AccountId: 011433970860
ContactId: d87fad8a-d772-4035-b64c-2d4255604b5a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 777780 ms
Total Talk Time (AGENT): 408119 ms
Total Talk Time (CUSTOMER): 297593 ms
Interruptions: 2
Overall Sentiment: AGENT=0.5, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/06/d87fad8a-d772-4035-b64c-2d4255604b5a_20250306T23:23_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL, this is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], yes, I'm wondering if you could help me. Um, we have, uh, APL insurance, um, but I'm actually, um, in a different state. I don't have my ID number, um.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I was wondering if you could help me look that up, um, because I wanted to give it to a surgery center for my husband to see if they, and actually I had a question about that. If he has to have a procedure, can they call and check and see if, if the supplemental amount would be covered by you, or does he have to have it, the actual procedure and then do we submit it to you? Cause I've, we've never used.
[CUSTOMER][NEUTRAL] This type of insurance before, so like our Aetna insurance won't cover.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, this procedure cause we haven't met our deductible. Um, so,
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm not, like I said, I've never used this before, so.
[AGENT][NEUTRAL] OK, yeah.
[AGENT][NEUTRAL] OK, yeah, let's take a look. So, um, who is the policy holder? Is it you or your husband?
[CUSTOMER][NEUTRAL] It's my husband, um [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII] First name is [PII] again?
[CUSTOMER][NEUTRAL] Mhm, yeah.
[AGENT][NEUTRAL] OK, let me, um, yeah.
[CUSTOMER][POSITIVE] Thank you very much.
[AGENT][NEUTRAL] Take a look.
[AGENT][NEUTRAL] And then if I could get his date of birth and the address we should have on file please.
[CUSTOMER][NEUTRAL] Yeah. Date of birth is [PII] and our address is [PII].
[AGENT][POSITIVE] All right, thank you so much. And then it looks like the uh email on file, let's see what that is, just wanna make sure it's correct so.
[AGENT][NEUTRAL] Looks like we have um [PII].
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] [PII] is that a work email form maybe?
[CUSTOMER][NEUTRAL] Sorry, say that again. I'm sorry. I couldn't, you cut out.
[AGENT][NEUTRAL] That's OK, yes.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh, OK, they've changed their email so actually that might be, yeah, it's actually actually [PII].
[CUSTOMER][NEUTRAL] Um, [PII]. So [PII].
[AGENT][POSITIVE] A lot. OK. We can update that. Yeah.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK, so the secondary plan does pick up any sort of deductible, co-pay, or co-insurance that your primary does not. And so secondary plans really have kind of an umbrella of either it's inpatient or it's considered outpatient. So is the surgery inpatient is defined as being in the hospital for 13 or 18 hours, excuse me, or longer.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and so do you know if he'll be outpatient?
[CUSTOMER][NEUTRAL] No, it's just an
[CUSTOMER][NEUTRAL] No, it's just a, yeah, it's just an endoscopy, um, so it's just, um,
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So it's outpatient, yeah, it's just.
[AGENT][NEUTRAL] OK. Uh,
[CUSTOMER][NEUTRAL] Outpatient endoscopy. Um,
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But so I wasn't sure like.
[CUSTOMER][NEUTRAL] If I had the surgery center like contact you guys for approval or if he does it and then we submit the paperwork like I wasn't sure how it worked, um.
[AGENT][NEUTRAL] The easiest way honestly is that they'll submit the claim for you. If you just advise the physician or surgery center that uh you said Aetna was your primary, so if you say, hey, I have two different insurances. I have Aetna as my primary, and then I have APL as my secondary, um, they can call us to verify the eligibility um and benefits. So,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so yeah, so they called Aetna and Aetna said we had met our deductible, and that's why I was calling you because I, as I said, I'm out of state and I don't have my um number or anything to give them to call you because they'd call and just say I didn't they called and just said his name if that was enough or if I needed to give them like our um.
[CUSTOMER][NEUTRAL] You know, number or anything, so that's why I was calling if they just called and said his name, is that enough or or if you could give me like our um ID number or anything that I had to give them.
[CUSTOMER][NEUTRAL] Um,
[AGENT][POSITIVE] Yeah, absolutely. So you're
[CUSTOMER][POSITIVE] When I call the woman back thank you.
[AGENT][NEUTRAL] Yeah. Here's your policy number whenever you're ready.
[CUSTOMER][POSITIVE] OK, I'm ready thank you.
[AGENT][NEUTRAL] 002553332.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And your outpatient benefit amount uh max is $250 so the max that this is gonna cover is $250. I'm not sure what your deductible with Aetna is.
[CUSTOMER][NEUTRAL] Our deductible with Aetna was 1000 but nothing so we would have had to pay, so, um, so they said the procedure was like 6 or 700.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So we would have had to pay the whole thing.
[CUSTOMER][NEUTRAL] Right, so,
[AGENT][NEUTRAL] Yeah, because the 250 that this would pay would just go towards your meeting your deductible.
[AGENT][NEUTRAL] Since it hasn't been met with Aetna, does that make sense?
[CUSTOMER][NEUTRAL] Right, but so then when we pay the 250, then the rest would be covered, is that how it works?
[AGENT][NEUTRAL] No, this plan is only gonna pay the 250 any sort of right, any difference would be um.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh, it's only pay the 250 and then OK so.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Well, I mean, it's better than nothing.
[CUSTOMER][NEUTRAL] You know,
[CUSTOMER][POSITIVE] Because, yeah, Aetna wasn't going to pay anything. So, it's still better than nothing, you know.
[AGENT][NEUTRAL] Yeah, no absolutely so they all they need is that policy number um to verify benefits and eligibility with us and then when they call if they need any additional information as far as how or where to file claims we can um advise on that too.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so it pays usually what percentage of.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Of um
[CUSTOMER][NEUTRAL] The supplemental pays like just a certain percentage.
[CUSTOMER][NEUTRAL] Of procedures and different things. It just depends on the cost or.
[AGENT][NEUTRAL] Um, your plan has just, it's not a percentage like a, it's not like a PTO or anything like that. It's just you have the calendar year max for your inpatient and outpatient, um, or let's see, this plan is per occurrence.
[AGENT][NEUTRAL] So what that means is that this plan is only gonna pay up to $250. It's not a percentage it's not that's the set amount of $250 for anything that falls under outpatient care.
[AGENT][NEUTRAL] And per occurrence means.
[AGENT][NEUTRAL] Per, um, how do you explain this? Per set diagnosis. So, um, if you're having the end endoscopy, it's gonna pay the 250 for that. If let's say 6 months later you have something else come up where you have to have another procedure done for a different ailment, then that would be a different occurrence. So then that, you would have the 250 again.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, the inpatient benefit on this is $500 per occurrence. So if you were admitted into the hospital for, let's say a stroke, you would have a max benefit of $500 for your entire inpatient stay. Um, it's only gonna pay the $500. If 3 months later after the stroke and you had a heart attack, that's a different occurrence because it's a different ailment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK, got it. OK.
[CUSTOMER][NEUTRAL] OK, great. Well, thank you for explaining that to me. So it's uh so that's basically what it is and then it's not, does it cover ever like co-pays or like anything like that if those aren't paid like co-pays or medicine or any stuff like that?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I don't think this one covers prescriptions. Let me see.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much. Like I said, I've never had this before, so I have no idea.
[AGENT][NEUTRAL] Covers.
[AGENT][NEUTRAL] Yeah, um.
[AGENT][NEUTRAL] Um, so yeah, it looks like it does carry, um,
[AGENT][NEUTRAL] A writer, so it does cover the physician's office visit. So if any time you go to see a physician, um, yeah, it should cover your co-pay also and reimburse you for that, so.
[AGENT][NEUTRAL] And urgent care is also.
[CUSTOMER][NEUTRAL] OK, so then
[CUSTOMER][NEUTRAL] Oh really? OK, so then how, so if we, because I, we've seen some, we always have to pay copay, so how do we, do we just submit.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The, the bill and that stuff.
[AGENT][NEUTRAL] Um, so for, yeah, you can submit any sort of, you know, expenses that you've had while the plan has been active, so you can go back if there's been any that you've missed or anything like that, there's no.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Time frame as far as getting those submitted, um, as far as what you would need to submit, the first thing that you need is the claim form, and those are.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Available on yeah on our website and the form that you need is the med link claim form. It's on page 2 they're in alphabetical order on the site.
[CUSTOMER][NEUTRAL] Online I saw, I think.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, so you'll need an itemized bill with diagnosis codes from the provider for the date of service.
[AGENT][NEUTRAL] And then you need the explanation of benefits from Aetna, your primary, because we need to see exactly what they paid and applied towards any deductible or co-pay.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And on the claim form when you find it on our site there's a link there to download it. Page one is simply just instructions for you as far as like what is needed so um it is all listed there as well and then you can submit those to us online if you've ever done the online service center that's an option um they can also be faxed or they can be sent in the US postal mail.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][POSITIVE] Great. Thank you so much for your help. I appreciate it.
[AGENT][POSITIVE] Yeah, no problem. Do you have any other questions or concerns?
[CUSTOMER][POSITIVE] Nope, that was it. I appreciate it. Have a great night.
[AGENT][POSITIVE] You too, take care.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye.