AccountId: 011433970860
ContactId: 5e85e1ab-0e03-4804-866e-d6e528cba236
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 839599 ms
Total Talk Time (AGENT): 294243 ms
Total Talk Time (CUSTOMER): 477537 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/28/5e85e1ab-0e03-4804-866e-d6e528cba236_20250128T15:51_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, hi. I just need some clarification on my benefits.
[AGENT][NEUTRAL] I can verify benefits.
[CUSTOMER][NEUTRAL] Um, and.
[CUSTOMER][NEUTRAL] And um yeah I can give you my, uh, do you need my policy certificate number or group number?
[AGENT][NEUTRAL] Policy number.
[CUSTOMER][NEUTRAL] OK, it is 024548.
[CUSTOMER][NEUTRAL] 89.
[AGENT][NEUTRAL] May I have your name and a good callback number?
[CUSTOMER][NEUTRAL] Um, [PII] and my phone number is [PII].
[AGENT][NEUTRAL] Thank you. Can you verify your date of birth, your mailing address, and your email, please?
[CUSTOMER][NEUTRAL] Yeah, um, [PII], and it's [PII].
[AGENT][NEUTRAL] Thank you for verifying that information. Please be advised that verification of coverage does not guarantee the payment of a claim. And which benefits can I provide for you?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well, I just again I, I, I, I don't think I've ever even called you guys, so here's the thing I have something from um
[CUSTOMER][NEUTRAL] Sorry, let me quickly, the date of service is uh.
[CUSTOMER][NEUTRAL] February, a year ago, well, almost a year ago, [PII].
[CUSTOMER][NEGATIVE] [PII] and apparently this we've gone to like you know my my son like had an X-ray got crutches all this crap and um it was never submitted to you guys.
[CUSTOMER][NEUTRAL] So I, you know, I have paid the bill but I have all of the documentation showing, you know.
[CUSTOMER][NEGATIVE] We like them submitting it to my initial, my primary insurance what I paid or whatever the total amount but like uh they're telling me that I could submit it to you guys because they won't do it now.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So is this to what's the threshold for the length of time?
[AGENT][NEUTRAL] There is no
[CUSTOMER][NEUTRAL] Expiration for me to submit some oh good.
[AGENT][NEUTRAL] There's no time limit to submit a claim.
[CUSTOMER][NEUTRAL] Oh good, OK, so I have all of this like how is it easy? Can I do this online or should I mail it in?
[AGENT][NEUTRAL] Yes, if you have registered your portal, you can go to [PII] and register.
[CUSTOMER][NEUTRAL] No, I don't know I.
[CUSTOMER][NEUTRAL] I don't, I don't think I did that. I did not do that, so I'm gonna have to do that. Sorry, I can't even find a pen. OK, first, let's get a pen and then um I will set that up. Is it do you guys have to send me a link or something to set that up?
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] No, ma'am. No, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK sorry so I'll write that down now where am I going?
[AGENT][POSITIVE] Secured.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So [PII].
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII] OK.
[AGENT][NEUTRAL] And you're gonna register as a new user.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you would need 3 items when you submit your claim. You would need an itemized bill from your provider, which you have. You will need your primary insurance explanation of benefits.
[CUSTOMER][NEUTRAL] Yep.
[CUSTOMER][NEUTRAL] Right, yep.
[AGENT][NEUTRAL] And you would need a Medlink claim form. Once you get into the portal, go under forms and Medlink is the one that you would need to submit your claims.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, a medli claim form.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] And then when you say something about my primary insurance, oh, I do. I have the summary benefits, so they knew what I needed to send in so that was nice they sent that to me, OK.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] I have all that and then I have my receipt I pay a copay and then they just made me pay the whole balance because it was overdue for like a year OK.
[CUSTOMER][NEUTRAL] Um, but, and how do I state like that you got if you guys are gonna cover any of this I need to get paid and not university like not the.
[CUSTOMER][NEUTRAL] Medical facility.
[AGENT][NEUTRAL] Correct. So since you submit the claim, reimbursement will go to you.
[CUSTOMER][POSITIVE] Oh good, OK, OK, so that's good. OK.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] So I have that and then um what else there was another question.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Oh, and then I, I'd be able to go in there and see though, for example, like this is where I just don't understand like um I was, I, my doctor wanted me to get like um a sonogram and because I'm having an issue, but then I'm told I have to pay $500 because I have like a deductible, so can you just help me understand.
[CUSTOMER][NEUTRAL] What my
[CUSTOMER][NEUTRAL] The co-insurance thing is or deductible.
[CUSTOMER][NEUTRAL] That I have annually.
[AGENT][NEUTRAL] Well
[AGENT][NEUTRAL] So when you go to your
[CUSTOMER][NEGATIVE] Because I didn't get it.
[AGENT][NEUTRAL] When you go to your providers, always give them your secondary card and have them file.
[CUSTOMER][NEUTRAL] I do.
[AGENT][NEUTRAL] Yes, ma'am. And then if they don't, which sometimes they do, sometimes they will, anything outpatient, it allows $500 per calendar day.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Anything inpatient allows calendar year benefit amount of $6000.
[CUSTOMER][NEUTRAL] Oh, so that you said 500 for outpatient? OK.
[AGENT][NEUTRAL] Per day, yes ma'am.
[CUSTOMER][NEUTRAL] So when you say that, what does that mean? Like, sorry.
[AGENT][NEUTRAL] So each day, the [PII], you get 500 to [PII], you're allowed 500 to [PII], you're allowed 500.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] That's the max per day.
[CUSTOMER][MIXED] All right, but meaning, but like, you know, these are just right, so it's an outpatient like it's an X-ray or something or you know a sonogram. Why are they asking me to pay $500?
[AGENT][NEUTRAL] And that we have no idea that's how that provider may choose to bill or the provider's choice.
[AGENT][NEUTRAL] But the benefit plan that you chose allows 500.
[CUSTOMER][NEUTRAL] Huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Meaning like you guys will pay 500?
[AGENT][NEUTRAL] Yes, ma'am. It will pick up your co-pays, your co-insurance, and our deductibles up to $500 per day.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] Alright, so let me write this down you said copay, coinsurance.
[AGENT][POSITIVE] Good. And deductibles.
[CUSTOMER][NEUTRAL] Really?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] That's what they're saying. So they're saying I have a deductible of $500 and I have to pay it.
[AGENT][NEUTRAL] And if they make you pay it, as long as that bill comes in before anything else on that day, you have that 500 benefit.
[CUSTOMER][NEUTRAL] Ah
[CUSTOMER][NEUTRAL] Really? Oh, OK, so then when you say like even a copay, like when I, like, let's say I go to a specialist and it's $60.
[CUSTOMER][NEUTRAL] You know, like a specialist is from with the um insurance that my primary insurance, it's $60 co-pay, you guys will give me that back.
[AGENT][NEUTRAL] If you had it on the plan, yes, this plan does not have the office visit, nor does it have the office treatment.
[AGENT][NEUTRAL] Benefit.
[CUSTOMER][NEUTRAL] Oh, alright, so you just said office visit.
[CUSTOMER][NEUTRAL] Or treatment.
[AGENT][NEGATIVE] In the office is not covered under this plan.
[CUSTOMER][NEUTRAL] It's not covered. Oh.
[AGENT][NEGATIVE] It's not covered.
[CUSTOMER][NEUTRAL] Huh.
[AGENT][NEUTRAL] So under this plan, you do have the options of
[AGENT][NEUTRAL] Under the outpatient, the emergency room, urgent care, any surgeries in the hospital or outpatient facility, a free-standing surgery center.
[AGENT][NEUTRAL] Any diagnostic tests in a hospital, outpatient facility, or MRI?
[AGENT][NEUTRAL] Any outpatient, yes, your, so your diagnostic tests fall under your outpatient of $500.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Ambulance, physical therapy, emotional, mental disorders, outpatient. They do have a max of 30 days, but yes, all that falls under your outpatient. No office visit, no office treatment.
[CUSTOMER][NEUTRAL] Huh.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] So diagnostic though MRI X-ray because that's what I'm really asking about too. OK. Um, but for, wait, so you said the 30 day mark though because like my son, the reason why um this wasn't an urgent care.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Facility technically I think.
[CUSTOMER][NEUTRAL] Oh maybe not and then.
[CUSTOMER][NEUTRAL] Mm, I don't know. I guess I'll just have to submit it to you guys and see what you do with this one, the old one, but like for example.
[AGENT][NEGATIVE] Yes, there is no.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I'm sorry, there's no time limit to submit the claims. So as long as your policy was active, you can submit a claim from [PII]. The 30 days is for mental or emotional disorders in a hospital outpatient setting.
[CUSTOMER][NEUTRAL] It's OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, OK. OK, and I'm not there yet. Maybe I will do it. OK.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] But good to know.
[CUSTOMER][NEUTRAL] But and that if that ever happened that's so expensive that that would we would do that quick, you know, whatever be submitted OK OK so.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] All right, I'm just getting because perhaps the sonogram that they submitted it wasn't labeled as diagnostic and that could have been the issue, um, because if it's labeled diagnostic, they'll submit it to you and then it would be accepted, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let's see, I do show.
[AGENT][NEUTRAL] We did receive something on [PII]. Let's see what that is for you.
[CUSTOMER][NEUTRAL] It might have been my daughter, she had an MRI.
[CUSTOMER][NEUTRAL] Last week.
[AGENT][NEUTRAL] Uh, let's
[CUSTOMER][NEUTRAL] But I had a preauthorization or you know, they submitted it was gonna be a sonogram or ultrasound.
[CUSTOMER][NEGATIVE] And they told me, right, I was going to pay $500 and I was like, I'm not doing that.
[AGENT][NEUTRAL] OK. This looks like physical therapy from [PII].
[CUSTOMER][POSITIVE] Oh yeah, right, so I have been going to physical therapy and you guys have been paying that, which has been great.
[AGENT][NEUTRAL] Yes, so this falls within your 500 per day. So yes, that was received.
[CUSTOMER][NEUTRAL] So that's been working.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Uh, OK.
[CUSTOMER][NEUTRAL] So, but do you have anything there for like an ultrasound? Oh, I can actually, I have the imaging thing right in front of me. Let's see where that went.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I'm the patient
[CUSTOMER][NEUTRAL] Where am I here? uh.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Now of course I don't have it in front of me but I did.
[AGENT][NEUTRAL] Yes, I'm showing physical therapy.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] In your history.
[CUSTOMER][NEUTRAL] No, yeah, this is for this is like I'm gonna now I'm gonna call them back though but this is.
[CUSTOMER][NEUTRAL] Rhode Island Medical Imaging.
[CUSTOMER][NEUTRAL] And I was supposed to go.
[CUSTOMER][NEUTRAL] Maybe on the [PII].
[CUSTOMER][NEUTRAL] Yeah, I was supposed to go on [PII].
[CUSTOMER][NEGATIVE] And I canceled because um I wasn't gonna pay that.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Yes, so it looks like the only claims we have received lately were for the physical therapy.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Sure, OK.
[AGENT][NEUTRAL] But once you register your account, you can go in and see every claim that was ever submitted for your family.
[CUSTOMER][POSITIVE] Right, OK, that's good though. OK, so.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] All right, here we go. I got all this here. OK, I found the the imaging order so that's interesting so they never even like contacted you guys and the ironic thing is the imaging order does have um.
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] The secondary insurance listed, it has you guys on there.
[CUSTOMER][NEUTRAL] Because sometimes the doctor will like not will screw up and not put the secondary, but that's all on this imaging order so I'm gonna call them back, OK.
[CUSTOMER][NEUTRAL] All right, well this is I will register online. I'll call back if I have any issues and then I will submit my claim but at least I have a little bit a better understanding though that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] But now if I wanted to upgrade, I, I wonder if that's an option now is it's too late? Like it was it wasn't, I think we only have one plan available but if I did want to have my plan.
[CUSTOMER][NEUTRAL] Cover co-pays, co-insurance, and deductibles.
[AGENT][NEUTRAL] For office visit?
[CUSTOMER][NEUTRAL] Is that an option?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That would have to go through the employer. We just handle the claims portion. We don't actually administer the policies.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Right, right, right.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Yeah because we I think we really did not have that option, OK.
[CUSTOMER][NEUTRAL] All right, so.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] OK, I think I'm I'm more clear thank you so much and I will go online.
[AGENT][POSITIVE] You are so welcome. Well, [PII], if you need further assistance, just give us a call.
[CUSTOMER][POSITIVE] OK, have a good day.
[CUSTOMER][POSITIVE] OK, thanks so much.
[AGENT][POSITIVE] You're welcome and thank you for calling American Public Life. Have a great day. Bye-bye.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] You too bye.