AccountId: 011433970860
ContactId: 6d595c17-1d46-432a-84ee-7d383dcd4a7e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1112839 ms
Total Talk Time (AGENT): 347296 ms
Total Talk Time (CUSTOMER): 696742 ms
Interruptions: 7
Overall Sentiment: AGENT=0.4, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/04/6d595c17-1d46-432a-84ee-7d383dcd4a7e_20250304T21:23_UTC.wav
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[AGENT][POSITIVE] And thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], I'm trying to find out some information about my insurance, um.
[AGENT][NEUTRAL] Um, yes.
[CUSTOMER][NEUTRAL] OK, I have gap um under APL.
[CUSTOMER][NEUTRAL] And I had some procedures and some health stuff going on at the end of last year.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, which then those tests and and other things followed up through uh starting into [PII].
[CUSTOMER][NEUTRAL] So I have some bills for [PII] and I had to meet my deductible, um.
[CUSTOMER][NEUTRAL] For [PII], which I did, um.
[CUSTOMER][NEUTRAL] My my regular insurance that I have is Allied.
[CUSTOMER][NEUTRAL] And I met my deductible is 24 let's see.
[CUSTOMER][NEUTRAL] On [PII].
[CUSTOMER][NEUTRAL] $250.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Let me get your name and a good callback number.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah. OK. My name is [PII]
[AGENT][NEUTRAL] OK, and I'm sorry, there was a lot of static on the line. Could you please repeat your name?
[CUSTOMER][NEUTRAL] Yeah, it's [PII]
[AGENT][NEUTRAL] OK. And a good callback number, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. Thank you, [PII]. Now I need your policy number.
[CUSTOMER][NEUTRAL] Uh, would that be the APL number you need?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, 025.
[CUSTOMER][NEUTRAL] 644-53.
[CUSTOMER][NEUTRAL] Can I have you hold for just 1 2nd?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, I will let you in. I will let you in this time, but I need you to contact them directly to get in.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Maybe, maybe I won't.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] He should be able to give you a code.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][POSITIVE] Thanks for waiting.
[AGENT][NEUTRAL] Oh, no problem. Um, could you please verify your name again and your date of birth?
[CUSTOMER][NEUTRAL] Yeah, [PII] My birthday is [PII].
[AGENT][NEUTRAL] OK. And please verify your mailing address and your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And your email address?
[CUSTOMER][NEUTRAL] My email address should be letter [PII]
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] OK, this looks like this may be your work email?
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] Yes, ma'am. That's the one we have on file.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can I change that or with you or?
[AGENT][POSITIVE] Yes, ma'am. You can change it. Mhm. I can change it for you.
[CUSTOMER][POSITIVE] That'd be great because I'm gonna I'm gonna retire this year, so.
[AGENT][POSITIVE] Oh, congratulations.
[CUSTOMER][POSITIVE] At least um thank you.
[CUSTOMER][NEUTRAL] Can I wait.
[AGENT][NEUTRAL] And what
[AGENT][NEUTRAL] I'm sure. And what's your email address you would like to change it to?
[CUSTOMER][NEUTRAL] So let's change it to it's gonna be 2, it's gonna be well it's gonna be a lot of letters [PII]
[CUSTOMER][NEUTRAL] Like dog
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then we'll do [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then my last name [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] So that's [PII]?
[CUSTOMER][NEUTRAL] Yes, except the very beginning it's two letter [PII]
[CUSTOMER][NEUTRAL] Then [PII]
[AGENT][NEUTRAL] And then your last name [PII]? OK, OK. I got it updated for you.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] And which benefits do you need to verify?
[CUSTOMER][NEUTRAL] So I had to meet my deductible for 2024, um.
[CUSTOMER][NEUTRAL] Because whatever I just had to do that, um, you know, for some tests that I had had, um, and so I have bills going into [PII], um, my deductibles was $2500 for 2024, and then it was also $2500 for 2025. I've had to pay both of those deductibles because, uh, some of this.
[CUSTOMER][NEUTRAL] Some of the procedures I was having done were like heart catheterization, you know, big dollar procedures. And so, I'm trying to figure out um
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] How I go about, so I had tried to present my Gap card to all of my doctors, so they would bill gap first and then, you know, do whatever they've got to do. Well, I only have one doctor that I can tell billed the gap insurance, um, and so they paid $63 to that doctor, but the big bills that are coming from the hospital, I need, I wanted to try to get them to bill, but they say they don't bill third party.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Company, so I'm just trying to figure out how do I go about getting my gap, um, cause the gap insurance was supposed to cut my
[CUSTOMER][NEUTRAL] My deductible in half.
[AGENT][NEUTRAL] OK. Um, you can file the claim yourself. Yes, ma'am. You can file the claim yourself and we'll pay you directly. Um, what we'll need is your explanation of benefits from your primary insurance company for the date of service that you're filing the claim for.
[CUSTOMER][NEUTRAL] So, is that something that
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so, for example, one of these was [PII], um.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] See, I don't even know how to go about it, so I guess if my deductible is $2500 I need an explanation of benefit that is gonna at least show $1250 correct?
[AGENT][NEUTRAL] Right. Well, let's see under your policy, what was it for inpatient or outpatient hospital?
[CUSTOMER][NEUTRAL] So this particular one in [PII] was outpatient.
[AGENT][NEUTRAL] OK. Well, I'm showing that under your policy for outpatient services, we cover up a maximum of up to, let's see, up to 1500 per calendar year.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, so once you um send us that explanation of benefits, what we'll do is um.
[AGENT][NEUTRAL] Look over the explanation of benefits to review it and see what charges went towards your co-pay, your co-insurance or deductible, and we'll cover that up to $1500 for the calendar year.
[CUSTOMER][NEUTRAL] All right, so do you need that for the whole year and explanation of benefits?
[AGENT][NEUTRAL] Um, we just need it for the date of service that you're filing the claim for.
[CUSTOMER][NEUTRAL] OK, and so outpatient you said was what, 1500?
[AGENT][NEUTRAL] Yes, ma'am. 1500 per calendar year.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] And let's see, have you met any yet?
[CUSTOMER][NEUTRAL] 1500.
[CUSTOMER][NEUTRAL] And then
[AGENT][NEUTRAL] You said this was for [PII]?
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][NEUTRAL] This particular, yeah, I'm starting with [PII] and then I've got to go to [PII], but so is it different if you have inpatient?
[CUSTOMER][NEUTRAL] No, I haven't been in the hos so what is the inpatient?
[AGENT][NEUTRAL] Yes, it's different.
[AGENT][NEUTRAL] The inpatient is also 1500.
[CUSTOMER][NEUTRAL] Amount
[CUSTOMER][NEUTRAL] 1500. OK, is there anything else GA pays for besides?
[CUSTOMER][NEUTRAL] Um, you know, reducing your deductible.
[AGENT][NEUTRAL] Um, we cover the co-insurance and we cover the, um,
[AGENT][NEUTRAL] The deductible and the copay, we cover the copay as well.
[CUSTOMER][NEUTRAL] Co-insurance, copay, and what you tell me, sorry, deductible. OK. All right. So if, uh, so if I want to get the claim up to $1500 basically I just need to show you an EOB that shows patient responsibility of at least $1500 right?
[AGENT][NEUTRAL] Deductible. The deductible. Yes, ma'am.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, ma'am. That's correct. And if it's over $1500 that's fine. It, we'll just cover it up to the $1500. And I'm showing that for 2024, you've already met $60. So we'll cover 1500, let's see, minus $60 we'll cover up to $1440 for 2024.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] OK, so I'm gonna, I already, I have one explanation of benefit I'm looking at here that is 1,696, so I can just send you that I'm sure, um, and then do you know what that $60 was paid to?
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Yes, it was paid to, let's see.
[CUSTOMER][NEUTRAL] Doctor [PII].
[AGENT][NEUTRAL] It says Gainesville Eye Associates for data service 12-9-24.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 24, can you give me one minute here because that doctor.
[CUSTOMER][NEUTRAL] She's such a loan now let's see 12 9.
[CUSTOMER][NEUTRAL] This is my 3 bills from the let me just see.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I didn't have a bill from them.
[CUSTOMER][NEUTRAL] I, I went for a consultation. I wanna say on [PII].
[CUSTOMER][NEUTRAL] And was it $60 or was it $63?
[AGENT][NEUTRAL] It was $63.73.
[CUSTOMER][POSITIVE] All right, awesome. So what ended up happening is, so that, this particular doctor I went to in December just for a consultation. I needed to have some skin surgery.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And so she was the only doctor who agreed to go ahead and bill my gap insurance, um, and I'm not really sure why she billed it for 2024 because my actual surgery was [PII] [PII].
[CUSTOMER][NEUTRAL] But anyway, um.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Yeah, this was billed for the office visit. It wasn't billed for the surgery.
[CUSTOMER][NEUTRAL] What, what
[CUSTOMER][NEUTRAL] Yeah, yeah, so how crazy is that? And so what ended up happening is she said that my insurance said my deductible was not paid yet, so she took 2000, whatever, you know, the balance, the difference in my deductible, and charged it to my credit card, only then to hold that money because she got paid and she didn't submit her bills until [PII] for the actual surgery.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Oh wow.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And so now I have other doctors that my insurance is saying they are entitled to the deductible money first and then this particular doctor who took the $2300 some odd dollars that I had left, um, they need to refund me the money, but they won't refund until the insurance pays them and the insurance is gonna pay them in full because I've already met my deductible and max out of pocket.
[AGENT][NEUTRAL] Oh wow. OK, I see.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] I don't know.
[CUSTOMER][NEUTRAL] Because you're, are you connected to Allied at all?
[AGENT][NEUTRAL] No, ma'am, we're not.
[CUSTOMER][NEUTRAL] No, so you can't even see what they've got. Hopefully they're gonna pay them soon because I need that money to pay the other doctors, um, but anyway, so for [PII] I've pretty much figured that out. I can send you this and then for [PII].
[CUSTOMER][NEUTRAL] Let's see if I have a big bill.
[CUSTOMER][NEUTRAL] I mean if I don't have a big bill.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I mean I do have you need the EOB is that what you need? You can't go with a bill?
[AGENT][NEUTRAL] No, ma'am. We'll, we'll need the EOB and we'll also need the bill because um because the bill, hopefully on the bill, your diagnosis code is on there. If your diagnosis code is not on there, you would need to get documentation from your provider with your diagnosis code um on there and we would um you would need to send that along with the EOB.
[CUSTOMER][POSITIVE] Probably OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah, so I don't have the EOB for this particular visit yet as far as I know, but I do have a bill and the total current balance, uh, it shows what my allied is paying, um, but it says current balance 15,97741.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] And yeah, we'll basically go by what's on the EOB as far as the payment goes. We would um only need the receipt or the documentation from the doctor's office that shows your diagnosis code.
[CUSTOMER][NEUTRAL] So I don't, I.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, awesome. So I guess I'll just work on trying to get the EOB for that because the EOB has a diagnostic code on it, right?
[AGENT][NEUTRAL] No, the EOB doesn't um have the diagnosis code. It has the procedure codes but not the diagnosis code. And normally, you can get that from the doctor's office.
[CUSTOMER][NEGATIVE] It doesn't.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] All right, and
[CUSTOMER][NEUTRAL] OK, and so on that one that I was gonna send you for [PII], um, am I gonna also need diagnosis code on that?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, ma'am. You will need the diagnosis code for that also.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And do I just write that on or how do I?
[AGENT][NEUTRAL] You would need to get documentation from the doctor's office with a diagnosis code on there. Yes, ma'am.
[CUSTOMER][NEUTRAL] From the doctor.
[CUSTOMER][POSITIVE] OK, OK, all right, well let me keep digging around here. I appreciate all your help.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK. And do you know how to, do you know how to file the claim?
[CUSTOMER][POSITIVE] I don't, I don't. So that, that was a very good question.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, or do you have access to a fax machine cause you could fax us.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yes, I can I, uh, email it or no? I do have a fax machine, but I do have a fax.
[AGENT][NEUTRAL] No, ma'am.
[AGENT][NEUTRAL] OK. Well, our, our fax number is, let me give you that.
[CUSTOMER][NEUTRAL] Uh-huh, right.
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] [PII] and please attention it to the um claims department. And again, that's documentation from your doctor's office with your diagnosis code on there and also the EOB from your primary insurance company for the date of service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, it will be for.
[CUSTOMER][NEUTRAL] Date of service along with the diagnosis.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Code from doctor.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right. And also write your policy number on there, the 256-445-3. You can write it anywhere on the receipt or the explanation of benefits.
[CUSTOMER][NEUTRAL] OK, and then I just fax this in and wait to get $3000 in the mail.
[AGENT][NEUTRAL] Well, if it's for outpatient, remember, we only cover up to 1500 per calendar year. So for [PII], it'll be the remaining, which you have 1440.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Right, and that's right.
[CUSTOMER][NEUTRAL] Right, and then 1500 for [PII], OK.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, and so it's so gap is only one time per year.
[AGENT][NEUTRAL] Well, no, we cover up to 1500 per calendar year, so we cover up to that total.
[CUSTOMER][NEUTRAL] Right, but if you like, you know, some like.
[CUSTOMER][NEUTRAL] If you have some big procedures or stuff like that one time in the year, then basically you're only gonna get one payout per year because I thought somebody had, I thought.
[AGENT][NEGATIVE] Right, that'll wipe out the whole 1500.
[CUSTOMER][NEUTRAL] Yeah, cause I thought somebody had told me it's uh just, it's per incident, um.
[CUSTOMER][NEUTRAL] Or you know per.
[CUSTOMER][NEUTRAL] Uh, I don't know if it was illness or
[CUSTOMER][NEUTRAL] Hospital care or whatever it is.
[AGENT][NEUTRAL] Yeah, and some, some of our policies are set up like that. Those are daily benefits. They cover up to $1000 per day, some of them. And then some of them, it's per occurrence, um, and every occurrence is every 90 days where we'll cover up to $1000 per 90 days or for inpatient services, we may cover up to 5000 per admission.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, but that's not the policy I have.
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][POSITIVE] OK, perfect. So, it just is what it is. I appreciate it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, well let me get back to work and try to get some paperwork together. I appreciate it.
[AGENT][POSITIVE] OK, no problem, [PII]. Thank you for calling ATL. You're welcome. Have a great rest of your day. Mm bye.
[CUSTOMER][POSITIVE] Thanks so much.
[CUSTOMER][POSITIVE] All right bye bye. You too.
[AGENT][POSITIVE] Thanks.