AccountId: 011433970860
ContactId: a0f61bb0-b37d-48f5-95e5-d3c5dd1ed566
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 2709120 ms
Total Talk Time (AGENT): 1175460 ms
Total Talk Time (CUSTOMER): 1086046 ms
Interruptions: 15
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/24/a0f61bb0-b37d-48f5-95e5-d3c5dd1ed566_20250124T18:27_UTC.wav
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[AGENT][NEUTRAL] Good afternoon thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi. Um, my name is [PII]. So I, I have, uh, United Healthcare as an insurance and APL as, as a gap insurance in my understanding. So, like two months ago, I, I had to go to emergency and uh they, I gave them APL information in regards to my co-payment, not in regards to the bill.
[CUSTOMER][NEUTRAL] Um, because the my copayment for the ER is 3, let me see, I think $350.
[CUSTOMER][NEUTRAL] Um, and I received now from American Public, uh, Life Insurance company something saying that.
[CUSTOMER][NEUTRAL] Basically, everything was paid for.
[CUSTOMER][NEUTRAL] Uh, but I did not, uh, I did not provide that information in regards to this, but in regards to the my copay of $350.
[AGENT][NEUTRAL] OK, so you are, you have a question. I'm sorry, [PII], what was your last name? I didn't understand your last name.
[CUSTOMER][NEUTRAL] Um, [PII]. Um, do you want me to give you the reference number? Maybe you can find the
[CUSTOMER][NEUTRAL] Explanation of benefits. I, I received a letter saying that, saying that I don't know from to.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] OK, so first off, uh, yes ma'am, let's, let's just stop right there for a moment because I can't, I can't see anything yet. So what is a good call back number for you first off?
[CUSTOMER][NEUTRAL] Mhm. [PII].
[AGENT][NEUTRAL] OK, thank you. And then what is your policy number?
[CUSTOMER][NEUTRAL] The policy number is
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I think this is the policy number maybe. uh 025576.
[CUSTOMER][NEUTRAL] I'm sorry, 7860 ML 8.
[AGENT][NEUTRAL] OK, thank you. So give me a moment to get your information pulled up. [PII] once I do, I will once I get everything pulled up, I will have to verify several pieces of information with you first for security and also any information that is provided today would be a verification of benefits and not a guarantee of payment. So give me just a moment please.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so first off, [PII], if you could please verify your
[AGENT][NEUTRAL] Date of birth for me.
[CUSTOMER][NEUTRAL] Yes. [PII].
[AGENT][NEUTRAL] Thank you and your home mailing address please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and the phone number that you gave me, is that your best contact number? The [PII], is that correct?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you and then the last thing is going to be your email address and I believe this is going to be your work email.
[CUSTOMER][NEUTRAL] Um, the work email address is [PII].
[AGENT][NEUTRAL] OK, yes ma'am alright thank you so much for verifying that information. Alright and you said that do you have a claim number or do you have the date of service?
[CUSTOMER][NEUTRAL] So, let me see. Um, I believe it's the claim, I have a claim number.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 355
[CUSTOMER][NEUTRAL] 1640.
[AGENT][NEUTRAL] OK, one moment please.
[AGENT][NEUTRAL] OK, so this was for HCA Florida Aventura Hospital for data service [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes, yes. Mhm.
[AGENT][NEUTRAL] OK, so we received a claim from the facility for this data service and the remark on your you did receive an explanation of benefits, is that correct from APL in the mail?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So your remark on your explanation of benefits states to please provide copies of your explanation of benefits from your primary insurance carrier. When the facility filed your claim, they did not include that.
[AGENT][NEUTRAL] And because this is a supplemental policy to your primary insurance, we will always have to have a copy of the primary insurance company's explanation of benefits when reviewing a claim on this plan.
[AGENT][NEUTRAL] Now have you ever set up your profile in our portal at APL, the online called the online service center?
[CUSTOMER][NEGATIVE] I don't believe so, no.
[AGENT][POSITIVE] OK, well I have a user guide that gives the instructions on how to set up your profile that I will be happy to send to you. I can email that to you.
[AGENT][NEUTRAL] And once you get your profile set up if you have that explanation of benefits you can upload it into your portal for us.
[AGENT][NEUTRAL] Now the provider for the facility also received it should have received an explanation of benefits like you did with that same information on there.
[CUSTOMER][NEUTRAL] Um, and where can I find that explanation of benefits in my, in my insurance?
[AGENT][NEUTRAL] Well you would have to contact your primary insurance. Yes, ma'am, who, yes, your primary insurance carrier and get an get the explanation of benefits for that data service.
[CUSTOMER][NEUTRAL] In my unit itself
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] Um, so this is not something that the hospital will include, or they, they are like this is the first time I'm trying to use this.
[AGENT][NEUTRAL] Yes ma'am, so normally when they whoever files the claim, whether that had been you initially or the hospital, we always have to have the primary insurance company's explanation of benefits as well and they did not include that in what they submitted to us they just sent us the claim.
[CUSTOMER][NEUTRAL] OK. And is, is the, the co-pay of, of um ER something that you would cover if I send you that, that explanation of benefits from my insurance?
[AGENT][NEUTRAL] Let me look. So on your policy.
[AGENT][NEUTRAL] You have an outpatient benefit maximum per calendar day benefit of $500 and there is no deductible for an emergency room visit per occurrence.
[AGENT][NEUTRAL] So yes ma'am, that is something that we can review.
[AGENT][NEUTRAL] We just need to get that primary insurance explanation of benefits sent to us so that we can further review the information we received.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK. Because for that, that particular day, that's uh that's the only bills that I have of 350, and I, it's, it's a lot of money and um you know, when I
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Sure. Yes, ma'am. I understand.
[CUSTOMER][NEUTRAL] Were given the, the, um, uh, that insurance, APL like a secondary insurance. I, I've been told from my, from our provider that, that's something that they would, like you would cover. But I, you know, I, as I said, I'm using it for the first time and I don't know, you know, I gave it to the hospital and they said they sent it to you and I have no idea.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] About anything else.
[AGENT][NEUTRAL] They did, sure they did send us the claim. They just did not include all of the documentation that we need.
[CUSTOMER][NEUTRAL] Mhm mhm. And so this is something now.
[AGENT][NEUTRAL] So whether that is you providing it or you or the facility provides it, it doesn't matter once we receive it, then we will continue, you know, to process this claim. You also have another claim that you will see when you set up your um online service center portal.
[AGENT][NEUTRAL] Either it shows the same thing for another data service we received.
[AGENT][NEUTRAL] We, we also have a claim on file for you for 11/18.
[AGENT][NEUTRAL] 2024 and the same thing we need to receive the primary insurance explanation of benefits. We did not receive that with that claim.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That was for Vital MD Group Holdings.
[CUSTOMER][NEUTRAL] And is that from
[CUSTOMER][NEUTRAL] Um, is that, let me see. Um,
[CUSTOMER][NEUTRAL] OK. Let me see. And so, do, my question is, do I send you this explanation of benefits or they have to send it to you?
[AGENT][NEUTRAL] You can send it if you have it you can send it to us.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I don't, I don't have it, but maybe I can get it from someone, like,
[AGENT][NEUTRAL] You would get it from your primary insurance company.
[CUSTOMER][NEUTRAL] OK. So I have to call United Healthcare.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And, and tell them that I need explanation of benefits for those two claims.
[AGENT][POSITIVE] That is correct, yes ma'am.
[CUSTOMER][NEUTRAL] And then they, and then they're gonna send it to me and then I have to send it to you.
[AGENT][POSITIVE] That is correct. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And why they did not include the explanation of benefits when they send you those claims?
[AGENT][NEUTRAL] Now that I, I cannot answer for you, um, if I, I wish I could, but you would have to reach out to the facility. You may wanna contact the provider.
[AGENT][NEUTRAL] The two providers to see if they will since they file the claim if they will submit the primary insurance explanation of benefits but.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] anyone, anyone that has it can send it to us.
[CUSTOMER][NEUTRAL] OK. So, the, the United Healthcare, for sure, they have it.
[AGENT][NEUTRAL] Well, they've received your claim. I'm assuming. I can't speak for them. We don't have access to any other insurance companies, portals or information.
[AGENT][NEUTRAL] So you, I would, I would probably, if I were you, verify.
[AGENT][NEUTRAL] That the providers filed your primary insurance and did not for some reason think that this was your primary insurance.
[CUSTOMER][NEUTRAL] Um, I'm not sure that.
[AGENT][NEUTRAL] I'll probably there.
[CUSTOMER][NEUTRAL] I am not sure that I understand that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] We're, we're secondary to your primary healthcare insurance.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] I know that, yes, I, I know that. Uh, I just, I just.
[AGENT][NEUTRAL] So there's all, so.
[AGENT][NEUTRAL] So you can contact.
[CUSTOMER][NEUTRAL] I just want to know
[CUSTOMER][NEUTRAL] What's the best, what's the best, like, the best way for me to, because I know that, like, I called, I called uh Aventura Hospital, the HCA uh Aventura Hospital. I called them and like, and they, they confirmed with, with me that they send you, you know, they send you what they have to send you.
[CUSTOMER][NEUTRAL] And so now, I did not know that they did not.
[CUSTOMER][NEUTRAL] Submit the explanation of benefits. And I did not know that they have to, you know what I mean? I assume that they will send you what is needed to be sent. You know what I mean?
[AGENT][NEUTRAL] Sure. Right. And I think I would make sure that they filed both of your insurances. Now, you can contact your primary healthcare insurance.
[AGENT][NEUTRAL] Or log into their portal if you have a profile set up in your primary insurances.
[CUSTOMER][NEUTRAL] I do, I do have a profile with them.
[AGENT][NEUTRAL] OK, and search for those dates. OK, and search for those dates of service to see if you can locate the explanation of benefits.
[CUSTOMER][NEUTRAL] OK, um, let me see.
[AGENT][NEUTRAL] And then you can send that to us. Mhm.
[CUSTOMER][NEUTRAL] OK. OK, let me see. So, all right. I'm looking at that particular claim right now. Um,
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] OK, I see PDF with explanation of benefits.
[CUSTOMER][NEUTRAL] Uh yes, I see that. I see that document.
[AGENT][NEUTRAL] You do see that. OK. So again, you have for the for those.
[CUSTOMER][NEUTRAL] Yes, it's a it's a PDF and it says, it says on top explanation of benefits.
[AGENT][NEUTRAL] OK. So again,
[CUSTOMER][NEUTRAL] For that particular bill?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. Yes.
[AGENT][NEUTRAL] For, for [PII], we show that that emergency room bill was $35,278.
[CUSTOMER][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And then on your other claim for the day before that, for the vital MD Holdings.
[AGENT][NEUTRAL] That claim
[CUSTOMER][NEUTRAL] And you
[AGENT][NEUTRAL] That was for [PII], and we showed that that bill amount was $427.
[CUSTOMER][NEUTRAL] Puddings
[CUSTOMER][NEUTRAL] Um, MD Holdings. I don't have any, any MD Holdings here. I don't see that.
[AGENT][NEUTRAL] So you may want to reach out to them to make sure that they had indeed filed it with both of your insurance companies. They may have only filed it with APL.
[CUSTOMER][NEUTRAL] Um, for the [PII], I have, uh, from [PII].
[CUSTOMER][NEUTRAL] But it says, it says that that claim is under review.
[AGENT][NEUTRAL] We
[AGENT][NEUTRAL] Oh, OK. So it sounds like they're still processing that one possibly.
[CUSTOMER][NEUTRAL] I don't know. It just says it's under review and when I click on that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Actually, it's not opening it. But it says date of service, uh [PII]. And then total amount billed uh for uh $1,402.
[AGENT][NEUTRAL] OK, so we don't have a claim on file for that bill amount so that may be something different that hasn't even been filed with us yet.
[CUSTOMER][NEUTRAL] OK. Yeah, because that one is on the review, uh, the one, that one is from [PII].
[AGENT][NEUTRAL] Mhm. And the one that we.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEGATIVE] And I don't have anything for looking in the, in the insurance here, I don't have anything for
[CUSTOMER][NEUTRAL] You said $400?
[AGENT][NEUTRAL] This is $427. Yes, ma'am. Uh-huh.
[CUSTOMER][NEUTRAL] Oh, I see, I see [PII].
[AGENT][NEUTRAL] Let me
[CUSTOMER][NEUTRAL] Um, it says maybe this one?
[CUSTOMER][NEUTRAL] It says, um, yes, I know what that is. This is um during the same visit.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The total amount bill 427 plan discount, 257 plan paid.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 86. 11 and total amount owed by me is $8612.
[AGENT][NEUTRAL] OK, so we received the claim.
[AGENT][NEUTRAL] From, yes, from this is for Doctor [PII]. Mhm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh, we just did not receive the that explanation of benefits.
[AGENT][NEUTRAL] See, because this policy.
[CUSTOMER][MIXED] OK, but it says that I owe only, it says um that I owe only 86212 and that 4 2454 were paid one discount.
[CUSTOMER][NEUTRAL] And 18
[CUSTOMER][NEUTRAL] 8611. Let me see. Um, that one has also an explanation of benefits.
[AGENT][POSITIVE] Yes, ma'am, cause see this pop.
[CUSTOMER][NEUTRAL] I have another PDF as well.
[AGENT][NEUTRAL] OK. So on there, yes, ma'am.
[AGENT][NEUTRAL] Because this policy helps you with your co-pays, deductibles, and co-insurance amounts of coverage services. That's why we have to see the primary insurance company's explanation of benefits that shows those categories.
[AGENT][NEUTRAL] When we review claims.
[CUSTOMER][NEUTRAL] OK, so I need to send you those too.
[AGENT][NEUTRAL] Yes, ma'am. Uh-huh. And then the other claim that you said was still, the other claim that you indicated they were still under review with at your primary insurance. We haven't received a claim at all yet for that.
[CUSTOMER][POSITIVE] OK, perfect. I have it as a PDF.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um, yeah, I don't think, I don't think they, it doesn't, it doesn't say that it's processed yet. It says, it says only.
[CUSTOMER][NEUTRAL] It says only uh that um.
[CUSTOMER][NEUTRAL] It's under review.
[AGENT][NEUTRAL] OK, so once.
[CUSTOMER][POSITIVE] So, once, once, once it's processed, I'm gonna give you a call back.
[AGENT][NEUTRAL] That'll be fine, yes ma'am because um if you end up having to file your own claim, you most definitely can do that and we can get you the claim form. I didn't send that to you in the email that I sent with the user guide, um.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Since they had already filed these claims, but if you do have to file your own, yes ma'am, you absolutely call us back and we'll give you all the information you need.
[CUSTOMER][NEUTRAL] OK. I'm gonna, I think I'm gonna wait for them because the, I know that for sure that doctor works with United Healthcare.
[CUSTOMER][NEGATIVE] And um maybe it will not, I will not even be, you know.
[CUSTOMER][NEUTRAL] Needing to like, you know,
[CUSTOMER][NEUTRAL] Call you about, you know? I, I have no idea. I have no idea. Uh, you know, you, you're never, the thing is that I never, you never know until the bill comes, so.
[AGENT][NEUTRAL] I thought, well, it, well.
[AGENT][NEUTRAL] Sure. Yeah, I, yes, ma'am. I mean, I, I totally understand. I go to the doctor and, you know, and I, I have
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes, because, because this [PII] is, this [PII] is like apparently.
[AGENT][NEUTRAL] I have stuff too, so.
[CUSTOMER][NEUTRAL] You know, somebody who did some, some type of a test when I was there. So, and I don't know. So, um I'm gonna send you those explanation of benefits for both of them. And you said the, the easiest ways, how, how is, what is the easiest way to, to like, how to, how to send it to you? Should I send you like, should
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] The easiest way.
[AGENT][NEUTRAL] Oh, I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Should I send you an email with those two PDFs or I should create, create a portal?
[AGENT][NEUTRAL] No, ma'am. No, ma'am.
[AGENT][NEUTRAL] Uh, you need to create your portal and upload it from your computer into the portal because we cannot accept claims via email. They can be faxed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mailed or the quickest way to get them to us is by uploading them into the portal. But yes, ma'am, due to security, we do, we cannot accept email.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. OK. But you said those, but you said those two claims is, they are something that you can, that you can work with.
[AGENT][NEUTRAL] For claims.
[AGENT][NEUTRAL] We, we need the primary, we need your primary healthcare.
[AGENT][NEUTRAL] Explanation of benefits so we can further review what we have received.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] OK, let's, uh, I'm um I'm gonna create a portal then.
[AGENT][NEUTRAL] OK, and that email you should have that by now and it um is the email is from care team [PII] and I did put APL in your subject line for you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, I received it.
[AGENT][POSITIVE] OK, good.
[CUSTOMER][NEUTRAL] I received it, so.
[CUSTOMER][NEUTRAL] This is, this is the explanation how I should uh.
[CUSTOMER][NEUTRAL] Create the portal.
[AGENT][POSITIVE] It explains created and also how to use it as far as uploading your documents, it gives you those steps as well, yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so can I do that on the phone or uh like an app, or I should create it on the computer?
[AGENT][NEUTRAL] Uh, you will need to set up your profile on from a computer because you have to, you cannot upload documents from a phone. It has to be done from a computer.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] No, no, I, I, I understand. I'm gonna, I'm gonna do, but is it like uh I'm gonna upload the documents via via computer, but is, is, is that like an app that I can easily access also through through my phone or not?
[AGENT][NEUTRAL] No, ma'am, there is not an app for it. You can just, you know, book, correct, yes, ma'am.
[CUSTOMER][NEGATIVE] Oh, there is not an app for it. I have to, I have to create it. Yeah, I'm sorry because I'm looking at, I'm looking at the, at the phone now and I, I, it's so small I can't even see.
[AGENT][NEGATIVE] Right. No.
[AGENT][NEUTRAL] Oh goodness, that sounds like me. I can't hardly see my phone either.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Yeah, unfortunately.
[CUSTOMER][NEUTRAL] OK, so right, I'm gonna, OK, I'm gonna create uh an account.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I'm gonna upload, I'm gonna upload for those two documents and let's see um when they process the other one. OK. All right. Yeah, because as I said, I've never used it before and when I received that letter, I am not really understanding what does it mean, you know?
[AGENT][NEUTRAL] Sure. Now, ma'am, you, you always call if you have any questions and do always present both of your cards, your APL card and your primary insurance card anytime you go for medical services because that way most providers will file everything for you and they'll call to verify that your policy is active and to see if the type of service, you know, to get your benefit information as far as the type of service.
[CUSTOMER][NEUTRAL] So mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Um, to see if that's covered under the supplemental policy, so.
[CUSTOMER][NEUTRAL] And, and
[CUSTOMER][NEUTRAL] Mhm mhm. And also, like I, I did my mammogram and ultrasound yesterday, and they said that it's gonna be like a small copay and uh they did, uh, they, they said that they, they do work with you. They, they took your information. So, I don't know about how that's gonna be. I, I guess, you know.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Yes ma'am, we'll just need to receive the claim and have it reviewed now I can tell you that on your policy, um, either office visits themselves are not covered under the supplemental policy, the office visit charge portion, OK, but we can.
[CUSTOMER][NEUTRAL] Go please visit the portion of the co-pay.
[AGENT][NEUTRAL] Correct. It's not covered. But we can review treatment that's rendered in the office.
[CUSTOMER][NEUTRAL] OK, got it. Like
[CUSTOMER][NEUTRAL] Like, for example, for example, when I go to my primary or when I go to a specialist, when there is like $60 or $30 copay, you, you cannot cover that.
[AGENT][NEUTRAL] That would not be covered under here. That is correct.
[CUSTOMER][NEUTRAL] Got it, got it. Got it. But, but my co-pay in, in the ER, is that something else, or?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] that all falls under your outpatient benefit maximum. Any covered outpatient service, you have, if your maximum benefit is $500 per calendar day.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Got it. Got it. So, just the ER uh it goes under a different, a different category.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, ma'am. The only thing that is different about, so, for example, if you go to a doctor's, say you go and have an X-ray, OK, that is something that we could review, right? Like if you schedule that at a diagnostic facility, OK? And you went and had an X-ray. That is something we could review under that outpatient benefit and there would not be
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] There's not also not a deductible, but that is per calendar day. An emergency room visit does not have a a deductible and that's per occurrence.
[AGENT][NEUTRAL] But it all falls under your $500 per calendar day max benefit. Does that make sense?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] So, but
[AGENT][NEUTRAL] So if you went, if you went and had an MRI if, if you went to, say, an emergency room.
[AGENT][NEUTRAL] A doctor's appointment and
[AGENT][NEUTRAL] Uh, I don't know. I had some other testing done all on the same day.
[AGENT][NEUTRAL] Outpatient, OK? The maximum benefit that this plan would pay if approved would be $500.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, yes, I, that I understand. Yes, that.
[AGENT][NEUTRAL] For that date. So if you went, say if you had to go to have an MRI today.
[AGENT][NEUTRAL] And then tomorrow you had to go have a CT scan. Again, the maximum that we would pay for an approved benefit for today would be 500, the same thing tomorrow.
[CUSTOMER][POSITIVE] Got it, got it.
[AGENT][NEUTRAL] It would be a, does that make sense a little better?
[CUSTOMER][NEUTRAL] Mhm. 100, 100%, yes. It's just because, you know, how you said that the office visit and the specialist visit is something that you don't cover. And I remember that when Mhm. So I was wondering because, like I, like I've never went to ER before, right? That was the first time I ever went to ER. So those, you know, 350, that is like a, it, I think they're co-pay, right?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, and I, mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] On your primary insurance? See, I don't, I don't know what their copay, I mean, I don't have that information for your primary.
[CUSTOMER][NEUTRAL] Yes, yeah.
[CUSTOMER][NEUTRAL] Yeah, it's 350. So, but it's still a co-pay, you know?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm. So again, if approved, your maximum benefits, you know, could help you up to $500 per calendar day on this plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So, mm, because everything, mhm, no matter that is a, no matter that it's a co-pay.
[AGENT][NEUTRAL] Now,
[AGENT][NEUTRAL] Mhm. No, ma'am, go ahead.
[CUSTOMER][NEUTRAL] For the emerg.
[AGENT][NEUTRAL] That is something we would review to try and help you with.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you so much. I appreciate it because this is like the biggest deal, you know, and 350 just like so much, but I really needed to go to emergency that day. And
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Uh, I
[AGENT][POSITIVE] Yes, ma'am. Well, hopefully, you will not have to go back.
[CUSTOMER][NEUTRAL] Yeah, I hope it's something that
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Anytime soon, but when you set up your portal as well, um, I, you cannot see a copy, there is a copy of your policy certificate in the portal.
[AGENT][NEUTRAL] And it lists out the different areas that are.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Under your schedule of benefits, it gives you a description of the benefits that this plan covers and then the benefit amounts and the limitations.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] So you can look at that.
[CUSTOMER][NEUTRAL] Got it. No, but you, you were, you were pretty clear about those $500. I, I, I, I understand that 100%. And I also understand, you know, that you do not cover the, the diseases to the, to the office, um, or like either the primary or the specialist. My, I think the only, I think the only um
[AGENT][NEUTRAL] Mhm. OK.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] The only thing that I
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] I wonder and maybe because, you know, I, maybe the only thing that I don't understand, and because it's my biggest bill so far are the, those $350 that I have as a, as a co-pay, co-pay of, you know, of going to the emergency. But I guess, you know, after you review that, you're gonna let me know for sure.
[AGENT][NEUTRAL] Mhm
[AGENT][POSITIVE] Yes, ma'am. And you can.
[CUSTOMER][NEUTRAL] Because they
[CUSTOMER][NEUTRAL] Mhm. They are under the $500 but at the same time, they're listed as a co-pay, you know.
[AGENT][NEUTRAL] We just need that.
[AGENT][NEUTRAL] Right. So that's again, that's why we have to have that explanation of benefits. We can further review this claim. Now, you can opt you, when you're setting up your portal, a couple of other things, you can opt in for text notification alerts. When we have processed a claim, you should receive a text message letting you know that.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] Um, you can also add in direct deposit information so that if we we were paying benefits to you instead of say to the provider, then we could direct deposit those to you into your account instead of us having to mail you a paper check, but that is entirely up to you whether you would, you know, want to do that or not.
[CUSTOMER][NEUTRAL] Mhm mhm.
[AGENT][NEUTRAL] And that's something that you can
[CUSTOMER][NEUTRAL] Um, I do prefer, I do prefer if, if, you know, if benefits are paid from you to go directly to the provider.
[AGENT][NEUTRAL] OK. And most, and when they are providing, when they are filing the claim, then that's typically, it's typically whoever is filing. Yeah, I mean, you know, that we would pay the benefits too. So if now, mhm. But it's
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 2.
[CUSTOMER][NEUTRAL] Oh, so
[CUSTOMER][NEUTRAL] If they're filing, you send it to them.
[AGENT][NEUTRAL] Yes, ma'am, but if you provide us have them and they would go to you.
[CUSTOMER][NEUTRAL] If I'm finding
[CUSTOMER][NEUTRAL] OK. But the way that, for example, they provided to you now, um, and I will provide you, provide you the explanation of benefits. Are, are you gonna pay to them or?
[CUSTOMER][NEUTRAL] Because they, they, they, they.
[AGENT][NEUTRAL] Uh, it will probably be paid to you, but let, give, do you mind letting me put you on a hold for just a moment?
[CUSTOMER][POSITIVE] Yes, yes, of course. No problem.
[AGENT][POSITIVE] OK, perfect. OK, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh,
[AGENT][NEGATIVE] God damn it.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] Ridiculous.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh gosh.
[AGENT][NEUTRAL] She's had me on 30 minutes.
[AGENT][NEUTRAL] You know what, we'll see how long it takes somebody to answer this.
[AGENT][NEGATIVE] Fuck that. There are no.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Good morning.
[AGENT][NEUTRAL] It ain't that long.
[AGENT][NEGATIVE] You know what, not doing this.
[AGENT][POSITIVE] Nice.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Referring.
[CUSTOMER][NEUTRAL] For calling APL, my name is [PII]. How may I assist you today?
[AGENT][NEUTRAL] Hey, [PII], it's [PII]. Look, I'm not transferring a call, but I just have a, I've had a brain cramp. If a provider files a claim but didn't include the primary EOB and now the insured sends it in, would benefits if payable be go to the provider or to the insured?
[CUSTOMER][NEUTRAL] If we catch it, we are supposed to pay it to the provider and then deny the claim and tell the insured, hey, we pay the provider.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, OK, let me, I don't know, maybe I didn't say that right. So the primary insurance company, I mean, no, the provider files the claim with APL.
[AGENT][NEGATIVE] But only sent the claim and not the primary insurance EOB.
[CUSTOMER][NEGATIVE] Right, and then we denied the claim and asked for the EOB. But then in the meantime, the insured sent it in.
[AGENT][NEUTRAL] And the insured
[AGENT][NEUTRAL] Uh-huh, and the insured sent in.
[AGENT][NEUTRAL] The insured sends it.
[CUSTOMER][NEUTRAL] We're supposed to catch it if we catch it, cause I've gotten dinged on this a few times to where I just paid the, you know, I didn't see that the provider filed first and we asked for the EOB. I just paid the insurer, but if that's why I said if we catch it, so if we catch it, we're gonna pay the provider and then deny the claim and let the insured know, hey, we, we gave the money to the provider.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so I'll just tell her that typically it should go to the provider, which I've already done, but then I was like, I'm not sure.
[AGENT][NEGATIVE] I was like, I don't know, I, I mean, I just froze.
[CUSTOMER][NEUTRAL] Yeah, it, it's just uh it it's, it's a, it's something that the, the processor has to catch.
[AGENT][NEUTRAL] OK, but it, it, it should, uh, so that's what I'd already to send it.
[CUSTOMER][NEUTRAL] But that's the rule. That's the rule, but sometimes we don't catch it and then we pay the insured. So, but the rule is, yes, if we get an EOB and, and they file first, they, they have priority to get that money.
[AGENT][NEUTRAL] Right, right.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, you are the mom. Thank you so much.
[CUSTOMER][POSITIVE] All right thank you you have a good day.
[AGENT][NEUTRAL] OK, alright, you too, bye.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you so much, [PII], for holding for me. Did I, I hope you didn't think I forgot about you. I was just trying to get a clear answer. I was looking at a few things. So,
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] The way it should typically work is that because the provider filed that yes ma'am, regardless if you send it to us or they send it to us then yes we should.
[AGENT][NEUTRAL] Pay to the provider. Now there are times that, you know, it might would end up getting issued to you.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[AGENT][NEUTRAL] But technically, yes, ma'am, it should go to them since they had had initially sent it in and I was just trying to get clarification on that, you know, um.
[CUSTOMER][POSITIVE] Got it. Got it.
[CUSTOMER][POSITIVE] Got it, got it. Got it.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] So there is a possibility that it could come to you, but it should go to them.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][POSITIVE] Um, perfect. Thank you so much. And also,
[AGENT][POSITIVE] Well, you are very welcome.
[CUSTOMER][NEUTRAL] Also, um, I, I was looking now at the explanation of benefits. And actually for both, for a Ventura Hospital, AC, yes, with the, uh, mhm, yes.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh-huh. We need the primary insurance explanation for both of them. That's what I was explaining to you.
[CUSTOMER][NEUTRAL] Uh yes. Actually, it's, it's, it's one document for both of them.
[CUSTOMER][NEUTRAL] Or should I send you?
[CUSTOMER][NEUTRAL] Both, just in case.
[CUSTOMER][NEUTRAL] I mean, it's, they look exactly the same, I guess because the period, the period of, of, of explanation of benefits is like from that period to that period.
[AGENT][NEUTRAL] If it
[AGENT][NEUTRAL] Well, one.
[AGENT][NEUTRAL] OK, as long as long as it has the information for both of those dates of service and both of those providers and your co-pay, co-insurance or deductible amounts, if that's all included.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You can just submit the one thing, but you need to make sure that it has for both.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The one.
[AGENT][NEUTRAL] Those are 2 separate claims for 2 separate providers and 2 separate dates of service.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm. Um, the thing is that I, I, I'm looking at it right now and it says explanation of benefits, da da da da da da. And it's as of, and underneath, it says um plan balances as of [PII].
[CUSTOMER][NEUTRAL] [PII]. I'm sorry, [PII].
[CUSTOMER][NEUTRAL] And then it has all of, you know, all of the claims, I guess.
[CUSTOMER][NEUTRAL] But I'm gonna send you both. I'm gonna send you both documents because it's, I mean, they, they look exactly the same, but it doesn't matter, you know.
[CUSTOMER][NEUTRAL] Let's do both.
[AGENT][NEUTRAL] OK, so you can, yes ma'am, and we'll just review it's very hard for, I mean we can't pay claims over the phone and until we actually get those documents, I, I can't.
[CUSTOMER][NEUTRAL] I just wanna be, you know, yeah.
[AGENT][NEUTRAL] say specifically, you know, that that is or isn't what we need. Um, it sounds like it is, but if it is not, the, I mean, it will get reviewed and then we would.
[AGENT][NEUTRAL] Issue another remark stating that, you know.
[CUSTOMER][NEUTRAL] Mhm mhm. But if it says, if it says explanation of benefits on top of the, on top of the document, it should be this one, right?
[AGENT][NEUTRAL] Not these, you know what.
[AGENT][NEUTRAL] It should be, but it depends on how different insurance companies do it different ways. You just need to make sure that on that explanation of benefits, whatever that document is, it has.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Both of those providers.
[CUSTOMER][NEUTRAL] Yes, it has both of those providers.
[AGENT][NEUTRAL] And their dates of services and shows what was applied to the, either your co-pay, deductible, or co-insurance amount for both of those dates of service.
[CUSTOMER][NEUTRAL] Yeah, the thing is that everything is listed underneath.
[CUSTOMER][NEUTRAL] The thing is that everything is listed underneath, you know, because I'm looking at the one for now. I open, I opened both of them, but they look exactly the same. So it says explanation of benefits and then provider and then, you know, the plan balances network out of network, and then when you go down, it says definition of key terms and then details.
[CUSTOMER][NEUTRAL] Um, claim detail for Eva, right? And then, and then underneath all the providers that I have, that I have been to since I have the, the insurance.
[CUSTOMER][NEUTRAL] It, it's like, all, all of them is there.
[CUSTOMER][NEUTRAL] All of them. All of every single doctor that I've, that I've seen.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] And charge me anything is there. But also both of those providers that I am um looking for, you know, co-payment are also there.
[AGENT][NEUTRAL] OK, so if you want to just highlight the claims that we're reviewing.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] You know, like [PII], uh-huh, so that they'll, our adjusters will know which claim, you know, which provider they're reviewing.
[CUSTOMER][NEUTRAL] Uh-huh, highlight them.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, OK, yeah.
[CUSTOMER][NEUTRAL] OK. The, the, there is a charge for only those two. So I'm gonna, I'm gonna see how I can highlight them before I send it to you, yeah. But it's exactly [PII], it's one of them.
[CUSTOMER][NEUTRAL] And then, and then the uh HCA uh Aventor Hospital is the other one.
[CUSTOMER][NEUTRAL] I'm gonna see how to um
[CUSTOMER][NEUTRAL] I'm gonna see how to
[CUSTOMER][NEUTRAL] Highlighted.
[CUSTOMER][POSITIVE] And I hope, you know, I'm, I'm trying to, like, ask everything now, so I don't have to go, you know, again and again, and, you know what I mean?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] But, yes. OK. OK. I'm gonna, I'm gonna send it as a, as a PDF, right? To, to, to the, in, in the I'm gonna upload it as a PDF in the portal and I'm gonna highlight those two.
[AGENT][NEUTRAL] OK, yes ma'am and just once, once it has been reviewed and if you've opted in for text notification alerts, you should receive a text uh once that review has been complete.
[CUSTOMER][POSITIVE] Perfect, perfect. Thank you so much. I appreciate it. Thank you.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Well, you are very welcome. Yes, ma'am. And can I help you with anything else at the moment?
[CUSTOMER][POSITIVE] No, that's that's gonna be all for today. Thank you. Have a good day.
[AGENT][POSITIVE] OK. Yes, ma'am, you too, and thank you again for calling APL.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.
[AGENT][NEUTRAL] Uh-huh, bye-bye.