AccountId: 011433970860
ContactId: aefd088c-9019-4ab5-8ad8-3019b9fd80b8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 479720 ms
Total Talk Time (AGENT): 275243 ms
Total Talk Time (CUSTOMER): 182035 ms
Interruptions: 6
Overall Sentiment: AGENT=0.3, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/02/aefd088c-9019-4ab5-8ad8-3019b9fd80b8_20250402T21:05_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How may I help you today?
[CUSTOMER][NEUTRAL] Hi, my name is [PII], and my wife and I have a gap plan with APL and I'm trying to see what is covered because uh she fell and broke her wrist, went to the emergency room, went to an orthopedic uh doctor, had cast put on and had to have uh.
[AGENT][NEUTRAL] Yes, sir.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Physical therapy on her wrist afterwards and you guys have denied all the claims and I'm just wondering if if you pay anything.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, go ahead and give me your policy number please sir Mr. [PII].
[CUSTOMER][NEUTRAL] Yes, uh, do you have yours, [PII]?
[CUSTOMER][NEUTRAL] Your policy number?
[CUSTOMER][NEUTRAL] I, I've got a policy number here, um, it is 02563037.
[AGENT][NEUTRAL] Alrighty, and you did say your name is [PII], is that correct?
[CUSTOMER][NEUTRAL] Yes, my wife's name is [PII]. She's who broke her wrist.
[AGENT][NEUTRAL] Alrighty, uh, I do see her as being covered, um, insured, but due to the HIPAA, Mr. [PII], I have to speak with her and she has to give me permission to speak with you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, she's right here hold on. Hi there, this is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, [PII]. Yes, ma'am. OK, go ahead and verify your date of birth, your address, please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Alright and do you give me permission to speak to [PII] on your policy?
[CUSTOMER][POSITIVE] Yes, I do.
[AGENT][NEUTRAL] OK, and this is a one-time deal just for today?
[AGENT][POSITIVE] Alrighty, thank you for all that information and go ahead and give me a return telephone call just in case we get disconnected, please.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you so much, [PII], for all that information. OK, his question was, uh, we're denying physical therapy claims and wants to know what's covered. So let me get over here. Let's see what's going on. I see a couple of claims in-house, so let's see.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, I do see, I do see two claims that we were that we're denying. Um, looks like they are for occupational therapy, which is not a covered benefit under this, uh, medical supplemental plan here at all. But let me go over to your benefits and let me see. You asked what was covered, so let me pull that up.
[CUSTOMER][NEUTRAL] OK, so
[AGENT][NEUTRAL] OK, and of course what we are is just your medical supplemental plan. So the only thing that we would pick up and pay on is anything that is applied towards patients deductible, co-pay, or co-insurance as your primary insurance carrier for sickness and injury.
[AGENT][NEUTRAL] As long as this is a covered benefit here at APU. OK, so looks like the benefit that you have here, of course, is your inpatient max benefit of $2500 per calendar year.
[AGENT][NEUTRAL] You have an outpatient benefit max of $2000 per calendar year with no deductible.
[AGENT][NEGATIVE] But what you do not have is any type of office visit coverage or anything done in the office is not covered here.
[CUSTOMER][NEUTRAL] OK, so.
[AGENT][NEUTRAL] Yeah, looks like that's what was the other two claims denied.
[CUSTOMER][NEUTRAL] If she would with the X-ray when she went into the emergency room with the X-rays not be covered?
[AGENT][NEUTRAL] Uh, if they bill it as the ER, yes, it should be that should be covered. I don't have an ER bill though at all.
[CUSTOMER][NEUTRAL] At the
[CUSTOMER][NEUTRAL] OK, well then they must not have sent that in.
[AGENT][NEUTRAL] All I have is an office visit, yeah, possibility that we don't have that bill yet because all I have, um, of course, is your two occupational therapy bills, which is not a covered benefit here. And then, uh, looks like [PII] you wouldn't have an office visit and the X-ray done in the office, which is not covered.
[CUSTOMER][NEUTRAL] OK, um, now let me ask you another.
[AGENT][NEUTRAL] Yeah, but it sounds like maybe we don't have that ER bill. Mhm.
[CUSTOMER][NEUTRAL] Yeah, and let me ask you another one, I detached my retina.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] And now we, I don't know if any of those, I haven't gotten anything back from you on those, but uh I had to have surgery on my eye.
[AGENT][NEUTRAL] Are you covered here?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, well, what's your policy number?
[CUSTOMER][NEUTRAL] Uh, my policy number is.
[CUSTOMER][NEUTRAL] Uh, let's see here.
[CUSTOMER][NEUTRAL] 02563039
[AGENT][NEUTRAL] Alright, let me get you pulled up, [PII], let's just see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, verify your date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And is your address?
[CUSTOMER][NEUTRAL] It's the same [PII], which I don't know if you still have the old address on there [PII].
[AGENT][NEUTRAL] Let's just double check it. Let's see.
[CUSTOMER][NEUTRAL] That's where this came to. That's why it took so long for us to get.
[AGENT][NEUTRAL] What is the correct address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, that is what we have. I thought that's what you said, yeah, that is what we have correct, yes. OK, let me go to your file then and let's just see. OK, now what particular data service I see I see several things sent in on you.
[CUSTOMER][POSITIVE] OK, good.
[CUSTOMER][NEUTRAL] Yeah they're all dealing with.
[CUSTOMER][NEUTRAL] That's all dealing with the same surgeries.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Yeah, cause it looks like, well, the only one that I have this year, of course, is looks like a like an office visit, and that's not covered or anything done in the office and that was denied. Then we had some Jane I mean December and November as well that was denied.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Then you had uh maybe it looks like an eye surgery, [PII]. Now, that was paid.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, where did that pay them to the office then to the people that build it, OK.
[AGENT][POSITIVE] Yes, to the, yes, yes, sir.
[CUSTOMER][NEUTRAL] OK, now I got another question for you. As a result of that surgery, my eyesight in that eye is not good, and they said the surgery caused a uh cataract which they have to go in and fix now. Is that?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Would the outpatient surgery for that be covered?
[AGENT][NEUTRAL] As long as it's done outpatient and it's covered under your primary insurance, of course we're just your medical supplemental plan, yeah, so it has to apply towards your deductible copay or co-insurance at your primary, yes, as long as it's done outpatient though, yes sir, right, that is what the benefit that you have here, yes sir.
[CUSTOMER][NEUTRAL] Yep, OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right, which you will.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, alright, well that answers my question. Now at least we know what what is covered. I'll make sure they get that sent in correctly. Alright, thank you very much.
[AGENT][NEUTRAL] Well, OK.
[AGENT][NEUTRAL] Yes, sir.
[AGENT][NEUTRAL] Yes, sir. Was that all that I can help you with?
[CUSTOMER][POSITIVE] Yep, you did a good job thank you.
[AGENT][POSITIVE] OK. Well, yes, sir, and thank you so much for calling APM Mr. [PII], and you and [PII] have a great rest of your day.
[CUSTOMER][POSITIVE] Yeah you too bye.
[AGENT][POSITIVE] Thank you, sir. Bye-bye.