AccountId: 011433970860
ContactId: b26985e2-b7b7-46d1-ac56-7f65ea3398ac
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1111469 ms
Total Talk Time (AGENT): 523820 ms
Total Talk Time (CUSTOMER): 455495 ms
Interruptions: 4
Overall Sentiment: AGENT=0.7, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/13/b26985e2-b7b7-46d1-ac56-7f65ea3398ac_20250113T13:55_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] I have a question about the benefits please.
[AGENT][NEUTRAL] OK, how can I help you?
[CUSTOMER][NEUTRAL] Um, can I give you my health plan ID or group number name?
[AGENT][NEUTRAL] Mhm, let me get your, yes, and your first name?
[CUSTOMER][NEUTRAL] My first name is [PII] I M.
[CUSTOMER][NEUTRAL] Last name [PII]
[AGENT][NEUTRAL] And your policy number?
[CUSTOMER][NEUTRAL] I have a group number.
[AGENT][NEUTRAL] Do you have your ID card?
[CUSTOMER][NEUTRAL] I do.
[AGENT][NEUTRAL] It's a policy er number that begins with a 0.
[CUSTOMER][NEUTRAL] It doesn't take
[CUSTOMER][NEUTRAL] I do not have any such number that begins with a 0 on my card.
[AGENT][NEUTRAL] OK, what type of policy do you have?
[CUSTOMER][NEUTRAL] Um, Medlink select group MedPlus.
[AGENT][NEUTRAL] OK. And so tell me what's on your card from the top to bottom.
[CUSTOMER][NEUTRAL] Insured, I am Zitsky. Coverage family group number 15494. Effective date [PII] plan meddling select group supplement.
[CUSTOMER][NEUTRAL] In hospital benefits cert number and outpatient benefits cert.
[AGENT][NEUTRAL] OK, that's the number that I need, the number before the elm. It should be the same for both.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK 1480322.
[AGENT][NEUTRAL] OK, and what's a good phone number in case we're disconnected Ham?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you. Give me 1 2nd.
[AGENT][NEUTRAL] And could you verify your date of birth, your mailing address, and then your email address?
[CUSTOMER][NEUTRAL] [PII] [PII]. What was the last one?
[AGENT][NEUTRAL] Email
[CUSTOMER][NEUTRAL] Yeah [PII].
[AGENT][NEUTRAL] Looks like it's your work email address.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, it's the 2nd 1 that you're actually the 3rd, um, work [PII]. And I have Palmetto, Palmetto Bay for the city.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Yeah, that's, that's fine that works too.
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] OK, thank you. Uh, the phone number I have on file is [PII]. Do we need to update it to the [PII] number?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][POSITIVE] OK. And how can I help you today?
[CUSTOMER][NEUTRAL] So I have a question. You guys are, I, I've never called your company before. You're supplement this is through work, so I've never had any per se, but you're supplemental insurance, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, so what is it that you cover exactly?
[AGENT][NEUTRAL] So under this Metlink policy.
[AGENT][NEUTRAL] Um, it covers inpatient, uh, services, so if you're admitted to the hospital, and then it covers outpatient, outpatient is emergency room, um, service in a hospital setting.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Do you help in any sort of way with rehab?
[AGENT][NEUTRAL] What type of rehab?
[CUSTOMER][NEUTRAL] Um, my daughter has, um, a diagnosis called hip impingement, so she's going to PT.
[CUSTOMER][NEUTRAL] Um, that's why I need to know if it covers.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, so it's actually for physical therapy?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, let me look at your policy and you can also review your policy on the um online service center um you can create an account at secured.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] A L
[CUSTOMER][NEUTRAL] Can you email all this is I'm driving at the moment. Can you email that to me?
[AGENT][NEUTRAL] Uh, we generally don't email the information.
[CUSTOMER][POSITIVE] Absolutely
[CUSTOMER][NEUTRAL] No, so hold on one moment.
[CUSTOMER][NEUTRAL] What's the email and the website?
[AGENT][NEUTRAL] Secure [PII]
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] A [PII]
[AGENT][NEUTRAL] [PII], yes, [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I do show that physical.
[CUSTOMER][NEUTRAL] So I set up an account.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] OK, go ahead, no go ahead go ahead.
[AGENT][NEUTRAL] Uh, OK. I was saying that I do show that uh physical therapy benefit, there is a physical therapy benefit. It, it can be considered under the outpatient benefit and that outpatient benefit is $500 per calendar day, so it's a daily benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and so if I.
[AGENT][NEUTRAL] And so
[CUSTOMER][NEUTRAL] Uh, right now, uh, I'm looking to take her to the PT and they are charging me $50 co-pay. Is that covered?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct. Any mhm any amount applied towards your major medical deductible, co-insurance or co-pay, um, any covered amount, this policy will reimburse. So yes, we'll reimburse the $50 because the benefit is.
[CUSTOMER][NEUTRAL] From you guys?
[CUSTOMER][NEGATIVE] Oh, so I do have, I have to pay it then I get reimbursed from you guys.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh, you shouldn't have to pay it out of pocket. Um, usually they'll call.
[AGENT][NEUTRAL] [PII] as they want your primary to verify your benefit information.
[AGENT][NEUTRAL] And so
[CUSTOMER][NEUTRAL] Is there, I'm sorry, what's your name?
[AGENT][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Oh, my wife is [PII] also, but [PII] you can see I'm not lying. It's on, it's on there. It's a family thing. [PII], thank you. So is there a reason why they said no, we won't call or no, like, listen, I'm dealing with front desk people here who are new and they don't know anything. They don't know from now left from right, and they're like, no, pay 50 bucks. I'm like, but wait, we have this. They're like don't pay. So is there any legitimate reason they would tell me this?
[AGENT][NEUTRAL] 00, OK.
[AGENT][NEUTRAL] Uh-huh, I see it.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, I mean we, you know, you, it, it just depends on the provider we can't make them take the secondary insurance card or verify the benefits. So in a situation like this, you did present the APL card as well, right?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] OK, so for whatever reason, uh, we, we have no control of, of that, but what can happen is if they're requiring that you pay the 50, then, um, you can submit the claim to APL. Um, we do require 3 documents and their reimbursement can go to you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEGATIVE] Uh, so this is putting me through a headache right now, that's all.
[AGENT][NEUTRAL] Yeah, it would be nice if they could submit it on your behalf.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] I see.
[AGENT][POSITIVE] That keeps you out of the, you don't have to do anything.
[CUSTOMER][NEGATIVE] OK, um, if I, if I go there and they don't, uh, uh, play nice with me, what's my rig and reward that I need to do here in order to get reimbursed from you guys directly?
[AGENT][NEUTRAL] I would just, did you ask them if they could call to verify your benefits?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I, I, I will ask him today.
[AGENT][POSITIVE] That's the first thing that I would do.
[CUSTOMER][NEGATIVE] I don't know what they told my wife, my wife was like, I don't understand why they're not taking it. The other, the other rehab place was taking it. She went to a couple places.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So you now know what the benefit is, so you could tell them that you've contacted American Public Life and your outpatient benefit or covered for physical therapy.
[AGENT][NEUTRAL] Well, you better say outpatient because this is not specific to physical therapy, but the benefit is $500 per calendar day.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so APL will reimburse the $50.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] OK, alright, so that's good, that's one thing, um, OK, then just to give me a hard time. I'll just have to call you back or something whatever I guess.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] And maybe while you're in the office sometimes if you call them when you're there, if they, you know, they're kind of giving you a little challenge, they'll usually, you know, get on the phone or something like that.
[CUSTOMER][NEUTRAL] OK, I got.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] So I called this [PII] number and I think I pushed option 2 if I'm not mistaken and that's all I have to do, yeah.
[AGENT][POSITIVE] 2. Correct. Correct.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, OK, one second.
[AGENT][NEUTRAL] And as you're writing the information provided is verification, not a guarantee of payment until we get the actual claim.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] All right, but they, but they should take it. OK. Um, now, now, now that I have you on the phone with this, if I go to the hospital ER and they're asking for like $300 co-pay, is that covered?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, emergency room is considered outpatient and your outpatient benefit is up to $500 per calendar day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEGATIVE] Why am I, I mean, I get bills from the hospital like all the time, like post facto, and I'm like, I gave you this information. I mean, they don't call me and I don't call them and they waive the debt at some point in life, but is there.
[CUSTOMER][NEUTRAL] Uh, you're laughing. You know a lot more about this than I do, but I just feel something's not right.
[AGENT][NEUTRAL] Oh, I get it. I get it. So, uh you are presenting your major medical and your APL card, right?
[CUSTOMER][NEUTRAL] Yeah,
[CUSTOMER][NEUTRAL] Yeah, yeah, I think maybe one time historically they were like, you see now like this is a major hospital down here in [PII], uh, I, I don't know where you are, but um.
[CUSTOMER][NEUTRAL] I was like, I don't understand I think.
[AGENT][NEUTRAL] Uh, when I go to the doctor, yeah, when I go to the doctor, they sometimes say that they require me to pay a certain amount upfront.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And then of course I let them know, well, here's my insurance card, could you verify my insurance?
[CUSTOMER][NEUTRAL] Mhm
[AGENT][POSITIVE] And then usually they'll say OK well you don't have to put anything down so with you knowing what your benefit is is a little bit of a leverage um it's a $500 daily benefit which is good, a good benefit. It's not per calendar year, it's daily.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Um, if I go to, uh, a doctor, like my wife goes to the ENT and on my regular insurance card says co-pay $50.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Does APL also that
[AGENT][NEGATIVE] Now there is not a a benefit for service in a PCP or a specialist doctor's office.
[CUSTOMER][NEUTRAL] OK, OK, alright, so, OK, it's not, it's not considered outpatient. I don't know what the, the, the jargon is. This is not my area of expertise. You could talk to me about many other things, but not this.
[AGENT][NEUTRAL] Yeah, sometimes
[AGENT][NEUTRAL] Yeah, sometimes providers will say um office visit and they'll say outpatient, but it's, it's any, any service in like a primary care office or specialist office such as an ENT there is not a benefit for that. It's only when it's done in a hospital facility setting, emergency room setting that it's covered.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, a diagnostic facility in a hospital or an um MRI facility that's considered outpatient under your policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, urgent care is covered under the outpatient portion of this policy as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Urgent care is
[AGENT][NEUTRAL] Urgent care is.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][POSITIVE] I know I've paid urgent care visits before. Wow.
[AGENT][NEUTRAL] And it's up to you if you pay out of pocket and the date of service was, you know, within the time period you've had this policy I mean you can submit them yourself if you know.
[CUSTOMER][NEUTRAL] Plenty of times.
[CUSTOMER][NEUTRAL] I mean, I've had, um, we've had this supplemental APL for years. It's the first time I'm calling. I'm probably 10 years for, for my understanding. Uh, am I eligible for reimbursement if I get receipts or whatever from back in the day?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Yeah, there is no timely filing limit to submit your information and I do show you've been on the policy since [PII] [PII], so.
[AGENT][NEUTRAL] I know you said that you're driving, but there are 3 documents that you would have to obtain and get that information to us, which will be a little bit of leg work and.
[CUSTOMER][POSITIVE] Wow.
[CUSTOMER][NEUTRAL] What are those?
[AGENT][NEUTRAL] So the APL.
[CUSTOMER][NEUTRAL] Yeah, what I'll have to, yeah, go ahead.
[AGENT][NEUTRAL] The the APL claim form.
[AGENT][NEUTRAL] And I can email that to you that way it is available on our um website, but I can email you that form.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] OK, that'll be good.
[CUSTOMER][NEUTRAL] What else?
[AGENT][NEUTRAL] And then the itemized bill.
[AGENT][NEUTRAL] So you would obtain that from, in this instance, the physical therapy office. Let them know you need an itemized bill.
[CUSTOMER][NEUTRAL] Mm I know you need to find.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And then since this policy is secondary, we would need a copy of your major medical explanation of benefits that corresponds with the date each date of service.
[CUSTOMER][NEUTRAL] Uh, I'm sorry, say it's, uh, since it's secondary it's it's, it's, uh, you kind of broke up there. I need that.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Who is your primary insurance?
[CUSTOMER][NEUTRAL] Oh, OK, so you need the prime, a copy of the primary insurance. Can you hold on one second, please? 1 2nd, 1 2nd.
[AGENT][NEUTRAL] Sure, sure.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hello. Yes, OK, I'm OK, so then, then you need what, a copy of the of the main insurance card?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] No, the explanation of benefits.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Oh, explanation of benefits that I get.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK. All right.
[CUSTOMER][NEUTRAL] OK, alright, uh, and you can email that to me, the claim form?
[AGENT][NEUTRAL] I'm sending it now.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment. I'll get it in just a few seconds.
[CUSTOMER][NEUTRAL] So this will cover urgent care, the PT I'm getting now.
[CUSTOMER][NEUTRAL] And and the co-pay even for hospitals, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Like the ER
[AGENT][NEUTRAL] Yeah, anything applied towards, uh, deductible, co-insurance, or copay.
[AGENT][NEUTRAL] For if if it's an emergency room visit, urgent care.
[AGENT][NEUTRAL] Physical therapy.
[CUSTOMER][NEUTRAL] OK, what, what about dental?
[AGENT][NEGATIVE] I don't believe this, this does not cover dental. This is a medical policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. What was the dental emergency? No.
[AGENT][NEUTRAL] Let me look at your policy. sometimes if it's related to an accident, but let me check that for you. Give me one second.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEGATIVE] Otherwise, it's not covered.
[AGENT][NEUTRAL] Just emailed the claim form to you.
[AGENT][NEUTRAL] Going back to your policy document.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Let's see, dental or this is under the exclusion. So dental or vision services, including treatment, surgery, extractions, or X-rays, unless resulting from an accident occurring while the covered person's coverage is in force and if performed within 12 months of the date of such accident or due to uh the, a congenital disease or an anomaly of a covered newborn child. So if it's an accident.
[CUSTOMER][NEGATIVE] I need to call, I need to call my attorney.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Alright, so if it's an accident, I, I asked if I had to call my attorney to understand that. So you're saying if it's an accident?
[AGENT][NEUTRAL] It's, it
[AGENT][NEUTRAL] Yeah, if it's as a result of an accident.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] That occurs while your policy is active.
[CUSTOMER][NEUTRAL] OK, so if it's an accident, not like my daughter had like an emergency root canal just out of the blue for no no apparent reason, it doesn't cover that.
[AGENT][NEUTRAL] Yeah, you can
[AGENT][NEUTRAL] Correct. That would not be an accident.
[CUSTOMER][NEUTRAL] OK, alright.
[AGENT][NEUTRAL] be considered an accident.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, so that's helpful. OK, alright, I appreciate that.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] All right, anything else you think I should know that would help me out? Like a common question that I'm not asking that would be helpful. What, what something I'm not asking I should ask?
[AGENT][NEUTRAL] No
[AGENT][POSITIVE] You actually asked the right questions.
[AGENT][NEUTRAL] You said you don't know a lot about it, but you asked the right questions and just know that inpatient and outpatient.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um, services are covered, covered services, and then any service in a doctor's office, a PCP or specialist office are not covered.
[CUSTOMER][POSITIVE] OK, alrighty.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. What, what about procedures like uh co-pays for, I don't know, uh, oh, I guess it's an outpatient, if you do like a colonoscopy or something like that, that's considered outpatient.
[AGENT][NEUTRAL] Yeah, so if it's for a medical concern, but if it's for like a screening, it's not covered.
[CUSTOMER][NEUTRAL] OK, what about like an MRI?
[AGENT][NEUTRAL] Mhm. MRI is usually done in a hospital or or an MRI facility that's covered under outpatient.
[CUSTOMER][NEUTRAL] CAT scan.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] All righty. OK, you've been very helpful. I appreciate it, [PII].
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] Absolutely. And how do you pronounce your first name?
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] Thank you
[CUSTOMER][NEUTRAL] I am [PII]
[AGENT][POSITIVE] I am, OK, I am, no other questions, thanks for calling. Go ahead.
[CUSTOMER][NEUTRAL] Uh, I do
[CUSTOMER][NEUTRAL] Yeah I appreciate I I didn't get the email. I don't know if you sent it while we're on the phone together or not.
[AGENT][NEUTRAL] I did.
[AGENT][NEUTRAL] I did.
[CUSTOMER][POSITIVE] Um, let me check my. Oh, you sent to email [PII]. Got you, got you. OK, perfect. OK, I appreciate it. Thank you so much. You have a good day.
[AGENT][NEUTRAL] And I'm gonna verify that address again.
[AGENT][NEUTRAL] It's coming from [PII]. Yes.
[AGENT][POSITIVE] Oh, you're welcome. Hi, and thanks for calling ATL. Have a good day as well.
[CUSTOMER][POSITIVE] Alright thank you you too bye bye.
[AGENT][NEUTRAL] Bye-bye.