AccountId: 011433970860
ContactId: c517df5a-638b-46ef-891e-66b8ee608590
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 733479 ms
Total Talk Time (AGENT): 370789 ms
Total Talk Time (CUSTOMER): 321620 ms
Interruptions: 3
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/c517df5a-638b-46ef-891e-66b8ee608590_20250213T14:14_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, ma'am, how are you?
[AGENT][POSITIVE] I'm good, thank you. How may I assist you?
[CUSTOMER][NEUTRAL] Good. Um, ma'am, before, before I begin asking questions, um, can you kinda explain to me how this gap insurance works? So I have, um, the gap with my, my job, so I have, um, Aetna PPO and, you know, we were told, OK, the gap covers, but is this something where every time I go to the doctor, I give the card.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] To them and they should know what it, what it is, because sometimes I give it to them they're like, I don't know what this is.
[AGENT][NEUTRAL] Um, um, it depends. Um, there's a lot of places, um, usually hospitals, they know about secondary insurance. Um, most of the primary insurance or primary doctors know about a secondary insurance. Now, this is not a gap, this is a secondary supplemental plan, so probably that's um why they don't recognize it. um, but
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah. Mm.
[AGENT][NEUTRAL] There's some, maybe some new places that they don't know about it, but.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That will be like outpatient facilities or urgent cares, which are the newest ones. Um, now, for benefits, I cannot provide benefits or I cannot tell you if it covers an office or anything like that unless I pull your policy because we have many products. There's a lot of different products with some benefits with other benefits. So, um, it is hard for me to tell you where to use it unless I'm looking at the policy.
[CUSTOMER][NEUTRAL] Got you, OK.
[CUSTOMER][NEUTRAL] Get
[CUSTOMER][POSITIVE] Right, awesome.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] No, that's fine. Now, now my, my, here is my question, my reason for calling. So I submitted two claims and I received an explanation letter, right? And um, one of them was I went to an urgent care, right? And I guess this is so I understand whether this covers it or not. I went to an urgent care and I paid the $50 of my co-payment. Does this plan cover co-payments?
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Again, it depends on the policy.
[CUSTOMER][NEUTRAL] OK, so who do I speak to that they can explain to me better my my policy then?
[AGENT][NEUTRAL] I can. I just need to ask you some some questions. OK, may I have the, may I have your name and a callback number just in case we get disconnected?
[CUSTOMER][POSITIVE] Oh, OK, perfect.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] And the number [PII].
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And do you have the policy number with you?
[CUSTOMER][NEUTRAL] Yeah, it's 02497912.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and I need to verify your date of birth, mailing address and email address on file.
[CUSTOMER][NEUTRAL] Yeah, it's uh sorry, [PII].
[CUSTOMER][NEUTRAL] And what were the other oh [PII] and what was the other question? I'm sorry.
[AGENT][NEUTRAL] Uh, the date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, perfect. Thank you. All right, let me pull your benefits and see exactly what is covered under your policy. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and before I give you any benefit information, I need to let you know that this is not a guarantee of payment, just a verification of coverage and that's just a disclaimer.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] You have inpatient and then you have outpatient. Let me get the outpatient benefits hold on.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so for the outpatient benefits, um, you have $2500 per covered person per calendar year. Um, this is to help with the deductibles, co-payment, and co-insurance. And now the co-payments, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The
[AGENT][NEUTRAL] Yes, you do have benefits or coverage for urgent care facility. So we do cover the co-payment for the urgent care. Um, the only co-payment, well, you do have co-payment benefit for the office visit as well. So you have both of them on this one.
[CUSTOMER][NEUTRAL] OK, so then my, so then before I continue, cause I have a couple questions I want to better understand what it is. So for instance, my daughter and I are covered on both of my insurance with Aetna and this um insurance. Now when I go visit her, her, we're paying, you know, so every time that I go, do I have to pay them and then submit a claim for reimbursement, or they should automatically know, you know what I mean? That's what I'm trying to understand.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Mhm. Correct.
[AGENT][NEUTRAL] It depends on the place. Um, again, there is some new places that they don't know about this part, they don't know about the secondary policy.
[CUSTOMER][NEUTRAL] Well, this place isn't new. This is, this isn't new. This place has been around for a while. So my thing is, and again it's, it's, it's, uh, here's the, the gap, it should cover my co-payment or I submit the claim, you know what I mean? So they know I shouldn't be paying anything, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Not exactly, uh, no, um, they don't know the benefits and they don't know a lot of places they, they don't have a system to put a secondary insurance, so, um, but.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right. Cause I think that's what happened with my daughter.
[AGENT][NEUTRAL] Mhm. So if they don't have a system to put a secondary insurance, they, they are gonna charge you that co-payment, and then you can submit a claim for reimbursement. So either the, the provider is going to take the card and they're gonna go ahead and just submit a claim and get the payment, or they're just gonna to let you know we, we cannot take it because we don't have a way of putting it in the system and then you can pay out of pocket and get reimbursed. You have to send a claim for that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so then now on the remark because I did send over the copayment right for the urgent care and then the remark it says because the only thing they gave me was a receipt, so they're like we're unable to to do it. We need a full uh itemized bill of the diagnosis and procedures and then it said the primary carrier explanation of benefits for the charges.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, I, where do, I mean, the itemized bill, I guess I have to call the urgent care and get that um from them. Mhm.
[AGENT][NEUTRAL] Yes, um, yeah, you just need to let them know that you're trying to submit your own claim because you have to pay out of pocket and that you need an itemized bill with the diagnosis code. It needs to have the diagnosis code so it has to be detailed.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then the
[CUSTOMER][NEUTRAL] And then the what is the carrier explanation of benefits because I'm on Aetna right now, so what is it that you guys need?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, it's gonna be the one that is also detailed. It, it's gonna be the page that says this is not a bill and it's just gonna tell you how much they apply towards the deductible co-payment or co-insurance.
[CUSTOMER][NEUTRAL] Oh, OK, so it's, it's the one that says benefits medical coverage out of pocket, is that the one or you need something else?
[AGENT][NEUTRAL] Does it say only out of pocket or is it like break down the way that I like.
[CUSTOMER][NEUTRAL] Well, um
[CUSTOMER][NEUTRAL] Um, hold on, because I'm, I'm, I'm right now on the end of page it says medical coverage. So it says office visits, specialist visits, outpatient mental health testing.
[AGENT][NEGATIVE] Oh, yeah, no.
[AGENT][NEUTRAL] Mhm. No, no, it's not gonna be that one. No, it's you need to go to your claims, um, the claims they have processed, um, it's gonna say explanation of benefits, um, the statement sometimes doesn't have everything, but you can click on that, um, a specific date of service for that claim, and then there there should be a way for you to get the copy of the explanation of benefits.
[CUSTOMER][NEUTRAL] So I don't know if that's, uh-huh.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] All statements.
[CUSTOMER][NEUTRAL] Yeah well.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, I see, I see it here now. So I, so under, so it's under the uh explanation of benefit statement, that one?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm yeah.
[AGENT][NEUTRAL] Yes, mhm.
[CUSTOMER][NEUTRAL] OK, so then I can do a PDF.
[CUSTOMER][NEUTRAL] OK, download and print statement. That's what you need, right? Download PS statement claim and coverage information.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It sounds like it. um, when you pull it up, um, again, just make sure it it is break down like it has the date of service, the doctor, um, it has the amount they pay, the amount they discounted, and the amount they apply towards the deductible co-payment and co-insurance.
[CUSTOMER][NEUTRAL] Got you, yeah, so this one says explanation of benefits. This is not a bill that one?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Uh, yeah, that's correct. Mhm.
[CUSTOMER][NEUTRAL] Perfect. OK, so now this was for my daughter. I haven't submitted this one yet, but then you need, what is it that you need from from them? You need the, the copy that I paid it I can send my bank statement or you need the detailed explanation, right? from them?
[AGENT][NEUTRAL] No, no. Mm.
[AGENT][NEUTRAL] It is
[AGENT][NEUTRAL] Correct, yes. The, the only documents we need for all of our claims, and this is for all of our policies, um, basically, um, we need 3 documents. The first document is the itemized bill with the diagnosis code. Second document is the um explanation of benefits from the primary insurance, the one that says this is not a bill.
[CUSTOMER][NEUTRAL] Mm. Right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the third document is the claim form, the meddling claim form that you can find on our website at [PII]. So those 3 documents are the ones we need for any any claim, and once you have those 3, we can process the claim. We don't need the receipts.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] OK, but I'm looking, I, I don't, I recently went at the beginning of the year, but I don't see this on the Aetna, so I'm not sure why it's not on there.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Maybe they have not received the claim just yet from the provider of service.
[CUSTOMER][NEUTRAL] Well, we, well I.
[CUSTOMER][NEGATIVE] Well, no, they sent me the bill, because they, you know, they, the office isn't quick to send me bills. Now, I just don't know.
[AGENT][NEUTRAL] They do.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Oh, because this thing of service.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Yeah, if you don't see that it's reflected on your primary uh-huh.
[CUSTOMER][NEUTRAL] OK, so here's the goal. OK, so, so maybe this is what happened. I'm sorry. So I, I had, I had insurance.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And then I had the gap as well in [PII], but we went into uh [PII] with um including my daughter. So I don't know if the numbers are the same or not, you know, cause I see here, well, I'm just gonna submit this and see what you guys tell me and go from there. Honestly.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, you can do that. You can always just send what you have and let us look at it and see if that's what we need or if we need something else. Um, all claims are processed within 7 to 10 business days, so that's when we make a determination either we need information or either we go ahead and pay the claim.
[CUSTOMER][POSITIVE] OK. Perfect.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, perfect. OK, thank you so much.
[AGENT][NEUTRAL] You're welcome. Is there anything else I'm gonna help you with today, Mr. [PII]?
[CUSTOMER][POSITIVE] No, let's say you've been a lot of help.
[AGENT][POSITIVE] OK, well, thank you for calling APL. Have a good day.
[CUSTOMER][POSITIVE] Thanks you too. Bye-bye.
[AGENT][POSITIVE] Thank you, bye bye.
[CUSTOMER][NEUTRAL] Yeah.