AccountId: 011433970860
ContactId: b28229a3-2284-4bb1-9f11-8f3ea4f05039
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 969849 ms
Total Talk Time (AGENT): 466026 ms
Total Talk Time (CUSTOMER): 363185 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/12/b28229a3-2284-4bb1-9f11-8f3ea4f05039_20250212T17:43_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Afternoon, thanks for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, your name is [PII]?
[AGENT][NEUTRAL] No, ma'am, it's [PII]
[CUSTOMER][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, hold on, let me write that down, sorry.
[CUSTOMER][NEUTRAL] OK. Um, hey, I'm trying to figure out what my benefits are and if they could be applied to a recent, um, stay in the hospital. Um, I'm trying to figure that out.
[AGENT][NEUTRAL] OK, and your name is?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. Ms. [PII], do you have your policy number?
[CUSTOMER][NEUTRAL] Yes ma'am, you need the group number?
[AGENT][NEUTRAL] No, ma'am. Policy number on your card, do you see policy cert number or inhospital outpatient benefit certificate number?
[CUSTOMER][NEUTRAL] In hospital benefits certificate number, yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 02.
[CUSTOMER][NEUTRAL] 5508
[CUSTOMER][NEUTRAL] 85
[CUSTOMER][NEUTRAL] M as in man.
[CUSTOMER][NEUTRAL] L as in Lucy.
[CUSTOMER][NEUTRAL] 7
[AGENT][NEUTRAL] OK, thank you, thank you. And Miss [PII], do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Sure, [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you so much and verify your date of birth, mailing address and email address, please.
[CUSTOMER][NEUTRAL] [PII]. My email address is [PII].
[CUSTOMER][NEUTRAL] My mailing address is [PII].
[AGENT][NEUTRAL] OK, thank you. And you said your email address is [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes, unless, unless they have it hooked up to my work email, I'm not sure which one they have that worked up worked into, um, I think my.
[AGENT][NEUTRAL] Uh, we didn't have an email address. Um, so would you rather we use the work email or the one you gave?
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] The one I gave you, yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And you say you're verifying it, OK.
[CUSTOMER][NEUTRAL] Uh, it's [PII]
[CUSTOMER][NEUTRAL] Do you need me to spell the email address for you?
[AGENT][NEUTRAL] It's [PII] [PII] and your last name, correct?
[CUSTOMER][NEUTRAL] Yes, so [PII].
[AGENT][NEUTRAL] OK, thank you. And you say you're calling to verify if inpatient confinement is covered under your plan?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, it is. Um, with this policy is secondary, what it does, it helps with your primary insurance deductible, co-pay or co-insurance for in hospital outpatient inpatient is if you're confined in the hospital 18 hours or more.
[AGENT][NEUTRAL] And you can submit either that, or you can submit the billing, the itemized bill showing the diagnosis and procedure codes, and we will need your primary insurance explanation of benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so that's a list. Can you, can you slowly go through that so we can write all that down?
[AGENT][NEUTRAL] OK, um, what we need is the itemized bill.
[AGENT][NEUTRAL] Showing the diagnosis and procedure codes.
[AGENT][NEUTRAL] And we will need your primary insurance.
[AGENT][NEUTRAL] Explanation. Uh-huh.
[CUSTOMER][NEUTRAL] Hold on one sec.
[CUSTOMER][NEUTRAL] Oh hold on one second. All I have is itemized bill.
[CUSTOMER][NEUTRAL] Um, showing diagnosis and procedure codes.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then what was the second thing?
[AGENT][NEUTRAL] Your primary insurance?
[AGENT][NEUTRAL] Explanation of benefits.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you can either fax it, mail it, um, or if you set up on our online service center, we do have it to where you can upload it, the claim information to the system.
[CUSTOMER][NEUTRAL] Um, what is
[CUSTOMER][NEUTRAL] I guess, well, I don't know if I can upload anything. I don't know really how to do that. So the fax number that is on the back of my of my card is [PII]. Is that where we fax everything?
[AGENT][NEUTRAL] Uh, yes, ma'am. That's the claim, um, claims fax number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, I have a question too.
[CUSTOMER][NEUTRAL] Hopefully, I won't be in the hospital anytime soon. Um, but if I should ever go into the hospital again, um, do I give them this information upfront or is this something that you do sort of like afterwards?
[AGENT][NEUTRAL] Uh, you can. So if you were, well, this is for inpatient or outpatient services, whenever you give your primary insurance information, also give them our information and just let them know where you're secondary, that way the provider can call, verify benefits and submit claims.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So even outpatient as in if I'm going to any doctors or?
[AGENT][NEUTRAL] Uh, outpatient being ER, urgent care, ambulatory surgery center, or MRI or imaging center. Those are covered outpatient places of service.
[CUSTOMER][NEUTRAL] OK, do you need to hear that again, mom? Sorry, can you say that again? The ER urgent care, and what else?
[AGENT][NEUTRAL] Um, ambulatory Surgery Center.
[AGENT][NEUTRAL] Or MRI imaging center.
[AGENT][NEUTRAL] Those are covered places of services for outpatients.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And like I said, you can give them, when you give them your primary insurance card, give them your card with our company and let them know we're seconda[PII], and that way they can call and verify benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, my mother is here with me. Let me ask her if she has any questions. Hold on one second. Do you? OK, so she did not do that.
[CUSTOMER][NEUTRAL] At the at urgent care, she did not do that at ER. She did not do that at MRI imaging center if they were needed.
[CUSTOMER][NEUTRAL] Um, so what, how can we get this information that you are talking about the to the itemized bill showing diagnosis and procedure codes and the primary insurance explanation of benefits, can you advise us?
[AGENT][NEUTRAL] Uh, the billing, uh, itemized bill you will get from the hospital. Uh, you can contact the hospital billing department and request the itemized bill with diagnosis and procedure codes for that confinement.
[AGENT][NEUTRAL] And the explanation of benefits or EOB, uh, you can contact your major medical insurance and request that um EOB for that data service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Uh, yes, ma'am. Is there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] Yes, would you, do you think if it were you, would you ask for these two items that we're talking about?
[CUSTOMER][NEUTRAL] Would you ask them to send it to you and then you would fax it to APL or would you suggest that we give them your address or fax number?
[CUSTOMER][NEUTRAL] What is the fastest?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Well, the easiest way is if provider submits because sometimes uh they can give a billing, uh, but it doesn't have the diagnosis codes needed to process and so that could put a delay in processing the claim. So,
[AGENT][NEUTRAL] The easiest way is contact the provider, let them know, hey, I have secondary insurance and I give you my information and sometimes they can file the claim.
[AGENT][NEUTRAL] And when they file, they will have everything we need because they have your, have her primary insurance information and if she's given secondary, then more likely what they would do is call our office, verify benefits, and then they can submit the claim to us.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] But I would suggest, do not tell them it's a gap plan, just tell them it's a secondary policy.
[CUSTOMER][NEUTRAL] OK,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And, and you, you, you have experience, so we do not. So you would suggest that we do that, that we do this that way, call them up and give them the secondary policy number?
[AGENT][NEUTRAL] Yes, ma'am. It will be a lot easier. Uh, like I said, sometimes provider, sometimes you can get the billing from the provider, but it may be, it may misinformation that we need, so they can put a delay in processing and it can
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] It can be frustrating, um, as far as, well, this is the information they gave me and but it's not what we need. So it's it's it's actually better to give it to the provider.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, well, there are
[CUSTOMER][NEUTRAL] That's what I'm talking about. You, the experienced one?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, I would just give my information. This next time in the future, it would be uh just give them the information or like I said with as far as this confinement, just call the hospital and say uh the billing department, say, hey, I have secondary insurance, I forgot to give it at the time of uh service. Can you please call and verify benefits and you can submit a claim to them and it will be a lot easier.
[CUSTOMER][NEUTRAL] OK, just a minute. Uh, I'm writing something, something down.
[AGENT][NEUTRAL] I just wouldn't tell them it's a gap plan, um, because most gap policies uh don't pay the provider, so they won't accept it. So I would say just uh let them know it's secondary.
[CUSTOMER][NEUTRAL] Secondary, OK, um, when they again because of your experience, um, when they ask us for information on the secondary policy, um, would we expect that they take down?
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, more likely they would need the policy number, the effective date, and the group number, group name.
[AGENT][NEUTRAL] And our phone number too so they can call.
[AGENT][NEUTRAL] But if she gives them, um, she can even give them a copy of the card and that way they can call.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright, so you may have to go in person. I don't know. All right, thank you, thank you [PII], thank you very much.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] You're welcome. And is there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Do you know the coverage? Yeah, that's what I was gonna.
[AGENT][NEUTRAL] OK, um, for inpatient, uh, this is not a guarantee of payment, just a verification of coverage. The max we pay is up to $3000 per confinement. Uh, what that means is, um, after the primary has processed the claim, on that explanation of benefits, if they apply amounts towards deductible, co-pay or co-insurance, that's what we pick up and pay up to that $3000 benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And as um ER urgent care, ambulatory, how does that work? or MRI?
[AGENT][NEUTRAL] Uh, ER, uh, is the same way as far as when you give them your primary, give them secondary information. It's the same way as far as picking up primary deductible, co-pay or co-insurance, but you have an outpatient benefit up to $300 per calendar day, so it pays up to $300 per day.
[CUSTOMER][NEUTRAL] OK. Um, and urgent care would be the same thing?
[AGENT][NEUTRAL] Yes, urgent care, ER, ambulatory surgery center, MRI or imaging center, that all falls in the category of outpatient and so that goes towards that $300 per calendar day benefit for outpatient. Inpatient is if you're confined in the hospital 18 hours or more.
[CUSTOMER][NEUTRAL] 4
[CUSTOMER][NEUTRAL] Right, right, and but, um, so $300 per day, but is that, uh, is there a limit on that?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's just a per day. There's not a calendar year limit. It's just a per day limit.
[AGENT][NEUTRAL] So you can go to the ER today. I, I, I'm not putting this on you, but you can go to the ER today. And let's say, um 2 days from now, you have to go to an urgent care and we will still just pay up to that $300 per day.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And um Ms. [PII], I don't know if you set up on our online service center account, but you can view your policy and it would um kind of give you the breakdown of benefits or what is considered outpatient, what's considered inpatient and how it's covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. No, I have not done that yet, um, but thank you.
[AGENT][NEUTRAL] OK. Yes, ma'am. Uh if you go to the website, it's secured [PII].
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, yeah, I see it on the back of the.
[CUSTOMER][NEUTRAL] Of the card
[AGENT][NEUTRAL] Yes, ma'am. And also from the site, you can check claim status, you can um receive a text message on when a claim has been received and when it's been processed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Or if you need to print out your card, it's on the site.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Um, thank you so much. Do you have any other questions?
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you [PII] I appreciate your patience.
[AGENT][POSITIVE] Oh, you're welcome and thank you so much for calling APL. You have a great day, Ms. [PII].
[CUSTOMER][POSITIVE] You too. Thank you.
[AGENT][NEUTRAL] Mhm, bye.
[CUSTOMER][NEUTRAL] Bye.