AccountId: 011433970860
ContactId: 6afa2fd4-e938-4dcf-a83b-b08c45780968
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 490410 ms
Total Talk Time (AGENT): 231808 ms
Total Talk Time (CUSTOMER): 146174 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/31/6afa2fd4-e938-4dcf-a83b-b08c45780968_20241231T16:49_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. How are you?
[AGENT][POSITIVE] I'm good. How are you, [PII]?
[CUSTOMER][NEUTRAL] Good, good. The reason I was calling is because I, I got a bill that you guys did not cover the um the, the um
[CUSTOMER][NEUTRAL] Manage that I did.
[AGENT][NEUTRAL] OK, so are we checking on it sounds like a claim that you would receive something for, is that correct?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, do you have your policy number?
[CUSTOMER][NEUTRAL] Uh, yes, uh, the policy number is.
[CUSTOMER][NEUTRAL] 02
[CUSTOMER][NEUTRAL] 28 82 08
[AGENT][POSITIVE] Alright, thank you so much. Let me just pull this up.
[AGENT][NEUTRAL] And if you could verify please your last name, date of birth and address.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] Thank you, and your address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and the MS we have an MSN email address on file is that still a good email for you?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And the claim number that you're calling on, do you have that number? Does it end in 1767?
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] Looks like that was the last claim.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Would you see that number?
[AGENT][NEUTRAL] It would be the claim number if you have the EOB, it should be on there. It should start with 35417667 is the number.
[CUSTOMER][NEUTRAL] 354354.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 353-832-1
[AGENT][NEUTRAL] OK, 353-832-1. That's the one that you're checking on?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let me see here.
[AGENT][NEUTRAL] 353-832-1.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, so that claim looks like was processed on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that one actually was the claim was not denied. The claim was approved and a check was sent to you in the amount of 82896.
[CUSTOMER][NEUTRAL] That's correct because the thing is I clean about the the 25 and the 39 now the 700.
[CUSTOMER][NEUTRAL] Um, you guys send it to me, which is kind of correct, but it's not because I have a bill from, um, from the doctor that I need to pay $1,565 and they're saying the insurance, the, the APO did not cover the.
[AGENT][NEUTRAL] Well if the claims were submitted by you for the date of service and the payment was sent to you, then you would then remit the payment to the provider.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Well, uh, uh, it is kind of correct, but the thing is.
[CUSTOMER][NEGATIVE] You guys only send me $76563.96 but the, the insurance, the, the bill said that I need to pay 1,565 and, and, and it looks like you guys pretty much did not cover the entire thing.
[AGENT][NEUTRAL] Well, there were certain things on here that were not covered like your policy doesn't cover any sort of office visit fee.
[AGENT][NEUTRAL] So that part of the claim was denied, so that would be your responsibility.
[AGENT][NEUTRAL] Um, the claim.
[CUSTOMER][NEUTRAL] What do you mean? repeat that again?
[AGENT][NEUTRAL] The policy that you have with us does not cover the office visit fee.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, no, I, I, I know, I know that that's, that's correct, but I did a treatment which uh is uh on the outpatient.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] And uh um
[CUSTOMER][NEGATIVE] Because I had, I have a bill from, uh, from the doctor and the doctor said that the like the the IPO did not cover the, the, the $1,565 and I see you guys bill you guys send me the money to I guess to pay them but it it it was it looked like it it did not cover anything.
[AGENT][NEUTRAL] Um, well, the claim did cover a portion of the submitted costs. You're right, it didn't unfortunately cover everything. Uh, there were certain things within the claim that your policy unfortunately does not cover, so that's why the full amount wasn't paid.
[CUSTOMER][NEGATIVE] Well, if, if I wouldn't know if, if I wouldn't know you like the, the, the what the, the, the thing that I did it was not covered anything. I, I would not have done anything.
[AGENT][NEUTRAL] Um, the only other recourse you have, [PII], if you feel like it was wrongfully decided, you can appeal the decision, and you can send us a letter appealing the denial and stating why you feel like the claim should have been paid.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] But when I look at that claim, part of it was the office visit fee, which unfortunately your policy doesn't cover. There were some.
[CUSTOMER][POSITIVE] Which is which is correct.
[AGENT][NEUTRAL] There are some other procedure codes that were issued that benefits were only payable if your major medical paid. So if your major medical didn't pay on a portion of these, then we're not going to pay anything either. It's only covered if your major medical insurance covered a portion of it too.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] If you would like, I can give you the information to submit an appeal in writing if that's something you would be interested in doing.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So an appeal needs to be um sent via mail.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the address that you would send it to?
[AGENT][NEUTRAL] Is American Public Life Insurance, and it would be attention appeals.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, can you, can you give me the email address?
[AGENT][NEUTRAL] It's a mailing address. You're gonna have to put it in the US postal mail. You can't email it.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK, um, can you email me the the address where I need to send all of this information?
[AGENT][NEUTRAL] Yeah, I can send you an email you wanted to go to the MSN.
[AGENT][NEUTRAL] Email address?
[CUSTOMER][POSITIVE] Yes please, yes please.
[AGENT][NEUTRAL] OK. So, appeals take 30 days to render a decision.
[AGENT][NEUTRAL] And I will put in there you just need to have a written letter um stating the reason for the appeal.
[AGENT][NEUTRAL] And then um I'll include the address on that as well, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you have any other questions or concerns I can help you with here today, [PII]?
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] Alright, thank you for calling APL. I hope you have a nice rest of your day.
[CUSTOMER][NEUTRAL] You too.