AccountId: 011433970860
ContactId: e6c6ccff-6955-4e4c-a40d-bdb572951e25
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 646299 ms
Total Talk Time (AGENT): 337296 ms
Total Talk Time (CUSTOMER): 221246 ms
Interruptions: 3
Overall Sentiment: AGENT=0.7, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/30/e6c6ccff-6955-4e4c-a40d-bdb572951e25_20241230T18:29_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, um, I just called a couple minutes ago because I had a question about um my policy, and, um, I was trying to register online but I'm no longer covered, um, so I was just wanting to see this might be a silly question, but like what kind of claims can I submit to you guys even if like during the time that I was covered.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Sure, OK, yeah, we can let me get your policy pulled up and we can take a look at that. uh, what was your name?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and [PII], can I get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and do you have your policy number?
[CUSTOMER][NEUTRAL] Uh yes. It's uh 02452173.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Alright, so you were trying to create an online account to submit some claims, um, of course you're unable to because your policy is terminated, is that correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, got you. Alright, and [PII], I'm just gonna verify some information really quick. Can I get your date of birth please?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] Thank you and then can I get your mailing address?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] Perfect. The last thing I need is the email address that we've got on file for you.
[CUSTOMER][NEUTRAL] The what? I'm sorry?
[AGENT][NEUTRAL] The email address we've got on file for you, uh, looks like it is a Gmail account.
[CUSTOMER][NEUTRAL] Uh, it should be [PII].
[AGENT][NEUTRAL] That's it. OK, thank you so much for verifying all of that. OK, so yes, well you would be unable to create or use our online portal you could still submit claim information so I've got your policy was active from [PII] up until [PII] so anything within that time, uh, you can definitely file those claims. I've got a mailing address, a fax number, um, how would you prefer to send those claims?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, probably by mail, but I, I'm like, I don't know what exactly, um, like, honestly, the, the policy is kind of confusing. I'm not too familiar with the, what claims I'm able to submit, yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] Oh, trust me, no, no, you're fine.
[AGENT][NEGATIVE] It is confusing
[AGENT][NEUTRAL] I work with it it's still confusing, um, so I can send you a copy of the policy if you'd like, [PII]. Uh, it's very easy to read and it does go through what is and is not covered dollar amounts, things like that. Um, in short, I can tell you the information that we would need to file claims. Um, let me know when you're ready.
[CUSTOMER][NEUTRAL] OK, go ahead.
[AGENT][NEUTRAL] OK, so we would need itemized statements that show diagnosis and procedure codes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then we would need the explanation of benefits from your primary insurance. So essentially that would this policy is very dependent on your primary. So if it's something that your primary did not pay on this policy cannot, we would have to see what your poli or what your primary paid.
[CUSTOMER][NEUTRAL] OK, so, um, you said the itemized statements that shows the diagnosis and the explanation of benefits and what else?
[AGENT][NEUTRAL] Um, so the itemized statement shows diagnosis and procedure codes.
[CUSTOMER][NEUTRAL] And procedure, OK.
[AGENT][NEUTRAL] Yes, and then the explanation of benefits uh from your primary showing what they paid and that we're gonna need that information for each claim.
[CUSTOMER][NEUTRAL] Gotcha. OK. Um, is there a way to find out like if
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] If what um.
[CUSTOMER][NEGATIVE] The procedure was like if it would be covered or would I need to submit all of this first? Cause I don't want to bother, you know, getting all this stuff and then it turns out it's not even covered or whatnot.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Sure, no, you're perfectly fine. Um, so yeah, I can take a look. Uh, I'll also send you your policy so you can kinda look if there's something you remember later and you're not sure, um, you can have that information there. Um, was it a, did you have a surgery or anything like that?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, I had like this um procedure like at the dermatologist, um, but it turned out it was like an outpatient, like her office is like at an outpatient facility. So I don't know, I saw it here on the card it says outpatient benefits, so I don't know exactly if that would um cover it or whatnot.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] What, what was the procedure?
[CUSTOMER][NEUTRAL] Um, she, uh, I don't even know exactly what to call it. She, she pretty much just like injected me with like this, um, medicine for like a bump that I had on my back.
[AGENT][NEUTRAL] OK, um, let's see, but it was an outpatient facility.
[CUSTOMER][NEUTRAL] It was, yes, at an outpatient facility.
[AGENT][POSITIVE] Alright, bear with me just a moment. I'm going to your outpatient benefits here.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK. So I don't see that that would be a covered benefit. Um, on your policy for your outpatient benefits, you've got um hospital emergency room, urgent care facility, uh, surgery, and then a hospital facility or outpatient surgical center,
[AGENT][NEUTRAL] Gnostic testing in hospital outpatient outpatient facility or MRI facility and then outpatient treatment for a mental or emotional disorder in a hospital outpatient facility and then you've also got physical therapy and then ambulance coverage.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Got you. OK, so if I, if I, because in another instance, I went to the ER. I didn't stay overnight or anything, so, but that would be covered as well. So how does it work? Because I obviously, uh-huh, go ahead.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, hospital emergency room.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, you're fine, go ahead.
[CUSTOMER][NEUTRAL] Um, like I didn't stay there or anything, and I was just there. They ran some tests, but, um, like the insurance did cover most of it. I can't remember exactly what I paid, so you guys technically, like what, what would be the purpose of submitting a claim like you guys would cover more of it or?
[AGENT][NEUTRAL] Yeah, so in short, what this policy uh is designed to do is help with co-pay, deductible and co-insurance. So after that that remaining balance after your primary pays, um, that's what this is designed to help with. So if you can get that original information, you can call that uh provider that you went to or that emergency room, they should be able to get all of this information for you.
[AGENT][NEUTRAL] So again just that itemized statement showing those codes and then the EOB from your primary and then you can send that to us and you know your outpatient benefit uh was up to let's see $1000 per calendar year so it would pay up to that amount for your outpatient.
[AGENT][NEUTRAL] I know you said you didn't stay in like you weren't there overnight. If you were, that would have just been your inpatient benefit.
[CUSTOMER][NEUTRAL] Gotcha. OK. Oh, cool. Yeah.
[AGENT][NEUTRAL] Does that make sense?
[AGENT][NEUTRAL] OK, I know it's confusing, trust me.
[AGENT][NEUTRAL] But the best thing is to, you know, if you send this information to us um and it turns out that there is some missing information or anything like that we'll be able to let you know um or if it's something that's not covered it's as simple as us just saying it's not covered but if it's something you're not sure about you can always call and ask or you could go ahead and submit it anyway you know best case scenario it is covered.
[AGENT][NEUTRAL] But it's not a big deal if it's not.
[CUSTOMER][NEUTRAL] Got you. Right. OK, cool. Um, do you mind sending me over still the, the, um.
[AGENT][NEUTRAL] Absolutely, your policy, did you want me to just email that to you?
[CUSTOMER][NEUTRAL] Policy, yeah.
[CUSTOMER][NEUTRAL] Oh yeah, if you don't mind.
[AGENT][NEUTRAL] OK, yes, just the [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Alrighty, yep, I will get that sent to you. Did you have any other questions for me at the moment?
[CUSTOMER][NEUTRAL] Um, no, are you able to send over the um the form like if I wanted to submit this claim for the um.
[AGENT][NEUTRAL] Oh yeah I can send you a claim form for sure and it's just for future um you can they are on our website as well, not the portal um our public website which is [PII] you don't have to sign up uh to go to that website and our we do have, uh, claim forms there as well if you needed any additional ones but I can go ahead and send you one as well.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][POSITIVE] OK, cool.
[AGENT][NEUTRAL] Yeah, of course.
[CUSTOMER][NEUTRAL] Um, and then I, one last question. I remember a couple of years ago on my old employer, I had a plan, um, kind of similar to this, I guess, and there was like a wellness, like a screening benefit or something like that it's like, it's like a questionnaire and then you submit it and you you get like a benefit for it is that something that you guys do as well?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] This plan does not no, um, as none of the, let's see, I think there was a, what did I say?
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Diagnostic testing benefit it's gonna be the closest thing to that but again that would be in a hospital outpatient facility or MRI so I would think that's for something a bit, but it's not so much a wellness benefit.
[CUSTOMER][POSITIVE] Gotcha. OK, cool. All [PII], good to know. Thank you for your help. Appreciate it. Mhm.
[AGENT][POSITIVE] Yeah, definitely, of course.
[AGENT][POSITIVE] You're very welcome. Thanks for giving us a call. I hope you have a happy new year.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you, bye bye.