AccountId: 011433970860
ContactId: 7ffbd278-060b-44a4-b469-fda2930092d1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1155609 ms
Total Talk Time (AGENT): 627015 ms
Total Talk Time (CUSTOMER): 569261 ms
Interruptions: 16
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/03/7ffbd278-060b-44a4-b469-fda2930092d1_20250403T15:39_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Line. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII]. Um, our family has a plan through y'all, and I just wanna get clarification on what's actually covered. I have had, we had a continuous plan since [PII], and I'm pretty sure I haven't filed claims accordingly like we're supposed to. Can you help me with that?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Sure, let me get you uh some information from you and I can definitely help you. Could I get a callback number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, my cell is [PII].
[AGENT][NEUTRAL] Thank you. And do you have your policy number with us?
[CUSTOMER][NEUTRAL] I do. It is 2104802.
[AGENT][NEUTRAL] And [PII], if you could verify your date of birth please.
[CUSTOMER][NEUTRAL] Yeah, so mine is [PII] and [PII]'s is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] And so you are calling today um.
[AGENT][NEUTRAL] You, you feel like you have been filed claims correctly or?
[CUSTOMER][NEUTRAL] I don't think we've, I think we've like literally not filed claims like we, I'm pretty sure we've had things that have happened and we never pursued it, um, and so I guess I'm just trying to get further clarification. I'm trying to read the, um, the EO the OB the policy, and so I just wanna try to see if you can if you can help me a little bit based on what I'm understanding here, um, but it looks like so.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Two questions. One, am I just out of luck for not filing anything from previous years?
[AGENT][NEUTRAL] No. So with this policy, you can go back as far as you've had the policy and file claims for reimbursement. So there is no timely filing limit limit on this policy. Uh, I do have a question cause I do show that you have uh quite a few claims have been filed on the family. Um, they, some we've requested, uh, additional information, some have just been, uh, denied, uh, because they're not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] And I think that's where I just got lost with like overwhelmed with work and stuff and I just like gave up and I was just like, OK, I'm done like I'll come back and help you with this later. Um, however, like I think my, my main question is like in [PII], OK, when the claim was filed for um the like when I had my tonsils out, OK, the maximum amount paid out on that claim was it $1500 or was it $1000?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][POSITIVE] And I'm sorry to be like so dumb about this stuff like normally I'm pretty good at this and I'm like.
[AGENT][NEUTRAL] No, no, no. Oh no, that's what we're here for to help you, um, you know, understand your policy. So it looks like on this particular claim, we did pay out $1000 which was the maximum for outpatient benefits.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] With outpatient is 1000 so the benefits when I go in here, OK, so outpatient is 1000 inpatient is 1500, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, so I think I just gave up on filing anything for myself, uh, in [PII] anymore because obviously I had maxed out my benefits, so that answers that question.
[AGENT][NEUTRAL] Correct, that would make sense. Mhm.
[CUSTOMER][NEUTRAL] So give up on that. I can go back. Now my question is I also think it might have been in 23, but I can go back and look. The like if let's say I had like I did have an MRI done, OK, um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] If it was in a different year, that would have been covered, correct?
[AGENT][NEUTRAL] Right, so it is a calendar year max. So yes, you may be maxed out for [PII], but all the way back to [PII], you still have the $1000 available. [PII], you have the $1000 available in 24, 25.
[CUSTOMER][NEUTRAL] As outpatient?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So can you tell me the policy, is it run calendar year or does it run the 101 to 101?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I show you have a calendar year policy.
[CUSTOMER][NEUTRAL] OK, so it is calendar year, so then we've got like 101 of 21 to 1 basically 11 of 22 and then 20 to 12:31, yeah, OK, 12:31 and then we've got 20, so we have [PII], [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 12:31.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII] and then we have 2025. OK, so if I, OK, so I understand the MRI part. I read that. What about like an X-ray or a CT scan? Did those count as well or no?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Those do also count. It is going to be determined by where the service was rendered. So please be advised verifying benefits does not guarantee payment. Looking here at your policy, you do not have coverage for any services rendered in the doctor's office. So if the doctor did the X-ray, um, but if it's done in an outpatient facility like in, uh, the hospital or uh for the CAT scan, if it's a MRI facility.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, yep, yep, that's fine.
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] Um, then you have that coverage under your outpatient benefit. So if those services were rendered in an outpatient setting, you can definitely file those for reimbursement.
[CUSTOMER][NEUTRAL] Yep
[CUSTOMER][POSITIVE] OK, cool.
[CUSTOMER][POSITIVE] OK perfect what about um.
[CUSTOMER][NEUTRAL] OK, so urgent care that would cover if we went to an urgent care facility?
[AGENT][NEUTRAL] Urgent care would be considered, yes. So, urgent care, even if your doctor, you know, some uh physicians have after-hour care, uh, and they do bill it as urgent care. Now, those services would be uh covered under your outpatient uh ser uh outpatient benefits or if you just went to an urgent care facility, uh, that is covered under outpatient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So would it be urgent care for like.
[CUSTOMER][NEUTRAL] Like the kids getting hurt or would it be urgent care just for sickness too?
[AGENT][NEUTRAL] It's, it's, so your policy pays for sickness and injury. So it can be, yeah, it is both. Mhm.
[CUSTOMER][POSITIVE] OK, it is both. OK, great, yep.
[CUSTOMER][NEUTRAL] Oh my goodness, OK, um.
[CUSTOMER][NEUTRAL] And then ER because I know for a fact I had an X-ray and an ER in 22, um, OK, that makes sense um OK so.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] Trying to think of any other questions I have. Oh, the labs, the lab piece is tricky. Like I submitted all those claims previously, right, because I like was shooting in the dark. I had no idea what the heck I was doing. And so what do you guys like what documentation to make this easier for everyone, right? What documentation.
[AGENT][NEUTRAL] OK, so yeah, I was about to go over that with you because I do show some claims that you filed. We just requested additional information. Um, let me look at this for, let me look under you. Let's start with you and just to make sure 2023 you're maxed out.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, is there anything?
[CUSTOMER][NEUTRAL] It's probably all 2023 because I was doing like I mean I think that's when I was just like oh what did I like.
[AGENT][NEUTRAL] Now, I see some charges here. These are your lab charges uh in [PII]. These are for you. Uh, it looks like we requested the diagnosis code. So the diagnosis code is the ICD 10 code. Um, we do.
[CUSTOMER][NEUTRAL] What are we doing? What did I miss?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] ICD.
[AGENT][NEUTRAL] 10. So you'll have to get that information from, uh, so for these lab charges, normally you don't just go get labs. The doctor orders the labs, you know, OK, hey, we need you to go over here and have, so you wanna get with your doctor and ask them um for uh documentation and they can send it to you through email and just say,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, you know, I went to get lab work done in April, on [PII], that was ordered by the doctor. Can you please send me something, uh, showing my ICD 10 code for the lab charges?
[CUSTOMER][NEUTRAL] OK, if I get a copy of the lab order that's like scanned in, would that work?
[AGENT][NEUTRAL] They make sure it's on there. Um, if I don't know if you're going to request that or just go into um like a system and try to find it, but just make sure they put that information on there. A lot of times the providers will not put that information due to privacy because it's basically telling us what was your sickness or injury in which they had to order the lab or when you went to the doctor, what was your sickness or injury.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You know, for this doctor visit because your, your policy does not pay for uh any type of routine services. And so we need that uh ICD 10 code to see what you were being treated for. Uh, now that does not apply to the lab. Uh, there is no limitation on the lab. Um, and let's see, so that's you for [PII]. See those lab charges.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let me make sure. I just go through everything and make sure.
[AGENT][NEUTRAL] OK, nothing for 2.
[AGENT][NEUTRAL] Uh, and I did see for your son.
[AGENT][NEUTRAL] Wired
[AGENT][NEUTRAL] Uh, there was some lab work for [PII]. This one also, we asked for the diagnosis, which is the ICD 10 code, so you would request the same there.
[CUSTOMER][NEUTRAL] Right, yeah.
[CUSTOMER][NEUTRAL] OK. It's got an IDC 10 code.
[AGENT][NEUTRAL] ICD pin code.
[CUSTOMER][NEUTRAL] OK. All right.
[AGENT][NEUTRAL] And then I do see lab work in April, on [PII] for [PII] in which we requested that information.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, perfect. So then I know [PII]'s got um labs that she's done she was sick last year so we can get those um OK, so my other question is I'm looking at the service for [PII] back in [PII], um, [PII].
[AGENT][NEUTRAL] OK, let me see.
[AGENT][NEUTRAL] OK, so [PII]. Uh, now there was an office visit in which, of course, we denied and looks like, what is this, um.
[CUSTOMER][NEUTRAL] She had an X-ray done.
[AGENT][NEUTRAL] OK. And so, uh, right, yeah, I see this 1 $408. Was that done in the physician's office?
[CUSTOMER][POSITIVE] I remember that very vividly.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No, it was done at Manatee Diagnostic Center.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. So on that one we also requested the ICD pin code.
[CUSTOMER][NEUTRAL] OK, so on anything, so my, my the way I was doing this previously was I was just uploading the EOB, um, what, so I need to get if I have like a detailed receipt, should that show the IDC 10 code or just make sure they do show that? Is that kind of what we're looking for?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, no. Most receipts, again, like I said, due to privacy, they won't just print that. Uh, that's normally something you would have to request. That's not information that providers will put on receipts or
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And is it OK if it's just like on letterhead?
[AGENT][NEUTRAL] Yes, it can be on letterhead. Just we just need to know that it is coming from a provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so we need the IDC codes on the lab charges we need them on the like any sort of like imaging.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, what about the urgent care? Same thing?
[AGENT][NEUTRAL] Same thing. So that is what's always needed when you file a claim. We need the explanation of benefits showing your patient responsibility, uh, and then we need the ICD 10 code, uh, and then your procedure code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the EOB plus plus the OK so the procedure code is the CBT code, right?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So it looks like you had all those, those came in.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEGATIVE] OK, so basically it's that ICD 10 code that's missing off all these documents.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, alright, great, that answers all those questions. um, OK, so how, what is the most cost is not cost, what is the most efficient and effective way?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] To upload stuff for you guys um when I do this like obviously there's claims that are already open, so I'm gonna try to cross reference what I already have and do I just send, do I click that? is there a way to reopen it or just continue to go under and upload claim?
[AGENT][NEUTRAL] So you, you, every time you're gonna upload as though you're uploading a, a brand new claim. We look at the dates and so we know that, OK, for this date, we did request that ICD 10 code she sent it in. We just go back and pull your old information and process the, you know, based on what you've already sent. So there's nothing you have to do, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Other than just upload your new information or whatever, you know, supporting documents that we've requested and then if you have new charge, new charges, just upload that information.
[CUSTOMER][NEUTRAL] OK, alright, I'm gonna try very digitally diligently to stay on top of it this year so we're not backdating all of these, um, OK, so.
[AGENT][NEUTRAL] And let me ask you something. So when you go to the doctor, are they, um, are they not, you know, because the doctors do have the right to not file on your behalf. Are you letting them know, because you don't have to file these claims yourself, like if your doctor is willing to send uh the claims to us as secondary, we just pay them directly.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And I, I'm I'm not sure.
[CUSTOMER][NEUTRAL] Oh no, I had no idea. I've not turned in this to anyone, so I'm supposed to have turned this into secondary insurance. Oh dear Lord, OK.
[AGENT][NEUTRAL] OK, I would say that is always gonna be your easiest. Just, hey, I have a secondary insurance, they do, you know, just kind of explain, they pay, uh, directly to the provider, um, if you would submit these on my behalf.
[AGENT][NEUTRAL] Secondary, they pay you directly and a lot of times most of the providers will file. They let us process the charges and if there's any patient responsibility after that, then they, you know, of course, they'll reach out to you, but most will file to work.
[CUSTOMER][NEUTRAL] Oh, so we could have been off the look of it, OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You know, but just know they do have the right to say, hey, you know, we, we don't, and what makes it easier for you if they say they do not at that time, go ahead and request like documentation that has your CPT codes and your ICD 10 code on there and then you'll just have to wait for them to file and your explanation of benefits to come in and then you can submit it. That's always the easiest at the time of service just to request the information you're gonna need if they're not willing to file the claim for you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, alright, that makes sense to me, um.
[CUSTOMER][NEUTRAL] OK, alright, I think, I think that kind of wraps my head around it. Is there anything I'm missing like if I besides like I've got.
[CUSTOMER][NEUTRAL] I just wanna make sure I'm on the same thing so I've got labs, any outpatient facility like X-ray, imaging, urgent care, ER.
[CUSTOMER][NEUTRAL] I'm missing anything else?
[AGENT][NEUTRAL] Um, physical therapy would be considered outpatient.
[CUSTOMER][NEUTRAL] Physical therapy? OK.
[AGENT][NEUTRAL] Mhm. Um, I think that's probably anything.
[CUSTOMER][NEUTRAL] I, I've got some of that from when I hurt myself, OK.
[AGENT][NEUTRAL] And then I, I also wanted to let you know on the emergency, I think you had like an emergency room charge. I think you said you had an X-ray. OK. Um, a lot of times it is hard to
[CUSTOMER][NEUTRAL] I did, yeah.
[CUSTOMER][NEUTRAL] I did.
[AGENT][NEUTRAL] Get information from the hospital. If you have your uh admit uh summary from that emergency room visit, it should have, um, OK, so it should have the description of your, your illness, like why, why you were admitted into the emergency room.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I do, yeah.
[CUSTOMER][NEUTRAL] OK, so now.
[CUSTOMER][NEUTRAL] Random questions, so I don't think we have this policy. I was like I was thinking about the kids and how old they are. I was like, no, they're both were born at this point. I, I had had them by the time we bought this, um, OK, um, it just took me a second. I was like I gotta go back and make sure I do the right thing, um.
[CUSTOMER][NEUTRAL] OK, yes, so I just went in here and I have an outpatient summary from [PII] where I had that X-ray and so just download that and up now you need the EOB as well from that which is Aetna should be able to provide.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] We do need the EOB, but that your admit and discharge summary should show what you're being treated for. So as far as like, OK, I need to contact the hospital to get the ICD 10 code, that description of your illness or injury should be in your, in the summary.
[CUSTOMER][NEUTRAL] OK, and is there a cap on how much is paid out on um.
[CUSTOMER][NEUTRAL] I'm thinking just bear with me I'm trying to think outside the boxers again is there a cap that's paid out on ER or is it just subject to whatever we spent?
[AGENT][NEUTRAL] It's just subject to the $1000 that's your cap.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][POSITIVE] Um, all right, I really appreciate you taking the time and walking me through this. I'm sure I missed something somewhere, but I was just making sure that I wasn't completely like I think we have some money coming back to us which will be ideal, um, in this day and age, so that's great, um, so I really, really appreciate it and uh I hope you have a great week.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Oh no
[AGENT][NEUTRAL] You too, [PII]. Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] No ma'am, um, oh yeah, actually I will ask what is the estimated roughly turnaround time?
[AGENT][NEUTRAL] So once received, um, the information claims are processed within 2 to 4 working days.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, and then like, so for instance, I just had like an outpatient procedure. The total cost of me was like way more than $1000. Um, so do you want all the documentation or do you just like want like, I mean like I have the I have the summary benefits from the hospital, like, I mean sorry, from the, the surgical center. I can get the ICD 10 from the surgical center, but the surgical center plus the doctor visit are gonna equal the $1000 so.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Do you guys care if I don't provide the rest of it even though clearly the EOB shows that I would get out almost $1700.
[AGENT][NEGATIVE] No, no, not at all. Um, there is no point in you sending it if you know, we're gonna deny it, but if you feel like, um,
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][POSITIVE] Yeah, I mean like for 25, like we'll be, I'll be done with 25 in about 5 minutes as soon as I do. I'm chopped out. That's what sparked this was like, oh, I think we have some deductible recovery and then I was like, oh, because the surgical center told me it was one price and it came back double, and I'm like, Oh, cute, um, so yeah, so that's why I just wanna make sure we're on the right page, so.
[AGENT][POSITIVE] Oh wow.
[AGENT][POSITIVE] Oh, thank God you have this policy. This is a great policy to have to get some of those expenses back.
[CUSTOMER][NEUTRAL] Exactly, exactly, exactly, so.
[CUSTOMER][POSITIVE] OK cool alright well I appreciate your help you have a great week OK?
[AGENT][POSITIVE] You're welcome. You have a wonderful day, [PII]. Thank you for calling APL.
[CUSTOMER][POSITIVE] Take care. Bye bye.
[AGENT][NEUTRAL] Bye bye.