AccountId: 011433970860
ContactId: 68120cff-b129-4214-8ed5-c4bf52c61d75
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 608760 ms
Total Talk Time (AGENT): 330237 ms
Total Talk Time (CUSTOMER): 145059 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/09/68120cff-b129-4214-8ed5-c4bf52c61d75_20250509T17:52_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, I was calling about the two claims I submitted online, um, and I had some questions about coverage and eligibility.
[AGENT][NEUTRAL] OK, so you're the insured and you have questions on claims that you have filed for yourself?
[CUSTOMER][POSITIVE] Yes, I am the insured, yes.
[AGENT][NEUTRAL] And the claims are for you, is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Yes ma'am, I can help you and who am I speaking with please?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh this is [PII] Last name [PII]
[AGENT][POSITIVE] OK, thank you and Ms. [PII], what is a good call back number for you please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, and your policy number?
[CUSTOMER][NEUTRAL] Oh, I don't have that.
[AGENT][NEUTRAL] Your full social security number?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] OK, thank you. Give me a couple of moments please to locate your information.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, Ms. So, so first off, any information provided today would be a verification of benefits and not a guarantee of payment. I will need to verify several things with you first for security, so if you could first please verify your date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and your home mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. The phone number that we have for you is the same as the one you gave me, so that is your best contact number. Is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Thank you and lastly your email address please, and this appears to be your work email.
[CUSTOMER][NEUTRAL] OK, [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] [PII]. I don't know. I can't remember.
[AGENT][NEUTRAL] It shows the first one.
[CUSTOMER][NEUTRAL] OK, [PII]. OK.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] All right, so I do see that there's a claim that will go through our processing tonight.
[AGENT][NEUTRAL] You have this, this is for [PII] [PII]?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Data service 424. There was a, this is shows a $53.14 payment.
[AGENT][NEUTRAL] And then one of the charges on that claim was denying the suitor, and the reason, the reason it was denied is because office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] There was also another claim that uh let's see.
[CUSTOMER][NEUTRAL] That wasn't an office visit. It was an outpatient um urgent care. Y'all don't cover those?
[AGENT][NEUTRAL] The way this is billed, there was the benefit paid for the part of it on.
[AGENT][NEGATIVE] Which is the $53.14 but the visit charge that they charged you is not covered.
[CUSTOMER][NEUTRAL] Oh, OK, OK. So this is, I don't get how they made it different, like the treatment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's come, but the visit is not?
[AGENT][NEUTRAL] Correct. If they, they billed it as an office visit.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And so therefore, that portion of it was not covered.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now there is another claim that has also been processed for you for data service of 425.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that is for.
[AGENT][NEUTRAL] Let's see.
[AGENT][POSITIVE] Equipped for life.
[CUSTOMER][NEUTRAL] Yeah, that was the uh the boot.
[AGENT][NEUTRAL] OK. And on that, that, that has been denied at this point and the reason for the denial is in order to complete the processing of your claim, we need itemized statements of services provided listing the charges, diagnosis code, and procedure code.
[AGENT][NEUTRAL] So we just need an itemized bill, including the diagnosis codes.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you can get that from your provider and when you have that information just upload it into your portal like you did your claims.
[CUSTOMER][NEUTRAL] OK, so those are the two claims I filed, so those.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes ma'am, those are the two, those are two separate claims, and you will be able to see the when you're able to sign into your portal, you should be able to see those explanation of benefits. Now the one that's gonna go through processing tonight that we talked about first, now that won't be viewable to you probably until tomorrow afternoon.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But you will be able to see both of them in your portal.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So regardless of, um, OK, so another question I have.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So does this, does this plan cover like, um, I know it doesn't cover offices, but if I had like a lot of blood work done, will it cover that?
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Lab, lab work done in an independent lab is something, yes, ma'am, that we can review under your outpatient benefits.
[CUSTOMER][NEUTRAL] OK, so I would have to get the the bill from the actual lab or would it be from the hospital?
[AGENT][NEUTRAL] Wherever the lab work was drawn and then make sure that you do also have the diagnosis code that would come from the provider whoever ordered your lab work.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and last thing.
[AGENT][NEUTRAL] We will
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] So it doesn't cover any office visit whatsoever, but any diagnostics or either like tests or, you know, X-rays, it'll cover that.
[AGENT][NEUTRAL] We can review those things for benefits. Yes, ma'am. But again, we would have to, we always have to have the itemized bills.
[AGENT][NEUTRAL] Including the diagnosis and procedure codes, along with copies of your primary insurance company's explanation of benefits.
[AGENT][NEUTRAL] And on the claim form that you submit for this type of meddling policy that you have, the instructions, the suitor are on the very first page of that claim form at the top. It tells you exactly what all you need to send us if you are filing the claim with us yourself.
[AGENT][POSITIVE] Now what I recommend.
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's much easier if
[CUSTOMER][NEUTRAL] I tried to give it to my doctor's office.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And they said they don't know, they don't, they, they wouldn't take it basically.
[AGENT][NEUTRAL] Well, most providers do file both your primary and your secondary.
[AGENT][NEUTRAL] But if they don't file it for you, then obviously you can file it just like you've had to do this time.
[AGENT][NEUTRAL] Most providers you'll give them your primary insurance card, your APL card, and they will call to verify your benefits and your eligibility, and then they will take care of filing your claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But that is a provider's decision whether they will file the supplemental or not, so.
[CUSTOMER][NEUTRAL] So if, if you go to the uh hospital out of town or whatever, it's gonna, it's, it's still subject to the $500 a day, basically like, no matter what we had to pay.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] The benefit maximum on this supplemental policy that you have for outpatient is a $500 per calendar day for covered outpatient services.
[CUSTOMER][NEUTRAL] So would the ER be outpatient?
[AGENT][NEUTRAL] Yes, ma'am. Mhm. Unless you're admitted inpatient.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][POSITIVE] Alright, well thank you for clarifying all of that. I appreciate it so much.
[AGENT][POSITIVE] Oh, you're welcome. Absolutely, you're certainly welcome. So do you have any other questions that I could help you with?
[CUSTOMER][NEUTRAL] And now, well, one more thing, so if I send in my my hospital bill, is that all I have to send in? or do I have to send in the EOB too?
[AGENT][NEUTRAL] You will, you always have to send the primary insurance company's explanation of benefits because this policy helps you with your co-pays, deductibles and co-insurance amounts of covered services, so we have to have that EOB so that we can see those three categories.
[CUSTOMER][POSITIVE] OK, OK, got it. Alright, well thank you so much.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Well, you're very welcome. And so if
[CUSTOMER][NEUTRAL] Have
[AGENT][NEUTRAL] Oh, I'm sorry, I didn't mean to overspeak.
[CUSTOMER][POSITIVE] Oh no, you're fine. I'm sorry. I'm just telling you to have a good day and thank you for your help.
[AGENT][POSITIVE] Absolutely. Well, you're very welcome. It was my pleasure and thank you for calling APL. I hope you have a wonderful weekend.
[CUSTOMER][NEUTRAL] Alright, you too. Bye bye.
[AGENT][NEUTRAL] All right, Ms. Later. Bye-bye.