AccountId: 011433970860
ContactId: c075b438-4de0-4124-bc18-a02e547ad699
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 454959 ms
Total Talk Time (AGENT): 177219 ms
Total Talk Time (CUSTOMER): 256637 ms
Interruptions: 4
Overall Sentiment: AGENT=0.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/28/c075b438-4de0-4124-bc18-a02e547ad699_20250228T17:41_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ACL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, yes, I was calling to find out if you could help me on this. I was, I understand that the APL that we have from our employer that that should cover items like the copay and things like that that.
[CUSTOMER][NEGATIVE] Um, or things that are not covered under the regular insurance is how I understand it, but it doesn't seem to be paying anything to my knowledge, and I just had recently got received this in the mail for an explanation of benefits and on the on the second line it says benefit name not found, so is that the reason why?
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEGATIVE] Um, nothing is being paid.
[AGENT][NEUTRAL] OK, um, I can.
[AGENT][NEUTRAL] I can look at your claim for you. um, may I get your name and your policy number, please?
[CUSTOMER][NEUTRAL] Um, it's under [PII], last name [PII] and policy number and I have claim number too on the thing from you guys that I'm looking at.
[CUSTOMER][NEUTRAL] Which do you want?
[CUSTOMER][NEUTRAL] And a reference number too I see there's a reference number.
[AGENT][NEUTRAL] Uh, you can give me.
[AGENT][NEUTRAL] Give me the policy number first and the number.
[CUSTOMER][NEUTRAL] OK, I heard you say policy number 02506111.
[AGENT][NEUTRAL] OK, let me look up that policy real quick.
[CUSTOMER][NEUTRAL] Cause I had mentioned that.
[AGENT][NEUTRAL] OK, Ms. [PII]
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh, can I please verify, we need to verify your policy. Can you please give me your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you ma'am, and then what is your address, phone number and email address that we have on the policy for you?
[CUSTOMER][NEUTRAL] Well, it's
[CUSTOMER][NEUTRAL] It's uh [PII].
[CUSTOMER][NEUTRAL] And my email is [PII].
[CUSTOMER][NEUTRAL] And phone number is that what the other one is the one I'm calling from [PII].
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes, please.
[AGENT][POSITIVE] Thank you very much. I appreciate you verifying your policy and the number that you gave me, um, is that a good number to call you back on if we get disconnected, Ms. [PII]?
[CUSTOMER][NEUTRAL] That's my only phone I have. It's a [PII].
[AGENT][POSITIVE] OK. OK, thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Alright, and then you said that you have a claim number. Can I get the claim number please?
[CUSTOMER][NEUTRAL] Uh yeah, the one it shows on here is 356-494-8.
[AGENT][NEUTRAL] OK, let me mhm.
[CUSTOMER][NEUTRAL] Otherwise, and I thought, oh, I'm glad this had come in the mail because I'm gonna swing by because it said, you know, it's my final notice that I gotta get these paid and I just assumed that it was still going through the APL process and so you know I don't want to end up going to you know whatever because I haven't paid them.
[AGENT][NEUTRAL] Yes, I under. Right, I understand. OK, so on this claim, we've got a couple of remarks. The claim was processed, but we've got two remarks. One of them is, um, we've received the primary explanation of benefits that was submitted with your claim. However, the explanation of benefits received does not list the amounts applied to the deductible, co-pay or co-insurance.
[AGENT][NEUTRAL] Please submit a more detailed explanation of benefits that shows these amounts.
[AGENT][NEUTRAL] So the EOB doesn't show that the, show the, you know, the deductible co-pay or co-insurance. And then also on your policy, the way your policy is written, office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Really?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, so the only thing, but they used to, I swear they did, maybe not.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] So, so office visits, you're talking like when you go to the doctor, that's obviously an office visit, that's not covered and if there's some co-pay that you have to pay, whether 25, 30, whatever, that is not covered either by this.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So what does it cover?
[CUSTOMER][NEUTRAL] If there's like a general that you can say without explaining in great detail.
[AGENT][NEUTRAL] It covers
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yes, absolutely, absolutely, and this is just to verify your benefits. It's not a guarantee of payment, so you, you can use it for inpatient for 18 hours or more and you've got a $2000 calendar year benefit for that. You do have outpatient calendar year benefit also of $2000 but you'll have to go to an ER urgent care center, MRI imaging center or an ambulatory center.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So they don't pay at all and I'm going through the drive through here so I just have to pick up a sandwich but so my understanding then is they don't pay basically at all anything just to go you have a sinus infection and so you go to get an antibiotic or whatever. Nothing will be covered by APL on that whether deductible, [PII], no [PII] for a foot long.
[CUSTOMER][NEGATIVE] Is that correct? They, they don't pay for anything you do.
[AGENT][NEUTRAL] Yes, that's
[AGENT][NEUTRAL] Right, for an office visit. Now, if you went to an urgent care
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII] that's different.
[CUSTOMER][NEUTRAL] Then they pay
[CUSTOMER][NEUTRAL] OK. And what do they pay for urgent? I mean, is it, are we better off going to um urgent care or ER or whatever? Does it pay in urgent care, did you say?
[AGENT][NEUTRAL] Correct for deductible. mhm.
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] It pays urgent care, co-pay, deductible, or co-insurance.
[CUSTOMER][POSITIVE] OK, so we'd actually be better off going to urgent care than our regular doctor.
[CUSTOMER][NEUTRAL] Which it's easier to do that because the hours are better, but you know, I was always told it's better to go to your regular doctor.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] That the insurance covers better for that, but it doesn't apparently I don't know.
[AGENT][NEUTRAL] Well, it's just, um, it's just the supplemental insurance policy and everything that the supplemental insurance policy is based on the explanation of benefits from the primary insurance.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] OK, OK, well, that kind of explains, but I guess either way I'll swing by there and, and get this paid while I'm thinking of it then and not be waiting on you. Well thank you, dear. I greatly appreciate your help. You have a good rest of the day.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Well, you're very welcome, Ms. [PII]. You too and have a great weekend. We thank you for calling APF.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Mm thank you bye.
[AGENT][NEUTRAL] Bye-bye.