AccountId: 011433970860
ContactId: 58153176-de0f-4a5e-812d-b83beacad713
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 777059 ms
Total Talk Time (AGENT): 342068 ms
Total Talk Time (CUSTOMER): 276428 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/22/58153176-de0f-4a5e-812d-b83beacad713_20250422T18:29_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Um, yes, my name is [PII], and I received a letter in reference to a claim. Um, would you be able to help me?
[AGENT][NEUTRAL] Um, yes, do you have your policy number, [PII]?
[CUSTOMER][NEUTRAL] I do not. If I give you my social security number, would that help?
[AGENT][POSITIVE] Uh, yes, absolutely. What is that?
[CUSTOMER][NEUTRAL] OK. It is um [PII].
[AGENT][NEUTRAL] OK, do you have a good callback number just in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[AGENT][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] Um, and do you know which policy you were calling on?
[CUSTOMER][NEUTRAL] OK. Um, so I got this letter.
[CUSTOMER][NEUTRAL] Um, and it says here we're, uh, we've seen a claim on your policy and a review of your claim has started. So, the only one that I've ever submitted, um, was to, it was from a patient first.
[AGENT][NEUTRAL] Was it like a a hospital claim or dental or?
[CUSTOMER][NEUTRAL] It's not really, it's, it's um.
[CUSTOMER][NEUTRAL] I guess, well, Patient first is considered as urgent care, but they're actually my primary care physician.
[AGENT][NEUTRAL] Oh, OK. Um, let me see if I can.
[CUSTOMER][NEUTRAL] Cause I go to them for everything, um, but it, it wasn't because it's an emergency care or urgent care, it's because, you know, they're listed as my primary care physician, so that's what anytime I have to have blood work or insurance or what, you know, anything that needs to happen, I have to go through them.
[AGENT][NEUTRAL] OK. Um, OK, I'm, I'm pulling it up under your hospital indemnity. Just need to verify a few pieces of information. What is your birth date, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And your address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And then lastly your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, let me see.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Um, what date was that for?
[CUSTOMER][NEUTRAL] Um, so, it was in March.
[CUSTOMER][NEUTRAL] I just got the letter, no, um, [PII], so I guess in March.
[AGENT][NEUTRAL] OK, I see.
[AGENT][NEUTRAL] OK, yeah, it looks like we have
[AGENT][NEUTRAL] We've gotten a claim from, yeah, patient first.
[AGENT][NEUTRAL] And yeah it looks like it's just it's pinned in our system we're just waiting on confirmation of your eligibility from your employer once we get that it'll go through and process.
[CUSTOMER][NEUTRAL] Which is first, but.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] My question, I guess.
[CUSTOMER][NEGATIVE] My, um, because of course, you know, you have to go to your GYN doctor, and because they don't accept the policy, I mean they don't accept this insurance. I'm gonna have to send everything to you guys, right?
[AGENT][NEUTRAL] Um, so you're going for an office visit or wellness or?
[CUSTOMER][NEUTRAL] Is that how
[CUSTOMER][NEUTRAL] Yeah, I, well, I had to go to, I had to get my uh mammogram done and my office visit.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Cause you know, you go, you know, you have to go annually.
[CUSTOMER][NEGATIVE] And nothing was submitted I guess to you guys because they said that they didn't accept that insurance.
[AGENT][NEUTRAL] Oh, OK, yeah, if they didn't.
[CUSTOMER][NEUTRAL] So I
[CUSTOMER][NEUTRAL] Mhm, yeah.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] So, go ahead, because um I was gonna say, cause you said if they didn't accept the insurance, then you're gonna say something. So I'm pretty sure that's you're, you're ready to say what I can ask you.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, so if they don't accept it, yes, you'll have to file it yourself, um, and what we'll need is like the claims that they would submit normally to insurance, so because we need to see what services were rendered, what was the diagnosis, the date you were seeing, how much were the charges, so that's the information that we would need, that you would need to submit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So the only thing they gave me, OK, um,
[CUSTOMER][NEGATIVE] It just breaks down what I, what happened as far as what they did.
[AGENT][NEUTRAL] OK, does it show like.
[CUSTOMER][NEUTRAL] And the charges is that
[AGENT][NEUTRAL] Yeah, does it show like mammogram and then what your diagnosis was and.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But there's no diagnosis because the mammogram was something I had to get every year.
[AGENT][NEUTRAL] OK. Um,
[CUSTOMER][NEUTRAL] So it didn't give me a diagnosis cause I wasn't diagnosed with anything. So, um, you know, of course, you can go in for a checkup. And so that's, it should be on the code as far as the checkup because I have to get a mammogram every year. And then,
[CUSTOMER][NEUTRAL] They send it to the radiologist and everybody so they can read it. So I need to submit all that stuff to you guys.
[AGENT][NEUTRAL] Yes, cause you do have a medical imaging test, um, benefit that pays $100.
[AGENT][NEUTRAL] Um, so that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And um let's see, that's not a guarantee of payment just a basic outline um let's see so yeah so like I said we would need something that showed what services were rendered what the diagnosis was so if you don't have the diagnosis, I would call them and see if they can provide you some type of documentation that has that because we will need that.
[CUSTOMER][NEUTRAL] OK, but it says diagnosis, but I wasn't diagnosed with anything. It's just a checkup.
[AGENT][NEUTRAL] Well, there's, there's always a diagnosis associated with any kind of procedure, even if the diagnosis is like routine checkup, um,
[CUSTOMER][NEUTRAL] OK, so that's gonna be, OK, so it, as long as it says like a routine checkup or something like that, then that's OK. So that's what it was. It was just a routine checkup.
[AGENT][NEUTRAL] You
[AGENT][NEUTRAL] If it specifically says diagnosis and then that the diagnosis was the routine checkup, but
[AGENT][NEUTRAL] A lot of the times those don't, cause there's coding, there's a code for the diagnosis.
[AGENT][NEUTRAL] Um, and then there's code, code for your procedures, so I'm not sure if those codes are on what you have.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, but, so I do get entitled to a routine checkup for my GYN, is that correct?
[AGENT][NEUTRAL] Um, under your hospital indemnity, let me see what, if it defines what the diagnostic testing benefit is.
[AGENT][NEUTRAL] Hold on one moment
[AGENT][NEUTRAL] OK, so the benefit covers
[AGENT][NEUTRAL] Um, it covers MRIs, CAT scans, PET scans. I don't see routine mammograms. This is your hospital indemnity though. Let me see if you have anything under, you've got several policies, so let me see what else there is.
[AGENT][NEUTRAL] Might be a benefit under a different policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm
[CUSTOMER][POSITIVE] Thank you for your assistance.
[AGENT][POSITIVE] Yeah, absolutely, um let's see.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, let's try.
[AGENT][NEUTRAL] We'll look at your hospital, um, critical illness policy. Let me see if that provides anything.
[AGENT][NEUTRAL] OK, I'm pulling up that policy. Let's see what that covers.
[AGENT][NEUTRAL] And again, just not a guarantee of payment, basic outline of the policy, um.
[AGENT][NEUTRAL] Pull this up.
[CUSTOMER][NEUTRAL] So what would prevent them from not paying on the policy?
[AGENT][NEUTRAL] So, the policies that you have, none of these are like major medical. You've got like a critical illness, um, you've got an accident policy. You know, these policies are very specific to what's covered. So, for example, like critical illness.
[AGENT][NEUTRAL] It covers very specific illnesses, um, that would be critical in nature like heart attack, stroke, um, organ failure, things like that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Right, but nothing like doctor's offices and stuff, right?
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Yeah, if you, let me see, I think your hospital indemnity does have some.
[AGENT][NEUTRAL] So the hospital indemnity does have a physician's office visit benefit.
[AGENT][NEUTRAL] It pays out $50.04 times a year. Urgent care pays $50.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You said 15?
[AGENT][NEUTRAL] 5050.
[CUSTOMER][NEUTRAL] OK, $50.
[AGENT][NEUTRAL] Yeah, um.
[CUSTOMER][NEUTRAL] So he only pays $50 for a doctor's visit.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. So, OK. So in other words, it really doesn't pay anything for visits. cause I mean it's $50 and, you know,
[AGENT][NEUTRAL] Yeah,
[AGENT][NEUTRAL] Right, these are, these are very limited policies. So it's again, not gonna be like a major medical like you would have like through United Healthcare or Aetna or something like that. So these have specific dollar amounts that it pays out for certain services.
[AGENT][NEUTRAL] Um, have you set up your account on, uh, on our portal because that will have all of your policy certificates where you can read through what's covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I haven't set it up. Um, so, so I guess it's best to get a supplement insurance. I guess that's what you're.
[CUSTOMER][NEUTRAL] Alluding to.
[AGENT][NEUTRAL] Well, I mean, I can't give you any advice on what kind of insurance to get. This is just the policies that are offered.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] These are the policies that are offered through your employer.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh through the staffing agency.
[AGENT][NEUTRAL] Um, which, like I said, they're, they're limited in nature, um, it's not gonna be like full blown major medical insurance, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Right, OK, I got you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, well, so I guess it's really no need for me to even file a claim, if that's the case, right?
[AGENT][NEUTRAL] Well, I mean, you still, you still have that benefit. You can collect on, um, urgent care facility, like I said, that pays $50. Um, I mean, it's, it is that dollar amount that you're entitled to, um.
[AGENT][NEUTRAL] But I'm not seeing a policy that's going to pay for like your routine services, um.
[AGENT][NEUTRAL] Based on the that I'm seeing here.
[CUSTOMER][NEGATIVE] Right, so that, that's why I said there's no, yeah, there's no need for me to do a policy for my mammogram and stuff because it's not gonna pay out, right?
[AGENT][NEUTRAL] Right, right, specifically for the mammogram, but if they did charge you an office visit, you could potentially collect on that.
[CUSTOMER][NEUTRAL] Yeah, they charged that so as far as like lab results or anything, they don't pay for any of that stuff, right?
[AGENT][NEUTRAL] Um, so, if it's, there's specifics on the diagnostic testing, and again, that would be like your MRIs, CAT scans, PET scans. It's gonna be those major types of diagnostic tests.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, under your hospital indemnity. Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Right, OK, alrighty, thank you.
[AGENT][NEUTRAL] OK. Anything else I can help with today?
[CUSTOMER][POSITIVE] Uh, that is it. Thank you so much.
[AGENT][POSITIVE] OK, thank you for calling [PII]. I hope you have a good afternoon.
[CUSTOMER][POSITIVE] You too. Thanks. Bye-bye.
[AGENT][NEUTRAL] OK.