AccountId: 011433970860
ContactId: 58440248-dc82-4ba5-8965-d5cf7a4410a4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 493739 ms
Total Talk Time (AGENT): 260772 ms
Total Talk Time (CUSTOMER): 208815 ms
Interruptions: 5
Overall Sentiment: AGENT=0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/58440248-dc82-4ba5-8965-d5cf7a4410a4_20250213T17:40_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, I have a question. Um, I have the gap insurance through my husband's employer, and um I didn't realize that it, um, like covers like if you had an MRI and things like that. So,
[CUSTOMER][NEGATIVE] Which I, which I had done and I paid. So my problem, my thing is, how do I file a claim? I'm not sure how to do this.
[AGENT][NEUTRAL] So your question will be how could you, what you need to submit to submit a claim. So could I get your um policy number to pull it up to make sure the policy is active and what type of policy it is?
[CUSTOMER][NEUTRAL] OK, there's 2 numbers in hospital and outpatient. There's 2 kinds of numbers. Does it matter?
[AGENT][NEGATIVE] Either one would be fine. No, ma'am, it wasn't.
[CUSTOMER][NEUTRAL] OK. 02478.
[CUSTOMER][NEUTRAL] 714 M as in Mary, L as in Larry 8.
[AGENT][NEUTRAL] Thank you. Can I have your name, mailing address, and your date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] And [PII], what is your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you and the callback number just in case the call is disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you, [PII].
[AGENT][NEUTRAL] So this policy has been active since [PII], so there is no timely filing. So if you have any claims back from [PII], move up until January, well, [PII]. 0, it's still actually active, so, um, you can submit a claim, so you will need your primary ELB from your primary insurance company for each date of service along with a diagnostic code, your ICD 10 code.
[CUSTOMER][NEUTRAL] ICD 10 code and uh the EOB. So I have to fill out a claim form?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, you'll be
[AGENT][NEUTRAL] Yes, you can, you can submit a claim form online or you can set up an online account at [PII]. However, if you don't wanna do that, you don't have to, but.
[AGENT][NEUTRAL] If you want to, you can submit a claim form with at [PII]. You can get it from there, retrieve it from there or create an account, fill out that claim form, then you still will need your EOB, which is your explanation of benefits from your primary insurance company and your diagnosis codes for for each date of service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, but what I'm, OK, so can I just send the EOB with the diagnosis?
[AGENT][NEUTRAL] You're definitely gonna need the diagnosis. You don't have to do a claim. You can send the upload it, yeah, but if you upload it on the website, I mean, the claim form is there.
[CUSTOMER][NEUTRAL] Or do I have to do a
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Oh, I don't have to do a thing. OK.
[AGENT][NEUTRAL] I'm not sure how you can maneuver around it. Like if you can just not fill out a claim form cause I have never been.
[AGENT][NEUTRAL] Access the online account because I don't have an account with [PII], so I don't know. However, you can submit your ELB I processed claims that had the ELB's information in regards to the member's informa just the patients account information which was here at American Public Life and then they have the ELB and the diagnosis code.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And claim is being processed.
[CUSTOMER][NEUTRAL] So what do I do, just fax it?
[AGENT][NEUTRAL] You can.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Now what happens if I've already paid for those services?
[AGENT][NEUTRAL] So you're submitting a claim. So if you did already pay for those services, if anything went towards your deductible copay and co-insurance because that's how this policy works for services that's covered under your policy, then the payment will go to you because you submitted the claim, your self-insured submitted claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I think I understand.
[AGENT][NEUTRAL] Cause nothing goes to the provider unless the provider submits the claim. Even if the provider submitted a claim, however, if there's no assignment of benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Attached to the claim, then we don't pay the provider, we pay the insured. So if you submit the claim it's gonna definitely go to the insured versus the provider.
[CUSTOMER][NEUTRAL] Like for the MRI that I had, they submitted the claim to the insurance. I paid them.
[AGENT][NEGATIVE] They didn't send it here.
[CUSTOMER][NEUTRAL] No, they didn't send it there because like I said, I wasn't, I misunderstood that this also covers MRIs. I didn't know that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I, I went about and paid it and then I come find out later from the agent that it covers MRI. So that's what I'm saying. That's why I didn't do, that's why it wasn't done that way.
[AGENT][NEUTRAL] Mhm, yep, your policy covers outpatient benefits of $300 per calendar day.
[CUSTOMER][NEUTRAL] So now it's after the fact.
[CUSTOMER][NEUTRAL] Right, I didn't know that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I thought it was just inpatient and outpatient.
[AGENT][NEUTRAL] Um, the MRI, when I, and when I say this, I'm not being sarcastic, but the MRI is considered as outpatient cause it's diagnostic testing.
[CUSTOMER][NEUTRAL] Yeah, I guess I misunderstood that. Now what happens with um like.
[AGENT][POSITIVE] Well, that's why we're here for you to call and ask those questions.
[CUSTOMER][NEUTRAL] I know
[CUSTOMER][NEUTRAL] What happens like, um, OK, so I know the policy pays $300 per calendar day. So what happens like if I go, right, so how about if I go for like, um, I have to go for physical therapy and it's like $20 a visit. So is that covered under, they they'll just pay the $20 every time I go?
[AGENT][NEUTRAL] For outpatient services.
[AGENT][NEUTRAL] This
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It falls under your outpatient benefits. Yes, it falls under your outpatient benefits of the 300 per calendar day, and this is not a guarantee of benefits, just a disclaimer of the policy's coverage.
[CUSTOMER][NEUTRAL] Yeah, so what is, when you go to the doctor, uh, or wherever and you give them both cards.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Can they say, well, you know, you have to pay upfront and then what we have to submit a claim. I mean, they're automatically gonna take the second card and
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] Or is that up to them?
[AGENT][NEUTRAL] That's up to them because we don't have control over that.
[AGENT][NEUTRAL] But you can definitely tell them, well, I have this insurance and then I have a secondary insurance and I would like to have my stuff submitted to the insurance company prior to you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEGATIVE] Making me pay anything because what if I don't have to pay anything?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right. OK. So on those two claims, I have my EOBs. I'm gonna put the diagnosis on it. Where do I fax it to?
[AGENT][NEUTRAL] Let me know when you're ready for the fax number.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] It's 1877365.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 942-3, that's 187736-59423.
[CUSTOMER][NEUTRAL] OK, so then what happens? They get it and if I, if I do the online account which I just did, then I check back in there to see the status of it?
[AGENT][NEUTRAL] Mhm, yes.
[CUSTOMER][NEUTRAL] OK, so no claim form, just the EOB and that correct?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK. OK. OK, that's fine. So when do you have to fill out a claim form? Or you don't ever?
[AGENT][NEUTRAL] Well, they suggest that you fill out a claim form, but some members don't, however, they suggest that you do because it's offer for you to fill it out online.
[CUSTOMER][NEUTRAL] What is it
[AGENT][NEUTRAL] It's just simply putting your name information.
[CUSTOMER][NEUTRAL] OK, so I have to sign that up.
[CUSTOMER][NEUTRAL] OK, so when I go on here, there's different claim forms, accident claim form, cancer.
[AGENT][NEUTRAL] Metlink.
[CUSTOMER][NEUTRAL] Netlink.
[AGENT][NEUTRAL] It's just a midlink gap.
[CUSTOMER][NEUTRAL] Oh, let me see.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Netlink claim form, that must be it.
[AGENT][NEUTRAL] That's it. Yes, ma'am.
[CUSTOMER][POSITIVE] OK, OK, so I'll just have to print that. OK, well, thank you for your help.
[AGENT][POSITIVE] You're welcome. Is there anything else that I can assist you with today?
[CUSTOMER][POSITIVE] No, that's it. Thank you.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL and have a great day.
[CUSTOMER][POSITIVE] Have a good day.
[CUSTOMER][NEUTRAL] Bye-bye.
[AGENT][NEUTRAL] Bye.