AccountId: 011433970860
ContactId: ba460fb6-c751-42dc-ab2f-d3eb89c42899
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1232119 ms
Total Talk Time (AGENT): 814115 ms
Total Talk Time (CUSTOMER): 404704 ms
Interruptions: 2
Overall Sentiment: AGENT=1, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/ba460fb6-c751-42dc-ab2f-d3eb89c42899_20250121T17:54_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Um, I just had a couple of questions because I have a lot of insurance and sometimes I'm not understanding the insurance stuff I have, um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I had, I don't know what this APO actually does.
[AGENT][POSITIVE] OK yeah I'd love to help you a look at that.
[CUSTOMER][NEUTRAL] If you can give me or instead of going through all that, instead of going through all that, I just wanna know if um cause I had went to the ER and when I go to the ER I hand them this, this card.
[CUSTOMER][NEUTRAL] And the lady told me, well, she scanned it. I've seen her scan my insurance and this card, right? She scanned it. So when I went up there to see if I owed any money to pay a bill, the lady says, well, I don't show you owe anything on this right now, or, or something like that, but then she starts telling me, oh, you're gonna get bills from an X-ray, you're gonna get bills from a doctor, you're gonna get this bill, you can get this. I'm like, what?
[CUSTOMER][NEUTRAL] I'm trying to figure out what I owe and you know, you can't, they can't really tell me. So what happened was she wants to know.
[CUSTOMER][NEUTRAL] Um, she told me that the girl did not put it in the computer that I have that.
[CUSTOMER][NEUTRAL] So I went to the ER.
[CUSTOMER][NEUTRAL] And it cost me $200.
[CUSTOMER][NEGATIVE] She was telling me I should if I have this insurance I probably shouldn't have to pay the $200 for the copay, but I don't know how that works.
[AGENT][NEUTRAL] OK, yeah, um, if you don't mind, I'd love to take a look at your policy so I can make sure I'm giving you like information that pertains like particularly to the policy you have. Do you mind if I get your name and your policy number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let's see, policy number. What, what would that be a group number?
[AGENT][NEUTRAL] It might say member ID or inpatient or outpatient certificate number.
[CUSTOMER][NEUTRAL] Oh, there's a
[CUSTOMER][NEUTRAL] There are certificate numbers. There's 2 of them.
[AGENT][POSITIVE] Oh, perfect. Either one of them will get me to the right spot.
[CUSTOMER][NEUTRAL] There
[CUSTOMER][NEUTRAL] 023303
[CUSTOMER][NEUTRAL] 83 ML 7
[AGENT][POSITIVE] Wonderful. Thank you very much, Ms. [PII]. And if you don't mind, would you be able to verify your date of birth for me, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And I'm just gonna have you verify your um mailing address, please, as well.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And it looks like.
[AGENT][NEUTRAL] If you could verify for me just your zip code, your email address and your phone number, I'll be able to dig in on that policy for you.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You said the zip code you said [PII].
[AGENT][POSITIVE] Perfect. And lastly, is that email address.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you so much, Ms. [PII].
[CUSTOMER][NEGATIVE] I really don't, I really don't do much. I really don't do much with my email.
[AGENT][NEUTRAL] That's OK, we don't, um.
[AGENT][NEUTRAL] You said [PII] though?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK perfect um we have it I mean I don't, we don't typically email you out unless you're requesting documents by email, um.
[AGENT][NEUTRAL] But I do have all that and your phone number, is that a good number to call you back if we were to get disconnected?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, perfect. Just want to make sure, thank you. Um, so I'm looking at the policy you have with us. You do have this meddling policy, so it's a gap insurance. The idea of it is that, um, we help pick up and pay on things that are applied to your co-pay, your coinsurance, or your deductible. Um, it looks like you do have an outpatient benefit with us, and I do want to let you know any benefit information I give you over the phone today. It's just a verification of coverage.
[CUSTOMER][NEUTRAL] It has a, it has, has an in-hospital and outpatient thing.
[AGENT][NEUTRAL] Yep, um, so when you're in the ER but you don't get admitted inpatient, it will fall under your outpatient benefits and you do have the benefit of $500 per calendar year.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] No, I'm so sorry you have a benefit of $500 per calendar day, um, not calendar year, so that benefit, um, is $500 that.
[AGENT][NEUTRAL] To help pay for things that your major medical left behind towards your your um co-pay, your co-insurance, um, deductible, those sort of things. Um, so what happens typically is like the ER is going to file a claim with your major medical and then your major medical sends them all the paperwork back and once they get all that information back, they should file a claim with us because we're your secondary, but they have to wait till they get their major medical information first and then they'll submit a claim on.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Your behalf, um, with their documents and then from there we, you know, if it falls within your policy we pay it and if it falls without of your policy, it might be denied um but that is how that policy is designed. It's helped close those out of pocket gaps left behind after major medical.
[CUSTOMER][NEGATIVE] So what I'm saying is you're saying $500 a day, what does that mean exactly? like I don't get it.
[AGENT][NEUTRAL] So per calendar day. So if you went to the ER today, um, you could have up to $500 available. And then say tomorrow, you have to go to urgent care um for something else or even for, you just, another day comes up and you have to go to the doctor again. Um, it resets every calendar day that $500 benefit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, but what I'm saying so.
[CUSTOMER][NEUTRAL] That's what I, I don't, so you're saying it pays $500 every time I go somewhere?
[AGENT][NEUTRAL] It can pay up to $500 every day. So say you went to like urgent care twice in one day, it
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You know what I mean? Like it's based on the calendar day of service or like for instance you went to the ER so and because they don't bill all together like the doctor might get a separate bill and your X-ray might get a separate bill and then you'll get the ER charge from the hospital. And so that could be 3 claims that come through. They're all gonna have that same date of service so your benefits is gonna go up to $500 in that date of service. But if you were to.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You know, need
[AGENT][NEUTRAL] Medical service the next day, that money resets for that next date of service.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Oh, well that's a good thing. Um, well, let me ask you this, how do, how, what do I need to do to make sure everything is taken care of?
[AGENT][POSITIVE] So I would always, I'm a huge fan of having the provider's office file every claim possible, um, and even just being like, hey, I'm not, you know, I'm not going to pay anything out of pocket until you file with my secondary. Some places won't file secondary, and it just stinks and you got to file the claim. But I would recommend always giving your APL card and just letting people know like, hey, I have a secondary insurance and I need you to file a claim with them.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, you know, I won't pay anything out of pocket until I see that they have a denied claim on hand. Um, so I would.
[CUSTOMER][NEUTRAL] So what do I do? What do I do? What do I do since this girl didn't put it in the computer?
[AGENT][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] She scanned it, but she didn't put it in the computer and the reason why.
[AGENT][NEUTRAL] You said you went yesterday?
[CUSTOMER][NEUTRAL] I went on the [PII].
[AGENT][NEUTRAL] The [PII], um, I would, I would call and talk to somebody in their billing department and just give them the information, your policy number, and that you have the insurance because they still have to file everything with major medical and get all the major medical information back um before they can file with us and sometimes it's like a longer process so they might.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let me ask you a question. If, if I pay $200 on the when I went in there, do she said I probably can get reimbursed for that. Who would reimburse me the insurance or the APL?
[AGENT][NEUTRAL] So, um, you could be reimbursed through us, um, and so, and I never want to guarantee anything, right? But, um, you absolutely can submit a claim with us. Um, what you would do is you could, um, you'd want to get your, and do you have a pen and paper handy because I actually have a particular form you can ask for. Um, so you're going to need an itemized bill from your hospital that has the procedure codes and how much was charged.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, but then you're gonna wanna ask for UB 04, U like umbrella, B like boy, number 04. Um, and that form right there will have your diagnosis code.
[CUSTOMER][NEUTRAL] And what did you say?
[CUSTOMER][NEUTRAL] You said you be what?
[AGENT][NEUTRAL] U B like boy, 04.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] O B.
[CUSTOMER][NEUTRAL] So I needed, uh, you said I need to get with somebody with the hospital about the auto autoized bill?
[AGENT][NEUTRAL] Yeah, you'll want to get your itemized bill that it's like your procedure codes, um, and how much they charge for each procedure.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] And then you'll want to get the UB04 form, and that's gonna have your diagnosis information.
[AGENT][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Where do I get the phone from?
[AGENT][NEUTRAL] So you'll have to reach out to somebody in the hospital department, either in their billing department or I don't think it would be medical records. I'd imagine it'd be the hospital billing department.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] See this is the, this is, I'm not, I'm not trying to complain or anything, but I have like other insurance, and I'll tell you what I had cancer insurance and they really screwed me over because they said, oh, you're uh preexisting so you can't do anything with that. So and I always thought that preexisting don't exist anymore, but that ain't what they told me and the thing about the insurance is I feel like when you call things should be taken care of instead of.
[CUSTOMER][NEGATIVE] Me having to go to the hospital, then I have to go get an as my bill that I have to go fill out forms, like it should be like, I just call and they just take care of it on the, the phone and I don't know.
[AGENT][NEUTRAL] Yeah, so.
[CUSTOMER][NEGATIVE] It just seems more hard, like, it seems hard like this, huh.
[AGENT][NEUTRAL] It
[AGENT][POSITIVE] It is honestly, and that's why I always recommend in any situation. I even recommend kind of trying to strong arm providers into filing like I'm not going to pay you anything until I see, you know, denied the claim from my secondary because they have access to all this information and they pay somebody to do it. And so I always recommend, I mean, we'll we'll absolutely if you file the claim we're gonna pay you, you know what I mean? But like.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm mhm.
[AGENT][NEUTRAL] Um, that money comes to you, not to the provider.
[CUSTOMER][NEUTRAL] So they, so they'll just send them, they'll just send the money back or send a check or?
[AGENT][NEUTRAL] So what happens is if you file the claim, any benefits payable get sent to you. Um, you can elect to have that set up through direct deposit and get paid to your bank, or they'll send you a check in the mail. But if you file the claim, the money of your benefits comes to you personally. If the provider files the claim, the money goes to the provider.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] And you know what, I, I'll be honest with you, I have a lot of, like I said, I have a lot of insurance at work and, and the insurance I had at work.
[CUSTOMER][NEGATIVE] I really don't understand it either because I had surgery and I was out for 14 days. So I told them, I said, well, I want to get paid since I'm out for like disability. Not that I was disabled. I'm just saying disability for work to get paid, you know what I'm saying? So they're like, they're like, they're like, oh we're not gonna pay you anything until after 14 days.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] Oh, that's that's
[CUSTOMER][NEUTRAL] And that was about the time I was out.
[AGENT][NEUTRAL] I have, I have a.
[CUSTOMER][NEUTRAL] And I was out about 14 days.
[AGENT][NEUTRAL] Disability with like a 90 day elimination period um before, so I understand that, that period so, because you're right, a lot of procedures happen and you're back in within 14 days.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah, and another thing is if I'm not mistaken, I read something on a policy that said you can't use your disability if you have PTO time.
[CUSTOMER][NEUTRAL] Like if your job pays you to be off that they're not gonna pay you and your PTO doesn't have nothing to do with the insurance you pay for that's what I figure.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] That's weird. I that.
[CUSTOMER][NEUTRAL] I read that somewhere. I read it in a fine line somewhere.
[AGENT][NEUTRAL] I have never heard that, but that is so, that's strange.
[CUSTOMER][NEGATIVE] And I was shocked.
[CUSTOMER][NEUTRAL] I read that somewhere.
[AGENT][NEUTRAL] Huh.
[CUSTOMER][NEGATIVE] Um, so, so in order for me to do all this, I have to get claims from the hospital. They don't come from you, no claim.
[AGENT][NEUTRAL] Yeah, so
[AGENT][NEUTRAL] So you'll wanna get just the bill from the hospital, um, and really the big things you need, they, you need your procedure codes and how much was charged for each procedure code and your diagnosis code. So those are the big things you need from the hospital and then from Cigna, you said you had as major medical?
[CUSTOMER][NEUTRAL] Paper or some
[CUSTOMER][NEUTRAL] No, I got Florida Blue, Florida blue.
[AGENT][NEUTRAL] Was that right?
[AGENT][NEUTRAL] Oh Florida Blue. I'm sorry. So from Florida Blue you'll just need your explanation of benefits and typically they send that in the mail to you, but you can also recall probably call them and request it to be emailed, um, if you want or check out their online portal as well, um, but their explanation of benefits because the way we just like we are able to um.
[AGENT][NEUTRAL] Like pay on claims is it's based on how major medical applies individual charges to your co-pay, co-insurance and deductible. So we have to see that come from your major medical provider. So it's those three things, something with your diagnosis code, your procedure codes on the itemized bill, and your explanation of benefits from your major medical. And you just send us those three things and we process the claim. So it sounds like a lot, and honestly, it's
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] What you said?
[CUSTOMER][NEUTRAL] It does. I'm confused. Exclamation of benefit and then you said out of my bill.
[AGENT][NEUTRAL] It's
[AGENT][NEUTRAL] Yep, with your procedure codes.
[CUSTOMER][NEUTRAL] And then procedure code.
[AGENT][NEUTRAL] Yep, those will be on your itemized bill. Um, so those are one, your procedure code and itemized bill should be together. And then something with your diagnosis code. So at a hospital, a UB04 form is gonna have your diagnosis code.
[CUSTOMER][NEUTRAL] Dang.
[CUSTOMER][NEUTRAL] And all of everything, don't they?
[AGENT][NEUTRAL] So what I can, I know it's, it's a and again it's a lot that's always why I recommend as much as you can as getting those providers to submit something on your behalf because it's a lot easier for them, but
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Does every place take this card or is it just for the hospital? Or where, where else does it take? You said urgent care and stuff like that?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Yeah, so you can urgent care, um, I would hand it out like [PII]. I'd say anytime you go anywhere, I, it's better to have a denied claim than not have one put through and miss benefits payable. I, every time you hand out your major medical card, I'd give them your APL card and tell him to file with your secondary, um, and then.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Because I've, I've been, I've, I've been to the dang of oncology and they charged me a lot to go there sometimes like on my.
[CUSTOMER][NEGATIVE] Like $90 for every time I was going I was going every 3 months, but now I'm only going every 6 months because I I can't afford this.
[AGENT][POSITIVE] Yeah, I definitely.
[CUSTOMER][NEUTRAL] You know, because I have to go all the way to [PII].
[AGENT][NEUTRAL] What in as far as your policy goes, you have, I'm sorry?
[CUSTOMER][NEUTRAL] But, but in order to
[CUSTOMER][NEUTRAL] The order, order, order to get paid for anything I have to make claims or they just have to give them the card?
[AGENT][NEUTRAL] Um, so in the future, give them the card and they will file the claims and then we'll pay them on your behalf. If you end up paying out of pocket or you just go to a provider, say you go to your gynecologist and they're like, we don't file secondary because they have.
[AGENT][NEUTRAL] You know, they have the right to say that they don't do that unfortunately um they can tell you just no um but if you're ever in a situation where they're like, hey, we don't file or you know, it's our policy doesn't do that, we don't do this at this practice, you can submit a claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, but I would, at that moment I'd be like, OK, well I need this and I need this, so then that way you're not stuck, you know, saying, trying later on to get those documents. It's sometimes easier to get them like right then and there, like, OK, well, if you don't pay for that, I need my itemized bill with my procedure codes and I need um my form with my diagnosis code so that way I'm able to file the claim on that behalf, um.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And so
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] I, but as much as you can highly recommend getting that, um.
[AGENT][NEUTRAL] Getting your provider to take care of that for you, um, they're just gonna have so much of an easier time and they do it all the time and they just have access to the documents they need, but what I'm doing, I know I've given you a lot of information, um, and I know you said you don't use email a lot, but can I email you a copy of our claim form that is going to have the information on it that I just gave you all three things that are like that we need for the claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then a copy of like our um online service center guide that can show you how to set up your online portal file claims, you know, elect direct deposit so it will give you a guide on how to use all the features in our online portal. Would you like me to email those out to you?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Can you send me, can you send.
[CUSTOMER][NEUTRAL] Can you send anything in the mail, that kind of stuff?
[AGENT][POSITIVE] Yeah, I absolutely can. I'm not sure about the user guide for the online portal, but I can send these claim forms out in the mail to through you, yes, absolutely.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, that'll be good.
[AGENT][POSITIVE] Perfect.
[CUSTOMER][NEGATIVE] So I can't do anything with this ER thing. I went on the [PII] on the by on the phone. I just have to do everything like you're telling me.
[AGENT][NEUTRAL] Yes, and then as far as the claims remittance, um, I'd recommend if you mail anything um to make copies and mail us the copies don't mail us the original documents just because you never know when stuff gets lost in the mail, um, but we also accept it through fax or you can obviously through our online service center you can file claims, um.
[CUSTOMER][NEUTRAL] Get all the claims
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so facts.
[AGENT][NEUTRAL] Mail or online as far as sending back that information but all of that will be on the claim form that gets sent out to you um our PO box or fax if you choose to do that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh and that lady was telling me too like when you have a secondary insurance like this, you shouldn't have to pay a copay at the doctor's. Is that true?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it always depends on um the individual policy. I'd recommend like when you go to the doctors is to ask them to file with your secondary and then if there's anything left over from that, you know, for them to bill you later um for our policies, we don't cover routine.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, so we cover like for accident or injury and sickness, but if you're just going to the doctor for like a routine wellness check, um, we don't have benefits payable for routine things. So you, you would likely have a co-pay in that situation, um, left behind.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then we also at doctor's office on your policy in particular, you have a benefit for treatment in an office. So say you like sprained your finger and you went to the doctor and they like checked it out and gave you a splint, you could have benefits for the treatment, but we don't necessarily cover like maybe a consultation.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Uh, you know what I mean, so it just depends on exactly what happens, which is why it's all based off of what's on that claim form, what the procedure codes were, what the diagnosis codes were, and then how your major medical paid on it. Um, but always I'd recommend, I'd, I'd recommend avoiding paying out of pocket until they file a claim with us, um, as much as you can.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][POSITIVE] All right then. I appreciate it, at least I learn learned a little bit.
[AGENT][POSITIVE] Yeah, and it's, I mean, if you are 2 weeks out from now you're like, oh my gosh, you gave me so much information I couldn't hold on to it. Like don't hesitate to reach out or to ask us to explain it again like we're here to take care of you. So um if you need any more information, please reach out to us and we'll do our best to take care of you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, all right.
[CUSTOMER][POSITIVE] All right thank you.
[AGENT][POSITIVE] Hey, it's my pleasure. Thank you so much for giving us a call and I hope you have a wonderful day.
[CUSTOMER][NEUTRAL] OK, mm bye.
[AGENT][NEUTRAL] Bye