yourself, please let us know. Um, there are multiple ways of filing that claim and we'll be glad to walk you through the process and, and let you know exactly what paperwork you need so that you can get that, that done, you know, that you can process it yourself. And then um if you do decide to file the claim yourself, of course, we, we make that, that benefit payment to you rather than to the, to the doctor.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, that sounds good. Thank you very much for your help.
[AGENT][NEUTRAL] Is there anything else at all?
[AGENT][POSITIVE] OK, well thank you very much for contacting ATL. You have a very good.
[CUSTOMER][NEUTRAL] No, that was actually it.
[AGENT][POSITIVE] OK, well, you have a very good morning. Thank you for calling us.