AccountId: 011433970860
ContactId: a0786815-61a8-4eea-8a09-4dfd58b9c95d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1003960 ms
Total Talk Time (AGENT): 326133 ms
Total Talk Time (CUSTOMER): 457968 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/04/a0786815-61a8-4eea-8a09-4dfd58b9c95d_20250404T17:35_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, um, I'm calling cause I have gap insurance with you guys and I had to, um, two situations that I wanted to, um, uh, I guess review with you, um, so I was hoping you could help me with that.
[AGENT][NEUTRAL] OK, may I have your name and a callback number?
[CUSTOMER][NEUTRAL] Yes, my name is [PII] and my callback number is [PII].
[AGENT][NEUTRAL] And [PII], may I please have your policy number?
[CUSTOMER][NEUTRAL] Yes, the uh group number is 24241.
[AGENT][NEUTRAL] OK, I'm needing your outpatient benefit certification number.
[CUSTOMER][NEUTRAL] Oh, got it. OK, so that is 01893619 M as in Mary.
[CUSTOMER][NEUTRAL] L as in Larry 8.
[AGENT][NEUTRAL] And I do need to verify date of birth and mailing address and email address on file.
[CUSTOMER][NEUTRAL] OK, so my birthday is [PII].
[CUSTOMER][NEUTRAL] My address is [PII].
[CUSTOMER][NEUTRAL] And my email is [PII].
[AGENT][POSITIVE] And thank you so much [PII] for verifying your policy. How may I assist you?
[CUSTOMER][NEUTRAL] So my first question is, um, I have a um a doctor that recommended physical therapy for my hand, and I wanted to know if this gap insurance will cover the, um the copay that I have for that.
[AGENT][NEUTRAL] OK, so in regards to physical therapy itself, verification and coverage does not guarantee the payment of the claim. You do have up to $500 per calendar day that we will pay towards your primary insurance deductible, co-insurance, or co-pay.
[CUSTOMER][NEUTRAL] So what does that mean?
[AGENT][NEUTRAL] We will pay up to $500.
[AGENT][NEUTRAL] Towards your primary insurance. If your primary insurance is it's your responsibility of deductible co-insurance or co-pay, then we will pay up to that $500 of that amount.
[CUSTOMER][NEUTRAL] So then I have, for physical therapy, I have to go multiple times, right? So if I go, like let's say I have to go twice a week.
[CUSTOMER][NEGATIVE] Um, for, I don't know, 4 weeks, um, does every time I go they'll, they'll call you guys to cover that co-pay that's like maybe $30 or $50 until it meets the $500 and then you don't cover any more?
[AGENT][NEUTRAL] This this is a per calendar day, so each day you have up to $500 that we will pay.
[CUSTOMER][NEUTRAL] Oh, every single day. OK, so then for sure this should be covered then because.
[CUSTOMER][NEUTRAL] Um, physical therapy won't, I won't be $500 a day or more than that, hopefully.
[AGENT][NEUTRAL] Yes, it's just of course, so see if they bill you that you're getting physical therapy, that's the difference. If they submit it saying that you're getting physical therapy, now, if you go to an office visit just for the visit, then this policy doesn't have the office visit benefit rider. But if you're getting physical therapy treatment, then that is up on that $500 but your primary insurance.
[AGENT][NEUTRAL] It's gonna have to cover it and say it's applied to your deductible, co-insurance, or co-pay.
[CUSTOMER][NEUTRAL] Yeah, the, the physical therapy office already confirmed that my main insurance does cover it.
[CUSTOMER][POSITIVE] And, and that's why I know I'm gonna have a co-pay.
[AGENT][NEUTRAL] OK, so once we receive that.
[AGENT][NEUTRAL] And they, you know, we review it or whatever we're just gonna see what benefits that you do have that is eligible for payment. It's just based off of how we receive the claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, is there anything I could get you ahead of time to like confirm? Well, my appointment is on my first appointment is on Monday, so I guess at that point they'll send that information and I'll know, they'll send the information to you guys and I'll know um if it'll be fully covered or not, right?
[AGENT][NEUTRAL] You can just give them the telephone number they can contact us and verify if any benefits is eligible for that services just like you just call, we would just verify it over the phone.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Oh, OK. All right, then I, I'll do that. I'll call them and say, hey, I have secondary insurance, and OK, I'll do that. And then my second question is regarding a claim that was placed. Um, it's the last claim that was placed with you guys. So what happened was I went to um a doctor's office and I needed to do um like a, a blood test.
[CUSTOMER][NEUTRAL] And that office selected a, a facility that was not under my insurance policy for whatever reason. I don't know why they did that. Um, I had no control of that situation and so I had to kind of like go back and forth with the office and my primary insurance and my primary insurance, what they ended up doing is they ended up matching.
[CUSTOMER][NEUTRAL] Um, the amount that uh would have been like normal if, if they covered the facility. So then they were able to, I guess, kind of cover it or, or cover it in the same cost.
[CUSTOMER][NEUTRAL] And so then when, when, uh, the claim was submitted to you guys, you responded back that because it wasn't covered, you guys weren't gonna cover that $250 but I'm wondering if you guys have a policy in place just like United Healthcare does where if something happens that's out of the patient's control on on what was selected for the facility, if you would still cover it, especially since the main insurance company did cover it.
[AGENT][NEUTRAL] Do you know which claim or date of service that was?
[CUSTOMER][NEUTRAL] I don't know the exact date.
[CUSTOMER][NEUTRAL] Uh, it was this year. I don't know if there's a chronological order on claims for, for this. Let me see, no, because I don't even have an app. Let me, let me see if I can get you more information. Hold on.
[AGENT][NEUTRAL] Because we don't have anything that was submitted in for this year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, you know what? That's right, we're in March. It had to be last year then.
[CUSTOMER][NEUTRAL] Oh no, we're in April. Time's going too fast. So yeah, it was last year then I'm sorry.
[AGENT][NEUTRAL] So I'm not seeing anything where we denied it.
[CUSTOMER][NEUTRAL] So,
[AGENT][NEGATIVE] That the primary didn't cover it.
[CUSTOMER][NEUTRAL] Yeah, I got a, a letter. OK, so maybe it's this one.
[CUSTOMER][NEGATIVE] So confusing.
[CUSTOMER][NEUTRAL] Let me see, I could, let me see if I could find the name.
[CUSTOMER][NEUTRAL] Of the facility.
[CUSTOMER][NEUTRAL] It starts with
[CUSTOMER][NEUTRAL] I can.
[CUSTOMER][NEUTRAL] It's like a testing facility.
[CUSTOMER][NEUTRAL] Yeah, it's like a $250 balance that I have.
[CUSTOMER][NEUTRAL] Let me see, I think it's this one.
[CUSTOMER][NEUTRAL] So this one says the date of service is [PII]. It might be this one.
[AGENT][NEUTRAL] For the emergency room?
[CUSTOMER][NEUTRAL] No, never mind, it's not. I'm sorry.
[CUSTOMER][NEGATIVE] No, no, no.
[CUSTOMER][POSITIVE] Oh my goodness.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Oh wait here.
[CUSTOMER][NEUTRAL] It's, it's a SpiA Labs.
[CUSTOMER][NEUTRAL] And date of service was [PII].
[CUSTOMER][NEUTRAL] Aspira.
[AGENT][NEUTRAL] OK, so we received that claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For Sear let me pull that one up.
[CUSTOMER][NEUTRAL] And here it says that it was approved by UnitedHealthcare on [PII], it says [PII].
[AGENT][NEUTRAL] I'm pulling the image up as well.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So when we excuse me, when we received the claim they did apply the full bill charge to your coinsurance. Now remind you at the beginning of the call I advise you that we pay up to $500 per calendar day. So for that claim we did pay the $500 for that claim.
[CUSTOMER][NEUTRAL] You're saying that you guys did pay $500?
[AGENT][NEUTRAL] Yes, we pay $500 on that claim.
[CUSTOMER][NEUTRAL] That's weird. The letter I, I mean that I, it was only 250, so that, that.
[CUSTOMER][NEGATIVE] That would have covered it, uh, that's weird because I got a letter saying that because it wasn't in network or something like that, you guys wouldn't cover it.
[CUSTOMER][NEUTRAL] And then it said that I still owe them 250.
[AGENT][NEUTRAL] We don't do anything in regards to in-network or out of network, that would be your primary insurance. We only pay off of your primary insurance.
[AGENT][NEUTRAL] We're just your supplemental or gap, so it's not an in or out of network for us, so you wouldn't receive anything saying in or out from us. So that could have been your primary insurance. So if your primary insurance is saying that you had a responsibility of less than that amount, then we will have to have that corrected EOB because on this EOB it's showing that your responsibility was $1,495 that was applied to your co-insurance.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, yeah, so that, that was like um I guess revised.
[CUSTOMER][NEUTRAL] Um, because the United Healthcare ended up like, you know, cover, like covering that, and then I was left with my primary responsibility of $250.
[AGENT][NEUTRAL] OK, so with that we will have to receive the corrected EOB and then that provider is gonna have to then send us that refund back that we made an overpayment because that is considered if it was 250, that's 250 overpaid to them.
[CUSTOMER][NEUTRAL] And then, and when you say them, you mean the doctor's office?
[AGENT][NEUTRAL] To api lab, yes.
[CUSTOMER][NEUTRAL] Mm, so I need, do I, so I need to call Spirit Labs.
[CUSTOMER][NEUTRAL] And tell him to give me the the document you're you're you're talking about the EEOB.
[AGENT][NEUTRAL] No, you would have to contact your primary insurance or you can go on to the website on your primary insurance website, and you should be able to pull up that data service. When you pull up that data of service, you should be able to download or upload your EOB.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For that day and it would tell you what your responsibility was for that date of service. If it's not the total bill charge and it's less than that, we will have to receive that EOB to even review it and then we will have to request a refund if it's a lesser amount.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I see. OK. All right, so let me, let me see if I could get that information and, and how do I submit that to you guys?
[AGENT][NEUTRAL] You can go on to our secured portal. Do you have access to that?
[CUSTOMER][NEUTRAL] I think I, I did open an uh an account online. I have to check, but yeah, I could go to the portal and and uh like upload it.
[AGENT][NEUTRAL] You can upload that EOB and we would just look at that data service to review it and we will go over it that way to see if that is the correct EOB and that there is a difference. If it's not then that amount that we paid out would have been correct, but we have to have that EOB showing a difference.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it. OK, alright, I'll, I'll, I'll try to find that information and then submit it to you guys so like that whole thing could just be covered.
[AGENT][NEUTRAL] Well, we, if, if it was only $250 we actually already paid it because we paid them $500 towards that bill.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] Yeah, cause they keep billing me that I owe, cause it seems like so UnitedHealthcare paid them, you know, the big chunk of money and they keep billing me saying that I owe 250. And um I, at that point, I gave api Labs this information, like, hey, I have APL, you know, contact them and they'll be able to cover that and then I end up getting that letter that said that I, I, I have to reread it now that you're mentioning how it works, so.
[CUSTOMER][NEUTRAL] Um, but pretty much they were saying that I still owed that 250, so I'm gonna get all that information, um, so you guys should take a look at it and make sure everything was, you know, to, to be corrected if it needs to be corrected, and, and so you see you could stop calling me about owing them money when they have it already. They have more it seems like.
[AGENT][NEUTRAL] Now if you wanna uh I can give you the check number as well and the claim number that it was paid to and if you wanted to contact the spirit you would have that information.
[AGENT][NEUTRAL] On that payment.
[CUSTOMER][POSITIVE] Yeah, that'd be great let me uh.
[AGENT][NEUTRAL] OK, are you ready for that information?
[CUSTOMER][NEUTRAL] Let me just get a moment to write something.
[CUSTOMER][NEUTRAL] Wait, wait, just give me a second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, I'm ready.
[AGENT][NEUTRAL] OK, so that claim was processed on.
[AGENT][NEUTRAL] 129 of 25.
[AGENT][NEUTRAL] The claim number, yes, of this year, we received it on 128th of this year and we processed it on [PII].
[CUSTOMER][NEUTRAL] Of this year?
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] And then the claim number is 355.
[AGENT][NEUTRAL] 75.
[AGENT][NEUTRAL] 25.
[CUSTOMER][NEUTRAL] And you supposedly paid them $500.
[AGENT][NEUTRAL] We paid $500 yes, and then the check number is 202.
[AGENT][NEUTRAL] 5060.
[CUSTOMER][NEUTRAL] So 2,025,060.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] And it actually actually cleared. It cleared on [PII] or 25.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] All right, I'm gonna get all the information and and see if this could be settled.
[AGENT][NEUTRAL] OK, and is there anything else that I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] Well, I do wanna thank you so much for calling American Public Life. You have a great rest of your day.
[CUSTOMER][POSITIVE] You too. Thank you so much.
[AGENT][POSITIVE] Thank you. Bye bye.