AccountId: 011433970860
ContactId: 8fd6b1f5-ac5d-4662-8ca3-dbeb1b06aea1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 922679 ms
Total Talk Time (AGENT): 453308 ms
Total Talk Time (CUSTOMER): 419898 ms
Interruptions: 0
Overall Sentiment: AGENT=1.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/06/8fd6b1f5-ac5d-4662-8ca3-dbeb1b06aea1_20250306T14:45_UTC.wav
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[AGENT][POSITIVE] Good morning thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I have a gap, um, plan through my husband's, uh, business, and I received two text messages saying, um, that my claim is complete.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, and I, when I went online, uh, to check, I saw only saw received, so I'm a little confused because I faxed over two separate claims, um, and I'm waiting, uh, I'm trying to understand what it is, if anything, that APL needs or if it's just um.
[CUSTOMER][NEUTRAL] Uh, if it's just to notify me that it's being processed.
[AGENT][POSITIVE] Well, it would be my pleasure to assist you, Ms. [PII]. Do you have that policy number available?
[CUSTOMER][NEUTRAL] Yes ma'am, hold on, I'm just looking. 01893557.
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] And what is your date of birth, please, ma'am?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And can you verify the current mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And then what is a good callback number in case we get disconnected, Ms. [PII]?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] All right, thank you.
[AGENT][POSITIVE] And you've got fellas like I do. I tell you what, my dogs will never bark until I'm on the phone.
[CUSTOMER][POSITIVE] Exactly, and she's downstairs at the front door greeting by my house.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] A person
[AGENT][POSITIVE] Let's say, hey, yep, that's a good thing though, at least you know when somebody's near. I figure if they're barking, they're doing their jobs, right?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Exactly.
[AGENT][NEUTRAL] OK, Ms. [PII], now I do see on [PII] we did receive a document and it is in line to be processed and that is your claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then there should be one.
[AGENT][NEUTRAL] Um, also for your husband.
[CUSTOMER][NEUTRAL] Right, and that one was faxed over on the [PII] at night.
[CUSTOMER][NEUTRAL] So that would probably have been looked at or received on the [PII], right?
[AGENT][POSITIVE] That's right.
[AGENT][NEUTRAL] And that one has been processed now if you received a text message um.
[AGENT][NEUTRAL] To view it on the portal, it could take up to 48 hours.
[AGENT][NEUTRAL] Did it, did it?
[CUSTOMER][NEUTRAL] OK, are you able to give me information on the phone?
[AGENT][NEUTRAL] For your husband's claim, I would not be able to give information regarding that claim. He would need to call um but the the the text message have that claim number included?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] I'm looking to see 357-062-1. I handle all of our medical uh insurance, all of our supplemental insurance, all of our gap insurance, and I'm.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] Got you.
[CUSTOMER][NEGATIVE] I'm uh I'm a a health uh behavioral health provider, so I'm very familiar with HIPAA. He signed every possible form for every possible insurance uh allowing me to access information. I cannot tell you how many times I'm told what you told me, and he's in meetings, so I can't even, you know, gain access, although maybe I can. I just, I really, it's such a frustrating process.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] You know it is and you know because of all these bad guys in the world, you know, we just can't share personal health information due to HIPA, as you well know we do have an authorization form. It's a simple form and you can just.
[AGENT][NEUTRAL] Um, if he can sign that and give us permission to speak with you, then we'll have it on file and there won't be any.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Any issues?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, that's what uh I'm not disputing, but I can't tell you how many of those I've signed so if I.
[AGENT][NEGATIVE] It is frustrating. It is so frustrating. Mhm.
[CUSTOMER][NEUTRAL] If I
[CUSTOMER][NEUTRAL] I call him and patch him in. Can he give you verbal authorization?
[AGENT][NEUTRAL] For each call, so it'd have to be per call without um authorization document on file we would have to have that verbal information per call permission.
[CUSTOMER][POSITIVE] OK, I'll be satisfied with just this one because I'd really like to know um what if any is additional information so can can you hold a moment while I patch him in?
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] Absolutely, that would be fine.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Hi, can you give verbal authorization please for me to get information about your hold on hold on.
[CUSTOMER][NEUTRAL] OK, all right, I have him on the phone now, go ahead.
[AGENT][NEUTRAL] Thank you. Is this Mr. [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Good morning, Mr. [PII]. Can you verify your date of birth, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] All right, and you give us permission to speak to [PII] regarding your claims or benefits for this call?
[CUSTOMER][NEUTRAL] I do.
[AGENT][POSITIVE] All right, I'll be happy to assist you. Thank you for that authorization.
[CUSTOMER][POSITIVE] Thank you. OK, honey, love you bye bye.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, sorry about that. Now on our [PII] there is an uh form authorization to disclose information if you want to get him.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] To complete that you can fax it back to us just include the policy number because it is uh it and you know even for yourself it's so hard just to get your own information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] I know, right?
[AGENT][NEGATIVE] It is horrible. OK, so let's look at Mr. [PII]'s. It just frustrates me to know he is.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][POSITIVE] Well, I can imagine people aren't very nice about it, so thank you for being nice about, you know, getting me the info. I appreciate that.
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] Well, absolutely. No, it's, it's my pleasure.
[AGENT][NEUTRAL] Um, so his claim was processed on the [PII], and if you're on the portal, if you see that claim number, you can click on it. If the EOB is available, you'll be able to the claim decision.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well, I don't know if I can uh let me see while you're on the phone, but you said you now that you got his verbal authorization you can tell me what, uh, what the outcome is.
[AGENT][POSITIVE] That's right.
[AGENT][POSITIVE] That's right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I'm pulling it
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm pulling it all up.
[CUSTOMER][NEUTRAL] I think when I looked,
[CUSTOMER][NEUTRAL] Uh, yeah, that's what's so weird is, um, claims pro I'm looking at the um dashboard and saying that his, his claim.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] I received. That's all it's saying, and I can't even click on it.
[AGENT][NEUTRAL] The 357-062-1 you see if you um you may have to scroll to the right a little to see if do you see the claim number?
[CUSTOMER][NEUTRAL] No, there is no confirmation number, there is no service date. It just has um received his name, our policy number, the date it was received. Hold on a minute.
[AGENT][NEUTRAL] And scroll to the right a little bit, maybe it's.
[CUSTOMER][NEUTRAL] Hold on a minute.
[CUSTOMER][NEUTRAL] They completed 34 OK um there's the number 357-0621 so if I click on that it'll tell me.
[AGENT][NEUTRAL] That'll pull up the explanation of benefits showing the claims decision and there is some additional information needed so.
[CUSTOMER][NEUTRAL] OK, um.
[AGENT][NEUTRAL] See if you can get that EOB pulled up.
[CUSTOMER][NEUTRAL] I'm working it right now.
[CUSTOMER][NEUTRAL] So you know I call.
[CUSTOMER][NEUTRAL] Crazy. I always call to find out exactly what's required and then um I'm told I need an itemized bill from the provider and an EOB from my um health insurance, both of which is attached so I don't know what.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's just take a quick look, let's see.
[AGENT][NEUTRAL] OK, so for the itemized bill.
[AGENT][POSITIVE] A lot of times if you just ask and I'm gonna kinda give you some specific information that will help.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] If he is in a hospital, for example, the Boca Raton Regional Hospital, I do see the itemized bill.
[AGENT][NEUTRAL] It does not include a diagnosis code.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the meddling policy pays towards sickness or injury, so we have to have the diagnosis code as well to indicate that in fact it is a sickness or injury. Of course we could look at the itemized bill and see that it would be for a sickness or injury, but we have to have that diagnosis code from the hospital.
[CUSTOMER][NEUTRAL] So what do I ask for from them?
[AGENT][NEUTRAL] It's
[AGENT][POSITIVE] Got you. The easiest thing to do is from a hospital.
[AGENT][NEUTRAL] Whether it's an outpatient hospital or inpatient hospital, ask for a U as in umbrella, B as in Bravo, 04. It's a UBO4.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] You know what she sent me that and I and it was different than this so I didn't think that um it was the right thing so OK so now if I send just that do I need to also include the 3 page claim form as well or just that? I don't OK.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] No, because this is additional information on an um.
[AGENT][NEUTRAL] An existing claim, so you don't have to fill in, you don't have to send in the claim form. Just make sure that we do have the policy number if you fax it, or you can upload it on the portal.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I see you've done that before, so definitely you can just upload it on the portal.
[CUSTOMER][NEUTRAL] OK, hold on just one second. I want to look and see, OK, that's mine while you're with me, um, to see if I can find the correct thing or not.
[CUSTOMER][NEUTRAL] So this.
[AGENT][POSITIVE] Sure, you just take your time. I'm, I'm here for you whatever you need.
[CUSTOMER][NEUTRAL] You alright.
[AGENT][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] You sent me.
[AGENT][NEGATIVE] And I was checking the explanation of benefits sent with that itemized bill. It does not have the hospital explanation of benefits. We've got.
[AGENT][NEUTRAL] For the surgeon, the anesthesia.
[AGENT][NEUTRAL] Information but not the hospital.
[CUSTOMER][NEUTRAL] Well, that's weird. See, let me just see, we're talking about, OK, so we need to print that, so I need the hospital EOB and I need.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So you, whatever it is that you do.
[AGENT][NEUTRAL] Yeah, UB04.
[CUSTOMER][NEUTRAL] Let me just see what what this is because I just have I have um.
[CUSTOMER][NEUTRAL] it's all, all of this is for me.
[CUSTOMER][NEUTRAL] So, OK, I'm gonna have to call them and ask for it. OK, OK, alright, and what is the um the benefit allowable benefit for this um are you able to tell me that benefit information?
[AGENT][NEUTRAL] I can. Now, you can also, if you ever want to view your policy benefits, you can click on the policy number.
[AGENT][NEUTRAL] And your policy certificate will be downloaded. Um, within the certificate, there is a page called a schedule of benefits page.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And it will list all the services covered for inpatient hospital and outpatient.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, your inpatient maximum benefit is $4000 per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, um, and is there a limit like uh per day or per month or just an annual?
[AGENT][NEUTRAL] It's an annual benefit from it that starts on [PII] and ends on [PII] of each year.
[CUSTOMER][NEUTRAL] And are you showing any of my benefit being paid up until today?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] For inpatient for [PII]?
[AGENT][NEUTRAL] No benefits have been paid for [PII]. Now the other option, Ms. [PII], is you can always, you and your husband can always show your APO card with your primary insurance card and the providers can file claims and then we can pay the providers any benefits payable.
[CUSTOMER][NEGATIVE] Well, I would much rather be paid. Oh, why, why would the provider be entitled to my benefit? I'm confused.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That's it.
[AGENT][NEUTRAL] A lot of times because this is a secondary policy, not major medical, and they can, if when you go to the doctor's office or the hospital and you sign that piece of paper that allows them to file for insurance, that is giving them an assignment of benefits, meaning that they can file the claims for you and we can pay them direct.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But that's an option. It's, it's, they're already gonna have the documents needed. So that's just an option and that way you wouldn't have to do all this extra homework, you know, let them do the work kind of thing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah, but, um, I would rather get the benefit paid to me than to them and have.
[AGENT][NEUTRAL] Sure, I understand that. And then you know exactly what's going on and yep, I get it.
[CUSTOMER][NEUTRAL] to get it
[CUSTOMER][NEUTRAL] All right, um, I got my work cut out for me. I tell you what, getting, getting all this documentation, unfortunately is never an easy simple process. They make it very difficult for you.
[AGENT][NEUTRAL] It does and that's, and that's another reason you might want to, you know, change and let the providers file the claims for you, um, but don't forget that, don't forget that authorization form that, um, that Mr. [PII] can fill out and give us permission to speak with you and then that way you don't have to worry about the call authorization. Yeah.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] part
[CUSTOMER][POSITIVE] Got it, thank you so much you have a great day.
[AGENT][POSITIVE] Oh, it's been such a pleasure to assist you, Ms. [PII]. If you need anything else, never hesitate to give us a call.
[CUSTOMER][POSITIVE] Will do thanks. OK.
[AGENT][POSITIVE] Thank you for calling APL bye bye.