AccountId: 011433970860
ContactId: 6bc14849-0565-4d88-b606-a087ad547e8d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 524659 ms
Total Talk Time (AGENT): 238485 ms
Total Talk Time (CUSTOMER): 250463 ms
Interruptions: 6
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/08/6bc14849-0565-4d88-b606-a087ad547e8d_20250508T17:58_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APL. My name is [PII]. How can I assist you today?
[CUSTOMER][NEGATIVE] Yes, hi, um, I'm calling because I, I logged in to, to check my claim status and it and it said it was denied and I just don't understand. um, I've never used this gap policy despite having it for many years, so I guess I need to understand what am I supposed to use it for if not for what I put in the claim for.
[AGENT][POSITIVE] I'd be happy to assist with your policy and claim status today. May I have your policy number, please?
[CUSTOMER][NEGATIVE] I was trying to get that for you, but this, this website is horrible. I have to tell you.
[AGENT][NEUTRAL] That's fine, um, we can use your social.
[CUSTOMER][NEUTRAL] Well, you can't log can't log in [PII].
[AGENT][NEUTRAL] And your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] And my shop, if you can give me a good call back number for you please.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and if you can verify your date of birth and email address.
[CUSTOMER][NEUTRAL] [PII] and um probably my work address uh which is [PII].
[AGENT][NEUTRAL] Thank you for that information. Please be advised the verification of coverage is not a guarantee of payment. So I do show um we work in conjunction with your major medical, um, so any time you're presenting your major medical card, you would also present our card that way they know you have gap insurance, um, and this is good for inpatient, outpatient, and also treatment at your office visits. It doesn't um cover the copay associated with the physician's charges.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Um, also DME and labs, um, let me see, the most recent claim that we received that denied.
[AGENT][NEUTRAL] Uh, one moment.
[CUSTOMER][NEUTRAL] So I only placed one claim, but I did one myself in the hospital with.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] We denied it because, I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] I presented the card as you say, with my medical insurance card at the time that I
[CUSTOMER][NEUTRAL] Scheduled my outpatient surgery. So, um, they were like, OK, great. You won't have to pay anything, whatever. And then that was that, never heard anything else. So, um, then, uh, then I got this $5000 bill from the hospital and I was like, OK, well, that's weird. Maybe I have to do it myself. So I put in the claim. So, um, this is for an outpatient surgery.
[AGENT][NEUTRAL] OK, so your benefits for outpatient covers $500 per day, um, so that's the max we would pay for, um, your outpatient prior to you filing a claim, two other providers filed a claim for that same data service, the hospital, which it looks like you sent in the same thing that they sent in.
[AGENT][NEUTRAL] Um, and also it looks like this is the anesthesia bill. So the first claim we received was the anesthesia bill. Your co-payment for that was $307.27 and we paid that. Um, the next one was the facility, the hospital submitted a claim, and I believe that's the $5000 charge you're talking about because um they submitted the bill for $5,215.22.
[AGENT][NEGATIVE] But because we had paid the $307.26 to the anesthesia, you only had $192.74 left which we sent to the facility and then you filed the claim and we denied it letting you know that we paid benefits to the provider.
[CUSTOMER][NEUTRAL] So, OK. I guess I need to understand then cause I, I basically
[CUSTOMER][NEUTRAL] was told like the gap insurance is for the gap between
[CUSTOMER][NEUTRAL] like, uh, you know, your deductible and, and this. So,
[CUSTOMER][NEUTRAL] I don't
[CUSTOMER][NEUTRAL] What, what um, what else am I supposed to submit then for? because I've had this gap insurance forever and I've never used it because I never really had anything major done so.
[CUSTOMER][NEUTRAL] Tell me all the things I can submit for.
[AGENT][NEUTRAL] If you're hospitalized overnight or under observation for more than 18 hours, um, for what you just submitted it for.
[AGENT][NEUTRAL] Um, which is for any outpatient that you.
[AGENT][NEUTRAL] You have any treatment or procedures that are performed at an office visit. It doesn't cover the copay for the visit, just any deductibles or co-insurance that's applied to any treatment or procedures that you have done at that visit, um.
[AGENT][NEUTRAL] Any independent lab like Quest Diagnostic or LabCorp, um, that would be covered in any durable medical equipment claims.
[AGENT][NEUTRAL] But remember, the
[CUSTOMER][NEGATIVE] So what I don't understand that.
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] If I can just clarify when you say the deductible.
[CUSTOMER][NEUTRAL] On the last thing you just said, I mean, basically she called me, uh, from the billing department and said your deductible for this year is $3500. That's what you'll need to pay. I said, OK, hey, what about this gap insurance? And she said, oh, I didn't know you have that, no problem.
[CUSTOMER][NEUTRAL] Uh, we won't even need to, to, to talk about this then. And then she took that and, and gone. So what did exactly do you mean by the last thing you said where you'd say deductible?
[AGENT][NEUTRAL] OK, we are responsible for your patient responsibility that includes deductible, co-pay, coinsurance.
[AGENT][NEUTRAL] But the key to this is.
[AGENT][NEUTRAL] For outpatient, the maximum we pay toward your patient responsibility is $500.
[AGENT][NEUTRAL] That's the max we will pay per day.
[CUSTOMER][NEGATIVE] So I did basically, OK, OK, so then I need to basically submit claims for every single appointment that I make, and you're going to pay what for a doctor's appointment where I pay an $80 co-pay, you're gonna pay me back for that?
[AGENT][NEUTRAL] Remember I said that it doesn't cover the copay, it covers any treatment or procedures at that visit.
[CUSTOMER][NEUTRAL] Treatment and procedures at that visit. You're saying co-insurance.
[CUSTOMER][NEUTRAL] OK, um, and labs.
[AGENT][NEUTRAL] So anything for the visit that's applied to your co-insurance or deductible.
[CUSTOMER][NEUTRAL] OK, so at all my doctor's visit, OK, so at all my doctor's visits I should give them the gap insurance card.
[AGENT][NEUTRAL] At that visit, but.
[AGENT][NEGATIVE] Yes, I would because if they do more, if it's more than just you walked in and the doctor talked to you for 5 minutes and left, then there's nothing for us to pay cause there was no treatment or procedure performed that you're being billed for. You're only being billed to talk to him, which is that is applied to the co-pay, and we don't cover the co-pay. But if you went, he talked to you, he gave you an injection.
[CUSTOMER][NEUTRAL] I understand. OK, got it. OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got you.
[AGENT][NEUTRAL] Now that's something that we can step in and take care of your patient responsibility up to that $500 max. So if they only charge you $150.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Then we're gonna pay that $150. If they charged you $600 for that, we're gonna pay $500 and you have to pay the $100.
[CUSTOMER][NEUTRAL] You're gonna pay $150 got it, OK.
[CUSTOMER][NEUTRAL] Got it. OK. So now,
[CUSTOMER][NEGATIVE] How I wonder if you can oh of course this thing after the 5th time of trying to log in it gave me that it let me log in 5 times it took same password, told me the wrong thing. Alright, so basically I understand this now and it sucks because I have a $5000 bill.
[CUSTOMER][NEUTRAL] Which I probably would have said, we'll skip the surgery if they, if I had realized that it, you know, it wasn't part of the plan, but anyway, I guess I'll figure that out. And then I'll submit, how far back can I go?
[CUSTOMER][NEUTRAL] On this
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] On on submitting documents because I've had this insurance for years and never used it because I only thought it was for like.
[CUSTOMER][NEUTRAL] Big stuff.
[AGENT][NEUTRAL] Um, you can go back to [PII] when your policy began.
[CUSTOMER][POSITIVE] OK. All right, great. Well, I guess I got my work cut out for me. I thank you for your explanation and have a great day.
[AGENT][POSITIVE] You you do the same thank you for choosing APL. Have a good day.
[CUSTOMER][NEUTRAL] OK alright bye bye.
[AGENT][NEUTRAL] OK.