AccountId: 011433970860
ContactId: ca00fd0c-ca46-44ad-b73a-8e77198cf249
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1009539 ms
Total Talk Time (AGENT): 378838 ms
Total Talk Time (CUSTOMER): 414741 ms
Interruptions: 1
Overall Sentiment: AGENT=0.9, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/28/ca00fd0c-ca46-44ad-b73a-8e77198cf249_20250328T20:59_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, hi. Good afternoon. Uh, my name is [PII], and I'm trying to, um, I have to submit some claims for my gap insurance, and I wasn't sure how to do that.
[AGENT][NEUTRAL] I can help you with that, Ms. [PII]. What is a good callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] Um, sure. It's [PII].
[AGENT][NEUTRAL] Thank you. And do you have your policy number available?
[CUSTOMER][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] Um, I do, so.
[CUSTOMER][NEUTRAL] Let's see here, the policy number is.
[CUSTOMER][NEUTRAL] 260
[CUSTOMER][NEUTRAL] 7944.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And can you verify your date of birth and current mailing address, please, ma'am?
[CUSTOMER][NEUTRAL] Yes. The address is [PII].
[AGENT][NEUTRAL] And your
[CUSTOMER][NEUTRAL] And what else do you need?
[AGENT][NEUTRAL] Your email please, ma'am.
[CUSTOMER][NEUTRAL] Um, yes, I don't know which one it was used, but, um, I'll give you my work email. It's um [PII].
[AGENT][NEUTRAL] That's the one we have on file. Is that the one you'd like to keep on file?
[CUSTOMER][NEUTRAL] Um, sure.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you for that verification.
[AGENT][NEUTRAL] Now, I am showing that your policy, the effective date was [PII].
[AGENT][NEUTRAL] So you can file claims since that effective date.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] And I'm looking, I don't see.
[AGENT][NEUTRAL] That you have an active account on our portal.
[AGENT][NEUTRAL] That is going to be the easiest way to submit claims, and you can also mail them or fax them if you're not comfortable doing it online, but you can go to secured and that, are you near a computer? I'll help you create that account.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah, I am um I'm trying to do it right now because last time because they didn't have a card, it didn't let me do it so let me try again right now here.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK. I think it's letting me.
[AGENT][NEUTRAL] And it looks like it's going through.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It says it's submitting so.
[CUSTOMER][NEUTRAL] Let's see.
[AGENT][NEUTRAL] I'm showing it's created.
[CUSTOMER][NEUTRAL] OK, so I'm in.
[AGENT][NEUTRAL] OK. So if you want to view your policy benefits, you would click on the policy number under the, under my coverage.
[AGENT][NEUTRAL] Where you see that policy number, you would just click on that, you'll be able to view all the benefits that are covered under your plan.
[CUSTOMER][NEUTRAL] OK, so, um, I have a few things that I need to submit. What, um,
[CUSTOMER][NEUTRAL] If it gets denied for some reason, do you know what the processing time is?
[AGENT][NEUTRAL] Sure. So I was trying to get, let's see, it looks like.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] We need to look at this other.
[AGENT][NEUTRAL] Hang on just a second.
[AGENT][NEUTRAL] I'm checking on your policy further, bear with me just one second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. I just wanted to check your policy. Yes, ma'am. So once the documents are submitted.
[AGENT][NEUTRAL] And the documents needed would be an itemized bill from the facility with the diagnosis and procedure codes.
[AGENT][NEUTRAL] And we'll need a copy, who's your primary insurance with?
[CUSTOMER][NEUTRAL] Cigna.
[AGENT][NEUTRAL] OK. Yeah, so we'll also need an explanation of benefits from Cigna, showing what they apply to your deductible, co-pay, or co-insurance for each data service.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now, on the diagnosis codes, your policy pays towards sickness or injury, so we cannot process a claim without that diagnosis code to indicate in fact that it is for a sickness or an injury.
[AGENT][NEUTRAL] So that is needed for each data service and then you can submit those documents online.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] There's also a direct deposit option if you prefer to have benefits go directly to your bank account.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] You'll get them a little bit quicker than coming by mail.
[AGENT][NEUTRAL] And I believe it just seems like the male is.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Struggling right now.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Normally takes between 7 to 10 business days to process.
[AGENT][NEUTRAL] Now there is another option if you have not paid for those services.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Then you can contact the provider and they can file a claim to us and we pay them direct.
[CUSTOMER][NEUTRAL] OK, so I'm interested in doing that because um this is what I wanna review so I had um.
[CUSTOMER][NEUTRAL] Let's see here uh.
[CUSTOMER][NEUTRAL] I had requested for Cigna to send me some of this um information but.
[CUSTOMER][NEUTRAL] Honestly, I don't know that they submitted anything yet.
[CUSTOMER][NEUTRAL] Let me just double check here.
[CUSTOMER][NEUTRAL] So you said that the explanation of benefits and all that, it's for each occurrence.
[AGENT][NEUTRAL] That's correct for each data service and each provider so I know um.
[CUSTOMER][NEUTRAL] Because what I asked, um sorry, so what I had, um, so I have two different scenarios. One was um blood work that wasn't covered fully for, you know, whatever the test that it was. So I requested them to send me the explanation of benefits. They just sent me the generic.
[AGENT][NEUTRAL] Go ahead. Go ahead.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You know, explanation of benefits that I have and then the.
[CUSTOMER][NEUTRAL] Provider gave me their invoice with the codes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so what I have to do with Cigna is I have to go online.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And look up that data service.
[AGENT][NEUTRAL] And click on the PDF file, the EOB claims details.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that will let us know what that was charged, what they paid, and what was applied to your deductible co-pay and co-insurance. Did you receive something that just says patient responsibility maybe?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, let me tell you. So, for example, one that I have right now is from
[CUSTOMER][NEUTRAL] Um, OK, so Cleveland Clinic, so I have in my my chart account because I have everything automated. I don't get anything, um, in paper, so I have an outstanding balance.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Of $1600 and then when I open it.
[CUSTOMER][POSITIVE] It gives me.
[CUSTOMER][NEUTRAL] Let me see.
[CUSTOMER][POSITIVE] OK, outstanding balance.
[CUSTOMER][NEUTRAL] That's very
[CUSTOMER][NEGATIVE] It's very hard to read because it doesn't it just opens up the whole story of the
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Of what I've paid and haven't paid.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Let me see if I can get a more detailed something here.
[AGENT][NEUTRAL] And in that instance, if you still have a balance, you could call them and make sure to give them your APL information and see if they will file the claim for you because they've already got all the documents needed.
[CUSTOMER][NEUTRAL] OK, so ask them to file the claim for me. OK, file claim.
[AGENT][POSITIVE] That's the easiest. Let them do the work for you.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Of course. Yes. And then, um, how did you say that I could see the, um, that I could see my benefits if, if I click on the group number, on the policy number?
[AGENT][NEUTRAL] The policy
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] On the policy number, it should download your policy certificate.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then this, um, I know that it was effective [PII]. It goes through when? [PII]?
[CUSTOMER][NEUTRAL] Of this year?
[AGENT][NEUTRAL] I am not seeing um I don't have a future termination date.
[AGENT][NEUTRAL] That I can see that would be determined by the group.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] It within when you open up that policy document, there's a page in there called a schedule of benefits page. That's the easiest page to look at for your benefits.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, let me just find the the schedule of benefits.
[AGENT][POSITIVE] Yeah, we can look at it together.
[CUSTOMER][POSITIVE] And benefits.
[CUSTOMER][NEUTRAL] In accordance with the section 5 benefits, would that be the one?
[AGENT][POSITIVE] Does it say schedule of benefits? I'm trying to get mine to pull up and it's just taking its sweet time.
[CUSTOMER][NEUTRAL] Oh, it's, I found one that just says benefits. So it says outpatient benefits.
[CUSTOMER][NEUTRAL] We will pay out of pocket amounts for treatment in a hospital emergency room.
[AGENT][NEUTRAL] Mm, this one, yeah, this one is like on page in my documents it's around page 34, and at the top it has schedule of benefits and these will show you the outpatient services that are covered and the benefit amount.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] OK, let me see.
[AGENT][NEUTRAL] So it's a little over halfway through the policy.
[CUSTOMER][NEUTRAL] I don't.
[CUSTOMER][NEUTRAL] Yeah, let me just check.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Schedule of benefits insert. OK, so it's probably at the end for me. Let me find it. OK, I see it. Schedule of benefits.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so outpatient maximum $500. Outpatient benefits link.
[CUSTOMER][NEUTRAL] So it's my maximum $500 is that what it is?
[AGENT][NEUTRAL] This per calendar day.
[CUSTOMER][NEUTRAL] 0 $500 per calendar day, OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So, emergency room, surgery, planning of patient diagnostic testing in hospital, outpatient facility or MRI. OK. So, for anything that I've um
[CUSTOMER][NEUTRAL] Let me see, anything that I paid out of pocket, I need to submit everything for anything that I haven't paid I I can ask them to send it for me.
[AGENT][POSITIVE] That's right.
[AGENT][NEUTRAL] And just make sure that we get the explanation of benefits from Cigna showing what was applied to your deductible, co-pay or co-insurance, and then we need that billing from the provider with the procedure codes and diagnosis codes. And sometimes,
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, just so you know what you're looking for for a diagnosis code, if in case you're not familiar with it, it's going to start with a letter.
[CUSTOMER][NEUTRAL] The code.
[AGENT][NEUTRAL] Followed by 2 numbers and then more for example M 54.92.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] It looks something like that.
[CUSTOMER][NEUTRAL] So because I'm gonna ask them to send it directly, it probably doesn't come to me. So I'll, I'll, I'll make sure that I ask for that, but where am I asking them to send this to you?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure, they can send it to our claims department. I can, I can give you the address. Do you have a copy of your card?
[CUSTOMER][NEUTRAL] I do mhm.
[AGENT][NEUTRAL] OK, so the address is on the back, that's at [PII] in [PII]ma City, Oklahoma.
[CUSTOMER][NEUTRAL] OK, and um is there like a electronic submission as well or or they don't have that option?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The electronic submission that is that payer ID I believe is listed on your card, it's 60801.
[AGENT][POSITIVE] And they can also fax claims directly to us as well.
[CUSTOMER][NEUTRAL] Alright, let me see what
[CUSTOMER][NEUTRAL] OK, so I don't have that um electronic submission. So what was that number?
[AGENT][NEUTRAL] 60801.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then is the fax the [PII]?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, so that is the the right.
[CUSTOMER][NEUTRAL] Um, OK. I think I, and then, so I'm asking Cleveland Clinic to send you.
[CUSTOMER][NEUTRAL] The itemized bill and then I'm gonna ask Cigna to send you.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] Coverage that I have for that particular
[CUSTOMER][NEUTRAL] Incident or whatever, right?
[AGENT][NEUTRAL] Right, so it's called an EOB and that is what they provide for each claim.
[AGENT][NEUTRAL] That EOB does show how they process the claim and what they applied to the deductible, co-pay or co-insurance for that specific data service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, so EOB data service, um, and then that comes from Cigna. OK, so whatever they denied, they need to send to you. All right, sounds good. Thank you so much. I appreciate your help.
[AGENT][POSITIVE] Oh, Miss [PII], it's been such a pleasure to assist you. Is there anything else you can think of before you go? I'll be happy to assist you.
[CUSTOMER][POSITIVE] Um, mm, that's it. Thank you.
[AGENT][POSITIVE] And thank you for calling APL. I hope you have a wonderful evening. Happy weekend.
[CUSTOMER][POSITIVE] You too thanks bye bye.
[AGENT][POSITIVE] Thank you. Bye-bye.