AccountId: 011433970860
ContactId: 8950dd1a-9b7a-40da-af33-92b2e1e15704
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 647059 ms
Total Talk Time (AGENT): 249292 ms
Total Talk Time (CUSTOMER): 319075 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/8950dd1a-9b7a-40da-af33-92b2e1e15704_20250103T14:42_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, how's it going? Um, I have, um, a, uh, a gap insurance policy with you guys, and, uh, I had a question about, um, a few of my claims.
[AGENT][NEUTRAL] I can verify claim status. May I have your policy number?
[CUSTOMER][NEUTRAL] Uh, yes, so.
[CUSTOMER][NEUTRAL] I'm on the website, um, logged in but I'm not sure where to find the policy number.
[AGENT][NEUTRAL] It should say certificate number or?
[AGENT][NEUTRAL] May even say member number. I'm not sure what the website.
[CUSTOMER][NEUTRAL] OK, um.
[AGENT][NEUTRAL] Is there a claim number?
[CUSTOMER][NEUTRAL] Uh, I do see, I think.
[CUSTOMER][NEUTRAL] Sorry, I have to go back, um.
[CUSTOMER][NEUTRAL] Oh, here's the policy number. I found it.
[CUSTOMER][NEUTRAL] Um, OK, are you ready for it?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, it's 214-464-5.
[AGENT][POSITIVE] Thank you and may I have a good call back number for you?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. Can you verify your name, your date of birth, and your mailing address?
[CUSTOMER][NEUTRAL] Uh, [PII]. Date of birth is [PII]. My address is [PII].
[AGENT][NEUTRAL] And do you have an email address?
[CUSTOMER][NEUTRAL] Um, it's [PII], my [PII].
[AGENT][NEUTRAL] OK, we have another one in our system.
[AGENT][NEUTRAL] Would you like to update it?
[CUSTOMER][NEUTRAL] Um, is the other one my, it's probably my work email. Uh, can you tell me what it is?
[AGENT][NEGATIVE] It's a food for the poor.
[CUSTOMER][NEUTRAL] Yeah, OK, um, I mean we can update it sure it's either one is OK.
[AGENT][NEUTRAL] OK, thank you for verifying that information. Please be advised that verification of coverage does not guarantee the payment of a claim. In which claim or data of service?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Um, there is, let's see, 123456 claims that were submitted on [PII], um, and then, um, completed, uh, yesterday, so, uh, I, I can give you the claim numbers but, um, essentially my question is, um, because I, I didn't submit those claims, I, I guess.
[CUSTOMER][POSITIVE] The, I had um some outstanding balances with um
[CUSTOMER][NEUTRAL] With the, the hospital that submitted them, um, and
[CUSTOMER][NEUTRAL] What it it seems like is that because the um maximum had already been met for 2024, they waited to submit these other claims um until the new year and so now they've been accepted for [PII] um.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] The, because I know there's a uh a maximum amount of coverage per year um.
[CUSTOMER][NEUTRAL] I guess it's a multiple part question, but what I'm trying to figure out is if now because those um claims were submitted and and completed in [PII] is, is the policy um like totally used up for the rest of the year is basically what I'm trying to figure out.
[AGENT][NEUTRAL] OK, so for these claims, you have for outpatient. Your outpatient benefit allows per calendar day.
[AGENT][NEUTRAL] So each day, you're allowed $500. So for these claims, they were submitted by the provider.
[AGENT][NEUTRAL] And there was a claim 354-6747. That claim process looks like UMHC on [PII] for an ER visit, and that, it looks like the copay co-insurance and our deductible was $500. So that one processed the $500.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And for the other one.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] It was 2:15 data service.
[AGENT][NEUTRAL] And it looks like
[AGENT][POSITIVE] This benefit paid.
[AGENT][NEUTRAL] 37,210.
[AGENT][NEUTRAL] Because it's a per calendar day.
[CUSTOMER][NEUTRAL] Yeah, I see those.
[CUSTOMER][NEUTRAL] OK, so, uh, just so I understand, so.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] The uh maximum coverage.
[CUSTOMER][NEUTRAL] That there isn't a uh a maximum for the year.
[AGENT][NEUTRAL] Correct. You have a calendar year plan?
[AGENT][NEUTRAL] But it's per calendar day for outpatient benefits. So anything that you've done on an outpatient is per calendar day.
[CUSTOMER][NEUTRAL] Oh interesting, OK.
[CUSTOMER][NEUTRAL] Um, she mentioned those two, the ones that were 372.
[CUSTOMER][NEUTRAL] But there's 4 others that were um that were submitted on that same day on [PII].
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Do
[CUSTOMER][NEUTRAL] Are, are those all outpatient?
[AGENT][NEUTRAL] So the one that is under claim 3546733, that one was for data service 262023.
[AGENT][NEUTRAL] And let's say you have another charge on [PII] or 23 that the provider has not submitted.
[AGENT][NEUTRAL] You still have a balance that they can use because they didn't utilize the 500 on that one.
[AGENT][NEUTRAL] So if you had another charge for that data service, they will still allow benefits for it because it didn't utilize that day.
[AGENT][NEUTRAL] $500.
[AGENT][NEUTRAL] 882022 was another one that the benefit only used 19818 on that day.
[CUSTOMER][NEUTRAL] So are all of these coming through as outpatient?
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So why do you think
[CUSTOMER][NEUTRAL] Um, because they submitted a handful on [PII].
[CUSTOMER][NEUTRAL] And then they didn't submit these other more recent ones until just a couple of days ago. Uh, why do you think they waited?
[CUSTOMER][NEUTRAL] Like several weeks to submit them again because it uh it seemed like to me they were, they were submitting them because
[CUSTOMER][NEUTRAL] It was, it would be processed in the new year, so I figured I had something to do with.
[CUSTOMER][NEUTRAL] The policy was maxed out for [PII] and now they were, do do you get what I'm saying?
[AGENT][NEUTRAL] Yes, I understand the way you're thinking. The provider, we have no clue as to when and how they bill, but this plan, regardless of when they submit, if you still have benefits in 24 and 23 and 22, it will process as long as your plan was active. There's no filing time limit to submit a claim.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So as long as you have those benefits, yes. As long as you have them, they will still process.
[CUSTOMER][NEUTRAL] OK, well, that's good to know.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and um.
[CUSTOMER][NEUTRAL] So it's 500 per day for um outpatient and then.
[AGENT][NEUTRAL] Co
[CUSTOMER][NEUTRAL] What about, or actually I'm trying to see if I can pull up the policy information on my end because.
[CUSTOMER][NEUTRAL] For some reason, um.
[CUSTOMER][NEUTRAL] Yeah, I just, I guess I didn't understand.
[CUSTOMER][NEUTRAL] How that worked, what is it, what is the coverage on it's um.
[CUSTOMER][NEUTRAL] Not outpatient but just um.
[CUSTOMER][NEUTRAL] I guess like a regular doctor's visit.
[AGENT][NEUTRAL] So for any treatment in the doctor's office, that still applies to the outpatient $500 benefit.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] It's still considered outpatient. There is no actual office visits. So if you go to the doctor and you have an office visit and he gives you an injection or X-ray or any other services in the office, that would be covered under the outpatient treatment, but not the visit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, right.
[CUSTOMER][NEUTRAL] Right, OK, so, um, I pulled up the, um, I guess it's the explanation of benefits on the website here and um this is the part, so it says um.
[CUSTOMER][NEUTRAL] Maxim in hospital benefit maximum 3500 per person per year and then, OK, yeah, so 3500 so.
[CUSTOMER][NEUTRAL] How does that
[CUSTOMER][NEUTRAL] Like if it's 500 per day, is it up until 3500?
[AGENT][POSITIVE] Correct, for inpatient. Anytime you're hospitalized, it will pick up the copays, the car insurance, and our deductible. Yes, for inpatient.
[CUSTOMER][NEUTRAL] Oh, inpatient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so inpatient has a maximum outpatient does not.
[AGENT][NEUTRAL] Per calendar day. Your maximum is per calendar day.
[CUSTOMER][NEUTRAL] Well, OK, right, right, per year, right, right, OK.
[AGENT][NEUTRAL] Right.
[CUSTOMER][POSITIVE] OK, OK, I understand now. Well, thank you, it's very helpful.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] You're so welcome. Is there anything else I can help you with?
[CUSTOMER][POSITIVE] Uh, no, that's it, thank you.
[AGENT][POSITIVE] You're so welcome, [PII], and thank you for calling American Public Life. Have a great day. Bye-bye.
[CUSTOMER][NEUTRAL] You too bye.