AccountId: 011433970860
ContactId: 8947df39-3376-4d31-92d5-e6c9460df1b0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 829340 ms
Total Talk Time (AGENT): 300269 ms
Total Talk Time (CUSTOMER): 322687 ms
Interruptions: 3
Overall Sentiment: AGENT=1.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/16/8947df39-3376-4d31-92d5-e6c9460df1b0_20250616T16:37_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, I just got a um a letter rejecting my claim, um, but it seems to be.
[CUSTOMER][NEUTRAL] I think it was applied incorrectly, so I wanted to contest it.
[AGENT][NEUTRAL] OK, may I have your name please?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] And [PII], may I please have a callback number?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] And the policy number please.
[CUSTOMER][NEUTRAL] 025
[CUSTOMER][NEUTRAL] 911
[CUSTOMER][NEUTRAL] 70.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And may I have your date of birth and then the mailing address listed please?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh, let me see, uh, email address.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] The name of the provider one minute.
[CUSTOMER][NEUTRAL] That's it.
[CUSTOMER][NEUTRAL] Just not sure if it's OK, so it is.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, now is this your personal email address or your business?
[CUSTOMER][NEUTRAL] Uh, yes, it's, well, I mean, my work is my personal email address.
[AGENT][NEUTRAL] OK, because normally we're trying to inform all people that we need the personal instead of going to their business address and also could you verify your, go ahead.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] I'm happy to give you my, I, I do have another personal email that's fine if you would prefer that.
[AGENT][NEUTRAL] Well, as long as you have access to this.
[AGENT][NEUTRAL] At home, then that is fine.
[CUSTOMER][NEUTRAL] Oh yeah, yeah.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Yeah, it's a single single member LLC it's mine, so yeah.
[AGENT][NEUTRAL] OK. And also, could you verify your mailing address or residential that's listed on the claim on the policy?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] And thank you so much [PII] for verifying the policy. Is this claim for you or someone else listed on the policy?
[CUSTOMER][NEUTRAL] Me.
[AGENT][NEUTRAL] OK, and do you have the date of service?
[CUSTOMER][NEUTRAL] Yes, uh, [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] So it looks like it denied as a non-covered service. Let me pull the claim up.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yeah, I paid out of pocket because they had trouble running my insurance, but now they're accepting it as a $50 co-pay instead of me paying full.
[CUSTOMER][NEUTRAL] So that's why I'm surprised that my claim got bounced back because, you know, for moving forward.
[CUSTOMER][NEUTRAL] It's accepted as a co-pay situation and not.
[AGENT][NEUTRAL] So it looks like the reason of the now is based off the.
[AGENT][NEUTRAL] The physician that you went to?
[AGENT][NEUTRAL] They're stating that this is not considered a physician.
[CUSTOMER][NEUTRAL] It's not a physician.
[CUSTOMER][NEUTRAL] Yeah, but it shouldn't be, uh, she's a psychotherapist. I went for mental health services, so she's not a physician, it's obvious.
[AGENT][NEUTRAL] OK. The only thing that I can inform you is that you're more than welcome to submit it in as an appeal.
[AGENT][NEUTRAL] And have the appeals department to review it, but they denied it, stating that this is not a covered benefit based off of the treatment of that provider or their physician practices.
[CUSTOMER][NEUTRAL] Can you check because like I said since then the provider has submitted.
[CUSTOMER][NEUTRAL] Bills on my behalf.
[CUSTOMER][NEUTRAL] That they, you know, are like, oh now you're covered and you just pay the copay, and then I paid that.
[CUSTOMER][NEUTRAL] So I'm not I'm not understanding the disconnect between putting in this claim that saying oh this isn't covered and then later having the, the, the psychotherapist their office submit for me and they had they accepted it and accepted a co-pay.
[CUSTOMER][NEUTRAL] So can you help me, can you help me understand the discrepancy there? like why would it this claim be denied if later they would accept.
[CUSTOMER][NEUTRAL] My insurance.
[AGENT][NEUTRAL] OK, I'm not saying that we have accepted anything. This is the only denial that they have submitted that we have and we have submitted as a denial. We haven't received any other claim from the provider.
[CUSTOMER][NEUTRAL] That's strange.
[CUSTOMER][NEUTRAL] They
[CUSTOMER][NEUTRAL] So the last bills that I pay, I've been 3 times, so it was the first time I paid out of pocket because they weren't able to process my insurance, and so I just paid.
[CUSTOMER][NEGATIVE] The 2nd and 3rd time I did not pay because I was waiting for my insurance to get approved.
[CUSTOMER][NEUTRAL] Then they waited to accept payment from me, um, and then they were like, oh OK, so we got your insurance approved, so then they changed the bill to me to a co-pay.
[CUSTOMER][NEUTRAL] So I don't know if that's not necessarily a claim, but they've accepted my insurance and said, yep, you just owe the copay. So what is that? What has been approved then?
[AGENT][NEUTRAL] Now they may have spoken to Benefit in a car other than us because we haven't received any other claims. So there is someone that they speak to prior to speaking to us as well.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, so help me understand what, what's my best course of action here because based on the fact that they're now saying yes we accept your insurance, yes, there's a co-pay.
[CUSTOMER][NEGATIVE] Not you pay full out of pocket, not like, you know, my claim is denied. Um, how can I use that to make sure that I can get reimbursed for this out of pocket expense?
[AGENT][NEUTRAL] You can, as I stated, you can, you're more than welcome to submit an appeal and have the appeals department to review it.
[AGENT][NEUTRAL] But as of right now, that claim has been denied. I don't process the claims. I can only just give you the advice of what you can do for your next step.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, OK, so this rem[PII] description, can you help me analyze this so I can frame my appeal? Um, because the fact that they accept my insurance now makes me think that I should win on appeal. But what is it that they're telling me in this description? They're saying it means a practitioner of the healing arts who's legally qualified and licensed to practice medicine, and who's practicing in the scope of his are licensed in the state where or so licensed. The woman I saw is obviously licensed in [PII] where I attended.
[CUSTOMER][NEUTRAL] So I, I don't know why, why it would be denied on those grounds. Can you help me understand that?
[AGENT][NEUTRAL] It's saying that treating provider does not meet the definition.
[CUSTOMER][NEUTRAL] Because based on the information received, the treatment provider does not meet the difference.
[AGENT][NEUTRAL] So it's stating that she's not a physician.
[CUSTOMER][NEUTRAL] She's not a physician, she's a psychotherapist. Yeah.
[CUSTOMER][NEUTRAL] And I'm saying I didn't claim she was, I claimed she was a psychotherapist.
[AGENT][NEUTRAL] So it looks like for your policy, they only cover physicians or licensed physicians. And it's, and it's stating that she's not defined as a physician.
[CUSTOMER][NEUTRAL] Yeah, but, um, according to my explanation of benefits, I have mental health coverage.
[CUSTOMER][NEUTRAL] Therefore, I could see a psychotherapist.
[AGENT][POSITIVE] I'm gonna pull your benefits up for you as well. Let me see if I can get those.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah, I was like, uh, I didn't say she was a physician. She's, I went for mental health counseling.
[AGENT][NEUTRAL] Yes, but that is the reason of the denial, so that's the, that's one reason why you may need to go ahead and just submit that appeal and have someone to look into it a little further, but it looks like you don't have that benefit listed for your policy, so that's the reason why it did not as a non-covered benefit.
[CUSTOMER][NEUTRAL] Can you double check that for sure?
[AGENT][POSITIVE] I'm pulling that up for you now.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] I appreciate your help. I know that not all of this is in your control just trying to.
[AGENT][POSITIVE] Oh, it's no problem.
[CUSTOMER][NEUTRAL] And get the coverage that I pay for, you know.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] So in regards to your policy, verification of coverage does not guarantee the payment of the claim. You only have physician benefits and since she's not listed as a physician, that was the reason of that denial.
[AGENT][NEUTRAL] So for the terminology of that physician, that's not considered a covered benefit.
[CUSTOMER][NEUTRAL] And then what does it say about?
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Is there anything in there that says anything about co-pays with mental health specialists?
[AGENT][NEUTRAL] It covers for this policy, it does cover accident and sickness benefits, so.
[AGENT][NEUTRAL] It's not saying that mental health physician.
[AGENT][NEUTRAL] The provider is not a regular physician. That's the only thing that's that's stopping it. So my advice to you is to just write that you would like for this claim to be reviewed as an appeal for a second opinion.
[CUSTOMER][POSITIVE] What in the policy, is there anything in the policy that I can cite that says, yes, mental health services are, that is a benefit that I enjoy because I bought this policy partially because I wanted mental health.
[CUSTOMER][NEUTRAL] Covered.
[AGENT][NEUTRAL] I'm not seeing that listed in the policy.
[CUSTOMER][NEUTRAL] You don't see anything about co-pays for seeing mental health specialists.
[AGENT][NEUTRAL] Mental health, no.
[AGENT][NEUTRAL] No, I'm not seeing that.
[CUSTOMER][NEGATIVE] Man, I hated her so much.
[AGENT][NEUTRAL] But no, that's why I'm just saying go ahead and just write, you can submit that same documentation back and just write a letter stating that you would like for this to be reviewed as an appeal.
[AGENT][NEGATIVE] For a second opinion. I'm not saying that it won't get approved and I'm not saying that it will get approved, but at least you do have someone else that can look at it and review it and possibly say this should be paid.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] And but you, you are not, um.
[CUSTOMER][NEUTRAL] Being anything about mental health services in my benefits.
[AGENT][NEUTRAL] No, I do see that it does cover uh accident and sickness. So that's the, so my only option is just to submit that in for a review.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEGATIVE] You don't see anything in the policy about covering mental health, um, that I have a copay and not.
[AGENT][NEUTRAL] I don't see anything indicating mental health. I only see information about sickness treatment.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK thank you I appreciate your help um.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] And is there any other um
[CUSTOMER][NEGATIVE] Uh, paperwork that I should submit or just say I'd like this to be appealed.
[AGENT][NEUTRAL] You would just submit the same documentation that you sent in and just either put something on the doc uh piece of paper just stating that you would like for this to be reviewed um or appealed.
[AGENT][NEUTRAL] Or just get a second opinion from someone else in regards to this denial of the claim.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome, and I do wanna thank you for calling. You're welcome. Thank you for calling American Public Life. Have a great day.
[CUSTOMER][POSITIVE] Alright, I appreciate it.
[CUSTOMER][NEUTRAL] You too.
[AGENT][NEUTRAL] Bye.