AccountId: 011433970860
ContactId: 9dedd1a0-6170-4175-8f6b-32e5011a5c64
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 762969 ms
Total Talk Time (AGENT): 297204 ms
Total Talk Time (CUSTOMER): 161312 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/9dedd1a0-6170-4175-8f6b-32e5011a5c64_20250408T13:16_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is So. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, I, um, submitted two claims last week and so they're just processed, but the amount paid was 0, so I'm just trying to understand what exactly happened or what's missing.
[AGENT][NEUTRAL] OK, sure, yes, I can assist you with claim status. May I have your name and a callback number?
[CUSTOMER][NEUTRAL] Um, sorry, my name and what number?
[AGENT][NEUTRAL] Um, it's gonna be your name and a callback number just in case we get disconnected.
[CUSTOMER][NEUTRAL] Oh, call back. Yeah, my name is [PII].
[CUSTOMER][NEUTRAL] And my number is [PII].
[AGENT][NEUTRAL] Thank you. And may I have the policy number?
[CUSTOMER][NEUTRAL] 2553219
[AGENT][NEUTRAL] Is that our policy number on
[CUSTOMER][NEUTRAL] Yeah, that's I'm looking at the website my coverage product meddling with benefit assignment, and that's the policy number.
[AGENT][NEUTRAL] OK, let me have that number one more time.
[CUSTOMER][NEUTRAL] 2553219
[AGENT][NEUTRAL] It
[AGENT][POSITIVE] 21. OK, thank you.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] Not your name
[AGENT][NEUTRAL] You said 2552219?
[CUSTOMER][NEUTRAL] 2553219
[CUSTOMER][NEUTRAL] 321 9
[AGENT][NEUTRAL] All right. OK. And for security, may I have your date of birth, mailing address and email address on file?
[CUSTOMER][NEUTRAL] Um, yeah, [PII].
[CUSTOMER][NEUTRAL] Uh, my email address is [PII].
[CUSTOMER][NEUTRAL] And then what else do you need my address?
[AGENT][NEUTRAL] The address on file, mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and that's in [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, and the claim is for [PII].
[CUSTOMER][NEUTRAL] Um, yeah, I have one for, well, there's 3 total. One for [PII], one for [PII], and one for [PII].
[AGENT][NEUTRAL] OK, OK, let me check and see what happened to the claim.
[AGENT][NEUTRAL] Let me pull the details and do you mind holding for me?
[CUSTOMER][NEUTRAL] No, that's fine.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding and being patient for me, Mr. [PII]. OK, so I went ahead and check all three and it looks like the denial reason is the same for all three. it looks like we're needing additional information. So we're needing a fully itemized bill with the diagnosis codes and procedure codes, and we also need the copy of the explanation of benefits from the primary insurance.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So is that, is that standard? You need those two things, um, for a claim to be processed?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, for any claims, um, for all claims submitted for a Metin, um, product, we need the claim form, the itemized bill with diagnosis code, and the explanation of benefits from the primary insurance. Those three documents are a must for a complete claim.
[CUSTOMER][NEUTRAL] Oh wait, so there's 3 documents. Sorry, I missed that. So the explanation of benefits, the itemized um details with the diagnosis codes and procedure codes, what was the third one?
[AGENT][NEUTRAL] Oh, the claim form, which it looks like that's what was submitted the claim form.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Alright, um, sounds good then I will get those documents and resubmit.
[AGENT][NEUTRAL] All right. So once we receive those, we'll go ahead and reprocess, OK?
[CUSTOMER][NEUTRAL] Um, and then, sounds good. Uh, I have one last question. It says my dependent, [PII], uh, has lapsed, um.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] You know why that is? And she was just born a few months ago.
[AGENT][NEUTRAL] Was it, um, was she added to your policy with your employer?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] She was
[AGENT][NEUTRAL] OK. So probably we just need notification from the employer indicating that she is added to the policy.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, because she's, um, only added to the policy for the 1st 30 days of life until we're notified by the employer.
[CUSTOMER][NEUTRAL] Um, OK, well, yeah, she's definitely added by the employer, so that's something that you can reach out to the employer to update?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, we, we don't reach out and usually whenever there is a change, they send us notification indicating there was a change on this um particular person and we'll go ahead and update the system.
[AGENT][NEUTRAL] Because we don't know about changes unless we're notified. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I will reach out to them then.
[AGENT][NEUTRAL] Mhm. Yes. So once we receive that information, we'll go ahead and update her in the system as well. But yeah, right now, we have not received anything and that's why she was terminated.
[CUSTOMER][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] But it could be reversed. Once we receive the information, we'll go ahead and put it as the day that she was born again, OK?
[CUSTOMER][POSITIVE] OK. Sounds good. Thank you.
[AGENT][NEUTRAL] You're welcome. Is there anything else I'm gonna help you with today, Mr. [PII]?
[CUSTOMER][NEUTRAL] Um, no, that's all.
[AGENT][POSITIVE] Alright, well thank you for calling APL. Yes, go ahead, yes.
[CUSTOMER][NEUTRAL] Well, actually I'm sorry. I, I do have one more question.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, I'm trying to understand what the expectations are in terms of like amount reimbursed, but what, what, what is my, what should my expectations be there for like out of pocket costs, for deductibles, for um co-pays? Is it like a percentage based? Is it case by case? Like what, what should my expectations be?
[AGENT][NEUTRAL] OK, let me give you your benefits. It looks like you need a breakdown of your benefits. OK, let me go ahead and pull a breakdown of your benefits.
[CUSTOMER][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] All right, and this is not a guarantee of payment, just a verification of coverage and that's just a disclaimer. And so we are the secondary supplemental plan to the major medical and we help with deductibles, co-payment, and co-insurance. Now it is limited to what copays we cover, OK? Um, in this case, let me see, so in this case, we do not cover office.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So co-payments for office specialists or regular doctors are not covered and service rendered in office is not covered. Uh, we do cover outpatient facilities or outpatient. Um, the outpatient maximum is 250 per occurrence, meaning that if it is related to the same treatment or condition, it needs to be separated by 90 days. Um, but we do cover the co-payment for the emergency room.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, we do cover the co-payment for the urgent care facility up to 3 urgent care visits per year per covered person or 6 per family combined.
[AGENT][NEUTRAL] Um, we also cover, um, surgery in a surgical center or in a hospital. We cover the co-payment or deductible or co-insurance for diagnostic testing either in the hospital or imaging facility.
[AGENT][NEUTRAL] Diagnostic centers.
[AGENT][NEUTRAL] Um, and we also cover for treatment for a mental or emotional disorder in a hospital, and this one is subject to 30 days of treatment.
[AGENT][NEUTRAL] That's your outpatient benefits. And then you have a separate inpatient benefit if um the, if you're in the hospital, either 18 hours or more for observation or admission is $500 per confinement.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so those are your banners.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][POSITIVE] Sounds good. That, that was helpful. Thank you.
[AGENT][NEUTRAL] You're welcome. Is there anything else I may help you with today, Mr. [PII]?
[CUSTOMER][NEUTRAL] Um, no, that's all.
[AGENT][POSITIVE] All right, well thank you for calling APL. You have a good day.
[CUSTOMER][POSITIVE] Thank you too.
[AGENT][POSITIVE] Thank you. Bye-bye.