AccountId: 011433970860
ContactId: b41b646e-a2f8-4fd2-820f-9ea80dd26ec4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 398000 ms
Total Talk Time (AGENT): 152525 ms
Total Talk Time (CUSTOMER): 173801 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/03/b41b646e-a2f8-4fd2-820f-9ea80dd26ec4_20250603T14:54_UTC.wav
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[AGENT][NEUTRAL] For calling APL, my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] Hi, [PII]. I'm fairly new to the gap insurance that my company provided that I'm paying for. Um, my girlfriend is on my
[CUSTOMER][NEUTRAL] Um, insurance as well, um, as a spouse.
[CUSTOMER][NEUTRAL] And she has a procedure today. The office just called saying that the deductible that we had to pay out of pocket for was $1400. My job is saying to call you guys and explain this to you and see the procedure of how to file the claim to get that.
[CUSTOMER][NEUTRAL] Money either reimbursed to me or how that process works.
[AGENT][POSITIVE] OK, I'll be happy to assist. May I have your policy number, please?
[CUSTOMER][NEUTRAL] Is that the group number?
[AGENT][NEUTRAL] No, it would say inpatient or outpatient benefit cert number.
[CUSTOMER][NEUTRAL] Oh, so if it's an outpatient um procedure it will be the outpatient one?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So it'll be 02.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 555 8
[CUSTOMER][NEUTRAL] 86 M as in Mike L as in Larry E
[AGENT][NEUTRAL] And your full name?
[CUSTOMER][NEUTRAL] My name is [PII]. Last name is [PII].
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And email address.
[CUSTOMER][NEUTRAL] The best one, you could use [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said this was a claim for the dependent on the account?
[CUSTOMER][NEUTRAL] So, this is, so what ended up happening, we're having a DNC um because of a miscarriage. Um, it's scheduled for today, the, the, the doctor's office actually just called us saying that we have to pay.
[AGENT][NEGATIVE] Oh no.
[CUSTOMER][NEUTRAL] $1400 to
[CUSTOMER][NEUTRAL] This is for like the doctor that's gonna be performing the surgery, but not the outpatient facility.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So it's gonna be the procedure is gonna be done in the outpatient by the doctor, but this is his fee that he, we have to pay.
[CUSTOMER][NEUTRAL] Um, I told him that we have the gap insurance that's supposed to take.
[CUSTOMER][NEUTRAL] Care of anything outpatient or hospital visit, but they said that we have to file the claim separately with you guys.
[AGENT][NEUTRAL] OK, so they're not willing to file, OK.
[AGENT][NEUTRAL] Alright, so, um.
[AGENT][NEUTRAL] You'll have to wait until after the claim has been processed with your major medical because the information that we need has to come directly from the insurance company. We need the explanation of benefits for the data service.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so once we get the EOB from in the mail.
[CUSTOMER][NEUTRAL] Um, from the insurance is when we call you and file the claim.
[AGENT][NEUTRAL] Correct. Um, and also, I guess when she's discharged, um, whatever paperwork they give you that states the diagnosis for the proc you know, that it was miscarriage or whatever the diagnosis is for this type of
[AGENT][NEUTRAL] Procedure, um, save that information because we'll need the diagnosis for this data service and the EOB from the insurance.
[CUSTOMER][NEUTRAL] OK. And do you know if it's something that I guess the ELV will take a while because they have to process it through the doctor and everything first, correct? So it'll take a little while for that to be processed or is that something that we could call through to the insurance and they'll be able to provide us earlier?
[AGENT][NEUTRAL] No, um, whoever the provider has to send the claims to your insurance and then they have to pro you know, it's the same regular claims process for any other data service.
[CUSTOMER][NEUTRAL] OK, then once it's filed and everything's confirmed, what ends up happening is you guys will send the check in the mail or something like that.
[AGENT][NEUTRAL] Once you file with us.
[CUSTOMER][NEUTRAL] Yeah, that's what I mean, yeah, so you guys will send the check later on in the mail.
[AGENT][NEUTRAL] Yeah, once you file the, right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Now just so that you understand and please be advised that the verification of coverage is not a guarantee of payment um so just so that you understand for your outpatient your per day maximum that we would pay is 500. So if, so is that the total amount that they quoted you for the procedure?
[AGENT][NEUTRAL] Or is that your patient responsibility that they quoted you?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] They, they said that's just a deductible that I have to pay.
[AGENT][NEUTRAL] Oh, OK, OK.
[AGENT][NEUTRAL] OK, well, we, for outpatient we cover up to 500, so if you were to, if your EOB says 1500 was applied to the deductible, then we would only pay the 500.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, makes sense.
[AGENT][NEUTRAL] Yeah, I just wanted you to be aware of that.
[CUSTOMER][POSITIVE] We appreciate it. So, we'll wait for the EOB and then we'll kind of file from from there.
[AGENT][NEUTRAL] And don't forget to.
[AGENT][NEUTRAL] Say whatever documentation that she gets that states why she had the procedure and the diagnosis.
[CUSTOMER][NEUTRAL] the paperwork.
[CUSTOMER][NEUTRAL] OK, so yeah, we'll save all the paperwork. And when we're calling back to file the claim or is it better to, is there a website that we go to the file? Is it the one that's on the back of the card?
[AGENT][NEUTRAL] Um, yeah, you need to upload it. Yeah, you can go to [PII]. Um, are you registered for the, um, well, you know, actually, even if you were, um, you have to re-register. So you'll go to [PII] and yeah, OK, good. Um, so you can register there, um, and then, um, upload the documents there under file a claim.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] I'm not yet, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I appreciate all the information.
[AGENT][NEUTRAL] OK, is there anything else I could assist with today?
[CUSTOMER][NEUTRAL] No, that'll be all.
[AGENT][POSITIVE] Well thank you for calling APL. You have a good day.
[CUSTOMER][NEUTRAL] You too.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Bye.