AccountId: 011433970860
ContactId: 85e64346-07ad-40d1-a213-d4b91ed299f0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 525210 ms
Total Talk Time (AGENT): 314709 ms
Total Talk Time (CUSTOMER): 184418 ms
Interruptions: 3
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/06/85e64346-07ad-40d1-a213-d4b91ed299f0_20250306T20:11_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, hi [PII]. My name is [PII]. I'm calling about an explanation of benefits I received today.
[AGENT][NEUTRAL] What would be my
[CUSTOMER][NEUTRAL] And I wanted to go over it.
[AGENT][POSITIVE] Sure, I would be happy to assist you with that, Mr. [PII]. Do you have the claim number or policy number?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yes, the policy, which one would you like? I got both.
[AGENT][NEUTRAL] Either, I, I can look it up either way. If I, if you give me the claim number, I can go ahead and pull your policy up with it too.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Sure, 357-1243.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And do you mind verifying your date of birth and current mailing address?
[CUSTOMER][NEUTRAL] [PII] I'm sorry, [PII].
[AGENT][NEUTRAL] All right, thank you. And also, do you mind verifying your email address and a good callback number?
[CUSTOMER][NEUTRAL] Yes, [PII] and [PII].
[AGENT][POSITIVE] Perfect, thank you. I appreciate that verification.
[AGENT][NEUTRAL] Let's see. So this is for [PII] for a diagnostic test.
[CUSTOMER][NEUTRAL] Correct, I had to get an an X-ray done right away for emergency.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Let me get this claim pulled up real quick and we'll take a look and see what's going on.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] So you know with your APL gap policy, we are secondary to your primary insurance.
[CUSTOMER][NEUTRAL] Correct, and my primary didn't cover this.
[AGENT][NEUTRAL] And we pay
[AGENT][NEGATIVE] It did not
[CUSTOMER][NEUTRAL] Did not
[AGENT][NEUTRAL] Yes, so we only pay towards your deductible, co-pay or coinsurance when your primary insurance processes your claim, and so whatever they apply to your deductible copay or co-insurance is what we can cover up to the benefit amounts listed on your policy.
[AGENT][NEUTRAL] So if they're gonna do.
[CUSTOMER][NEUTRAL] OK, so they, they, because I called into American Public Life, and I said because this is an emergency and I had to go out of to get it done right away and this provided and take my insurance so I paid out of pocket to get the X-ray.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And they said if I get an explanation of benefits from.
[CUSTOMER][NEUTRAL] UnitedHealthcare showing that they would still pay the claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Did your father claim with United?
[CUSTOMER][NEUTRAL] Yes, I did. I we sent that in with this.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so let me take a quick look.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] I uploaded everything.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] All right, let's take a look and see what we've got.
[CUSTOMER][NEGATIVE] It took me a few months to get the explanation from United because I had to go back, have the the diagnostic center file with Humana, I mean not Humana with United Healthcare.
[AGENT][NEUTRAL] So according to the explanation that we have on file.
[CUSTOMER][NEUTRAL] From from United Healthcare.
[AGENT][NEUTRAL] For the X-rays?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Looks like it is United.
[AGENT][NEUTRAL] Um, it looks like that they charged 2 I mean $127 for those two X-rays.
[AGENT][NEUTRAL] Two views of your X-ray. 11 X-ray.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I only paid it. I, I, I only paid $40.
[CUSTOMER][NEUTRAL] For the X-ray.
[AGENT][NEUTRAL] So, OK, so they charged $127.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] Right, and they paid nothing on it.
[AGENT][NEUTRAL] Right, so they did not apply anything to your deductible or co-pay or co-insurance.
[AGENT][NEUTRAL] So when you're looking at your explanation of benefits,
[AGENT][NEUTRAL] If there is something.
[AGENT][NEUTRAL] Applied to the deductible or co-pay co-insurance, that's what your APO gap policy could cover if it's a covered benefit on your plan. But if you're, if you look at that document that you uploaded.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm I'm trying to pull it up.
[AGENT][NEGATIVE] It does not have anything, yeah.
[AGENT][NEUTRAL] It doesn't have anything under the deductible co-pay or co-insurance column.
[CUSTOMER][NEGATIVE] Right, because they didn't pay anything towards it.
[AGENT][NEUTRAL] Right, so that's why we were.
[CUSTOMER][NEUTRAL] So was that a.
[AGENT][NEUTRAL] Yeah, that's why we were not able to provide.
[CUSTOMER][NEGATIVE] So I had to pay out of pocket the $40.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] I was under the impression I can still get that $40 back.
[AGENT][NEUTRAL] On only, only if the your major medical applies it to your deductible, co-pay, or co-insurance.
[CUSTOMER][NEUTRAL] Well, since they, they didn't pay anything, there's nothing to apply.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, and so therefore there would be no benefits payable toward that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I was misled then OK.
[AGENT][NEUTRAL] I am so sorry. Now, they might have thought maybe that, you know, went back and covered it.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] But anytime that you look at your primary EOBs or explanation of benefits, and they do not apply anything to the deductible copay or co-insurance, then there would be no benefits payable on the midlink gap policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What happens if I had to go out of out of network to get it done so there would be since they wouldn't cover it because I had to go out of network to get it done right away because it was an emergency situation.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Now, you do have a right to an appeal.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And if you want to send in a formal letter stating that you do not agree with the claim decision and state why, it will go before our appeal boards and they'll be happy to review it.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But with your APLA policy, it is secondary to your major medical, so we do, it has, it depends on how your major medical processes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK then.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Where do I send the appeal to?
[AGENT][NEUTRAL] You can actually fax it or upload it on your policy just the same way you do a claim.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] That can be uploaded.
[CUSTOMER][NEUTRAL] And what do I put in there?
[AGENT][NEUTRAL] So you can just um.
[CUSTOMER][NEUTRAL] Just so.
[AGENT][NEUTRAL] Uh, write a letter stating that this is in regarding to that claim. You can even attach our EOB if you'd like and just state that you had to go out of network due to an emergency situation to have this X-ray performed.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And you were under the impression that APL would would pay for that.
[CUSTOMER][NEUTRAL] OK, alright then.
[AGENT][POSITIVE] And they'll be happy to review it. It'll go before an appeal board, and they'll review the benefits on this policy, as well as the claim, how it was processed, and if it was processed correctly, we don't mind that at all. You have that right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Right, what do you say if it was processed correctly?
[AGENT][NEUTRAL] So what they'll do is they'll review the claim, and if they, they say that it was processed correctly and denied correctly, then they'll, you're gonna get a letter.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] From the appeal board and it'll either state that after their findings it was, you know, that they did find that the claim was processed correctly.
[AGENT][NEUTRAL] Or you know, if they do find something where they can go back and pay it, then you'll receive that as well.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, because I'm looking at the uh.
[CUSTOMER][NEGATIVE] The United AEOP and it says benefits for this service are denied. You saw a healthcare professional that is not in your network plans network.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] I wish they would do away with networks. I'm just gonna, I'm just gonna say that personally.
[CUSTOMER][NEUTRAL] Right, I know that.
[AGENT][NEGATIVE] I, I really do. It's just horrible when we have to be so picky and then we can't.
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] You know, there's not one available and then we're left out in the cold.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] Oh, it's getting bad out there in healthcare.
[AGENT][NEUTRAL] It really is, but we're here to help you any way we can and unfortunately, you know, that's, that's what we pay toward is the deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's been applied after your primary processes.
[CUSTOMER][NEUTRAL] OK, alright.
[CUSTOMER][POSITIVE] OK. Thank you for your help. I appreciate it.
[AGENT][POSITIVE] Well, it's been my pleasure, Mr. [PII]. Anything else?
[CUSTOMER][POSITIVE] Have a good day bye.
[CUSTOMER][NEGATIVE] No thank you.
[AGENT][POSITIVE] Oh, thank you for calling APL and I hope you have a wonderful afternoon.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Thank you bye bye.
[AGENT][POSITIVE] Thank you bye bye.