AccountId: 011433970860
ContactId: 6345b808-ad60-4688-a779-b377d409fa58
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 558739 ms
Total Talk Time (AGENT): 293985 ms
Total Talk Time (CUSTOMER): 236746 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/6345b808-ad60-4688-a779-b377d409fa58_20250428T20:37_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][NEUTRAL] Hi, [PII], it's [PII]. I have [PII]. I have [PII] how are you today?
[AGENT][NEUTRAL] Hey.
[CUSTOMER][NEUTRAL] I have [PII] on the phone. He's calling on policy 258751. I have verified his address and his phone number. A good call back number is [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh verify this.
[CUSTOMER][NEUTRAL] Address, date of birth, and his email address so um.
[CUSTOMER][NEUTRAL] He is calling about a claim.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So,
[AGENT][NEUTRAL] Like he's needing claim status?
[CUSTOMER][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] I think so or more information.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, that's fine.
[CUSTOMER][NEUTRAL] On that he said he was.
[CUSTOMER][NEUTRAL] Yeah, he's got some more information he had questions on that.
[AGENT][NEUTRAL] I can ask.
[AGENT][POSITIVE] OK. Well, I can definitely help him. We only um process one form, so I'm sure this is it. I I can definitely help them.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] OK, love.
[CUSTOMER][POSITIVE] All right, love. Well, thank you, and you have a great day.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] You too.
[CUSTOMER][NEUTRAL] All right, sweetie. All right, bye bye.
[AGENT][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Hello, Mr. [PII].
[CUSTOMER][NEUTRAL] Yes, hi.
[AGENT][NEUTRAL] Hi, this is [PII] with the care team and Male was letting me know that you had some questions about your recent claim here with us.
[CUSTOMER][NEUTRAL] Yeah, I just wanted to double check with you. I was a little confused because I, from what I understand, um, the, the policy that we have with through APL is for our out of pocket for deductibles and for co-insurance, correct?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So we pay towards the copay, deductible and co-insurance, correct, I covered charges, um, after your primary, depending on what it is.
[CUSTOMER][NEUTRAL] 00, because it came.
[CUSTOMER][NEUTRAL] OK, because I got a bill from you saying that it was not non-covered expenses paid zero. That's why I called. I was like, huh.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So that's why I said it depends on what it is because your secondary policy has its own benefits and your primary insurance has its own benefits. So, uh, that
[AGENT][NEUTRAL] The code that you see there that's saying that the office visits are not covered is true. Office visits are not covered on your policy, but that's not the only reason why there was some why there was a denial. That was just for that particular code for the office, but I can look into these other two also if you like.
[CUSTOMER][NEUTRAL] OK, so I, I guess I'm a little confused and so claim number 358-9185, what exactly did you guys pay? I'm confused. You mean, it doesn't, I'm.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] The claim was denied. There's a total of 3 codes here. One of the codes mentions what she said, the office visits are not covered, but there's 2 other codes here I can look into why they, they were denied also if you like.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yeah, that'd be great because, and then help me understand what I'm paying for, because I thought that's what we had purchased through APL was just to cover the cost of deductibles and co-insurance and out of pocket. And if it was a outpatient, it was 1000, if it was inpatient, it was 3000. [PII] I, am I on the right page here? Or I'm, I'm, this is the first time I've used your service, so I'm, I'm learning.
[AGENT][NEUTRAL] Yes, you are. Um, so in, so your policy is broken down like you said, into inpatient and outpatient. Inpatient is basically anything admitted in after admission. Outpatient is where your emergency rooms come in, your urgent care, um, outpatient surgeries, diagnostic testing.
[CUSTOMER][NEUTRAL] Yeah, that's, that's what I had to have was an outpatient surgery.
[AGENT][NEUTRAL] Right, but what's being billed right now is for the for an office visit. That's one of them. So your policy is
[CUSTOMER][NEUTRAL] Oh, so this billing from them.
[CUSTOMER][NEUTRAL] So this was strictly a bill they sent you for like the office visit, not the actual.
[CUSTOMER][NEGATIVE] Charges for the insurance that was denied I.
[AGENT][NEUTRAL] So, let me do this. Let me pull up the claim, so I can see the other two reasonings as to why it was denied, but to answer the question of why you received a denial saying office visits are not covered is because what I was trying to explain is because under outpatient, that is typically where your physician office or your office treatment rider would be. This policy does not have any coverage for the office setting, physicians, specialist, anything in the office.
[AGENT][NEGATIVE] There is an office treatment rider where the treatment in the office could be covered, but this policy does not have that also. So, but even if it did, it still would be denied because that's for the service, the place of service. So that's why that was denied because there's no coverage for in-office on this policy.
[AGENT][NEUTRAL] It's inpatient and outpatient.
[CUSTOMER][NEUTRAL] OK, but this wasn't in her office. This was an outpatient at a surgical center. And the person I spoke to on the phone, when I asked how to do this, said this would qualify under the outpatient surgical center.
[CUSTOMER][NEUTRAL] And I checked with her before I did this, before we had the procedure done, so.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So that goes back to what I
[CUSTOMER][NEUTRAL] I, I guess I'm
[AGENT][NEUTRAL] So just give me a moment. There are 3 codes here. Only 1 refers, only 1 refers to the office. The other 2 is a facility charge and a surgery charge. That's what I'm trying to see what happened with those two.
[CUSTOMER][NEUTRAL] Oh, no problem. I'm just trying to understand that's all.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I was just answering your question of why did you get that denial for an office visit, so that is why.
[CUSTOMER][NEUTRAL] OK, got you, yeah, because I.
[CUSTOMER][NEUTRAL] OK, so the, yeah, so because the office visit isn't a procedure there typically would be no co-pay, there'd be no deductible or anything like that, yeah, OK, now I'm following. I'm gonna get you.
[AGENT][NEUTRAL] There you go.
[AGENT][NEUTRAL] Correct. So now I'm gonna, yes, so now I'm gonna look at the, there's one facility charge and one, I can let you know the surgery charge because I just, I had that up already. Um, that one is denied, but not it's denied asking for additional information. So we just need something showing the diagnosis. It could be an itemized bill with the diagnosis code. It could be
[AGENT][NEUTRAL] Your, um, admission or discharge papers, it could be an office note, just anything that shows the diagnosis from um whatever was done on [PII]. So then that.
[CUSTOMER][NEUTRAL] Oh yeah, yeah, just it was a yeah we've got that we've got so what do you want me to do, where do you want me to send that? I'll get those and just email them to you.
[AGENT][NEUTRAL] So, so we can accept claim um documents through email, but you can upload it on the online service center.
[CUSTOMER][NEUTRAL] OK, uh.
[AGENT][NEUTRAL] And then let me see how you sent this one.
[CUSTOMER][NEUTRAL] I think on the APL.
[AGENT][NEUTRAL] Yes, so the same way you sent this one, that's the online service in our portal.
[CUSTOMER][NEUTRAL] OK, got it. OK, so it's just.
[AGENT][NEUTRAL] So you can just upload that and then
[AGENT][NEUTRAL] As soon as we get it, we'll continue processing for that one and I'm checking on the other, the 3rd 1 now.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] OK, so for the actual facility charge, like the
[AGENT][NEUTRAL] Outpatient facility charge is showing that the insured's primary insurance provided full benefits, so there was no benefit payable. So that one just wasn't paid to because it showed primary paid everything, so it didn't have a balance to pay towards.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, so the surgery so the once you get the additional information on the uh like the discharge paperwork which I can get I've got that and we'll get a copy of that. I'll get it uploaded on the portal then that one would be a max of 1000, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Correct. That's your, mhm, that's your $1000 for the calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, because it was done in-house as opposed to done I mean done at outpatient surgery instead of at the hospital.
[AGENT][NEUTRAL] At the hospital, right. Mhm.
[CUSTOMER][NEUTRAL] Because they said I had the choice. You can go to the surgical center, which they recommended because it's easier, it's faster, that's all they do is surgery, and you don't have to stay overnight. You can go home. You stay at the hospital, you gotta stay overnight. So, OK.
[CUSTOMER][NEUTRAL] All right, um, I will get to that, uh, portal and get that uploaded and take it from there.
[AGENT][NEUTRAL] Alrighty, well, as soon as we receive that documentation with the diagnosis, we'll go ahead and well not restart but continue um processing your claim. And was there anything else I can help you with today, Mr. [PII]?
[CUSTOMER][NEUTRAL] Finished. OK.
[CUSTOMER][POSITIVE] No, thanks for the education. I'll get that right to you and we'll go from there.
[AGENT][POSITIVE] Alrighty. Well, thank you so much for calling AP. I hope you have a great evening.
[CUSTOMER][POSITIVE] Thanks, you too. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye-bye.