AccountId: 011433970860
ContactId: b3833c8c-c479-4973-86bd-5bf0010fd98d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 389519 ms
Total Talk Time (AGENT): 182409 ms
Total Talk Time (CUSTOMER): 201584 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=1.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/13/b3833c8c-c479-4973-86bd-5bf0010fd98d_20250313T19:41_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, ma'am, I have a question please.
[CUSTOMER][NEUTRAL] Um, I have, uh, I have gap coverage through my employer.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Um, and
[CUSTOMER][NEUTRAL] I, I am getting surgery tomorrow morning and I just had to pay $500 for my surgery. I was wondering if you could tell me if that, if this will help me with that.
[AGENT][NEUTRAL] Um, yes, ma'am. I can assist you with your benefits. Um, first, could I get your name and a good callback number?
[CUSTOMER][NEUTRAL] Yeah, my name's [PII]
[CUSTOMER][NEUTRAL] My last name is [PII]
[CUSTOMER][NEUTRAL] And a good call back number is [PII].
[AGENT][NEUTRAL] OK. Thank you, [PII]. Now I need your policy number, please.
[CUSTOMER][NEUTRAL] Yes ma'am, it's gonna be 024.
[CUSTOMER][NEUTRAL] 792-43
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Thank you, [PII] and now, please verify your date of birth and your mailing address.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]. I literally forgot about my gap coverage and I got a, a notice, uh, something in the mail from APL yesterday that said a claim was denied and I don't even know who filed the claim because I've never submitted a claim. I guess the uh medical group tried to see or whatever. I have no idea. But um I'm having outpatient surgery. I'm having outpatient surgery tomorrow morning.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, let's see. Um, verify your email address real quick to make sure that we have the correct one on file.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. This may be your work email address.
[CUSTOMER][NEUTRAL] No, that's my regular email address.
[AGENT][NEUTRAL] Well, I'm talking about the email address that we have on file.
[CUSTOMER][NEUTRAL] Um, maybe it's [PII]. That's my work email.
[AGENT][NEUTRAL] Yes, ma'am. That's the one we have on file.
[AGENT][NEUTRAL] OK. And I'm showing that these two claims that um denied them, they were for office visits, and that's why they denied.
[CUSTOMER][NEUTRAL] Yeah, I know that like I don't even know why I, I don't know if my uh the office uh automatically called you got uh you know, tried. I've never submitted a claim, but now that I'm looking at my card it says outpatient and I'm getting a surgery tomorrow, so I was wondering what kind of coverage, if any, I would have for that.
[AGENT][NEUTRAL] Yes, there is coverage for outpatient facilities. Where will the surgery take place? Will it take place at an outpatient facility?
[CUSTOMER][NEUTRAL] Uh, let me show you. It's going to, hold on, it's going to take place at, let me see, I just messaged my dad because he's gonna meet me there. It's gonna be at Orthopedic Medical Group, and it's gonna take place at [PII].
[CUSTOMER][NEUTRAL] In [PII].
[AGENT][NEUTRAL] OK. And is that an outpatient facility? Surgery center or outpatient hospital? Yes, I'm showing that there is. We can't, we can't guarantee payment over the phone, but I am showing that your policy does cover outpatient surgeries and for outpatient services, we cover up to $500 per day after your primary insurance processes declined.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] It's yes it is.
[AGENT][NEUTRAL] So, the claim would have to be processed by your primary insurance first, and the charges that go towards the copay, the co-insurance, and the deductible will cover that up to $500 per day for outpatient ser services.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK. So, OK, so I paid $500. They would not let me get my surgery until I paid $500. So what would you guys do? Refund me that or what? How does that work?
[AGENT][NEUTRAL] Yes, ma'am. You can file the claim yourself and we'll refund you, but the claim would have to go through your primary um insurance company first. So you'll have to wait till after, after the surgery. And when the provider files the claim with your primary insurance company.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Once you receive the explanation of benefits for the surgery, then you'll submit that information to us along with documentation from your doctor's office which shows your um diagnosis code and um we'll get that processed for you and pay it up to $500.
[CUSTOMER][NEUTRAL] Uh huh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Oh wow, that makes me feel so good. Thank you so much because I'm freaking out here. I'm like, oh my [PII]. And then I was like, wait a minute, I have this gap coverage. So that's good to know. So I have to wait until I get my monthly statement from Blue Cross.
[AGENT][POSITIVE] Yes, ma'am. Your your explanation of benefits um for this surgery. Yes, ma'am.
[CUSTOMER][NEUTRAL] Right?
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] OK, and, and it'll, and I'll get that after the surgery, right?
[AGENT][POSITIVE] Yes, ma'am, that's correct.
[CUSTOMER][NEUTRAL] OK, and, and then I'll I'll just copy and scan that and send it to you and then send you what else will I need to get my receipt first of all.
[AGENT][NEUTRAL] You'll need to get
[AGENT][NEUTRAL] Yes, we'll need the receipt and we'll also need your diagnosis code so you can get documentation from your provider's office, um, the provider who will be
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So do the um surgery, perform the surgery, you'll get uh documentation from this office with your diagnosis code on there. We need your diagnosis code because we only cover charges that are related to an illness or an injury. So get the documentation on your uh diagnosis code and send that along with your EOB and we should be able to get that processed and paid for you.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, it is definitely an injury. It's the shoulders. I'm getting a shoulder surgery, so do you think that would be covered?
[AGENT][NEUTRAL] Yes, that sounds like something that would be covered and it also has to be covered by your primary insurance. If your primary insurance deny it, then we deny it also.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][POSITIVE] Nope, OK, I don't think I'm gonna have any problems. Thank you. Um, gap insurance is good, I guess. Thank you.
[AGENT][NEUTRAL] OK. Is there anything else that I can assist you with?
[CUSTOMER][POSITIVE] I look forward to talking to you one day.
[CUSTOMER][POSITIVE] No thank you ma'am appreciate you.
[AGENT][POSITIVE] OK, no problem, [PII] and I thank you for calling APL. You do the same.
[CUSTOMER][POSITIVE] Have a blessed weekend.
[CUSTOMER][POSITIVE] Thank you bye bye.
[AGENT][NEUTRAL] Mhm, bye.