AccountId: 011433970860
ContactId: e78d3ee8-b3e6-4ff9-a7c5-67e4c48c8312
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 710260 ms
Total Talk Time (AGENT): 235550 ms
Total Talk Time (CUSTOMER): 273375 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/10/e78d3ee8-b3e6-4ff9-a7c5-67e4c48c8312_20250110T16:21_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, I just called and I spoke with one of your other agents. Um, I'm calling about my claim number 3,514,630.
[AGENT][NEUTRAL] OK, may I have your name and a callback number?
[CUSTOMER][NEUTRAL] [PII] [PII]
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And I do need to verify your date of birth please.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Could you verify your mailing address and the email address listed on file?
[CUSTOMER][NEUTRAL] The what?
[AGENT][NEUTRAL] Your mailing address and your email address listed on file.
[CUSTOMER][NEUTRAL] Oh, I'm sorry, it's [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And um the email is [PII].
[AGENT][POSITIVE] And thank you so much, [PII] for verifying your policy. You're calling in regards to claim number 3,514,630. How may I assist you on that claim?
[CUSTOMER][NEUTRAL] OK. She, the lady said that.
[CUSTOMER][NEUTRAL] Y'all don't have enough explanation that y'all need to know a breakdown, but on the page that I faxed in on October, let me see, I'm trying to see where this stuff is. [PII] I faxed in the explanation of benefits.
[CUSTOMER][NEUTRAL] And it says, uh, all the information that she's saying that y'all need, it says it on the uh the paper that I faxed in.
[AGENT][NEUTRAL] To
[CUSTOMER][NEUTRAL] I don't know why I just take it.
[AGENT][NEUTRAL] I'm pulling that image up.
[CUSTOMER][NEUTRAL] This is ATM.
[CUSTOMER][NEUTRAL] She's saying that.
[AGENT][NEUTRAL] OK, so what we received in is saying explanation of benefit, but there's nothing that is showing that it was applied to your deductible, co-insurance, or co-pay that has to be listed on that image.
[CUSTOMER][NEUTRAL] So when it says,
[CUSTOMER][NEUTRAL] Your discount 14.
[CUSTOMER][NEUTRAL] 2450, what is that?
[AGENT][NEUTRAL] That is probably the discount that they give you for either going in network, so the provider gave you a discount that does not say deductible, that does not say copay or co-insurance.
[CUSTOMER][NEUTRAL] OK, and then whenever it says your plan paid $168 what is that?
[AGENT][NEUTRAL] That is your insurance pay making that payment.
[CUSTOMER][NEUTRAL] So what, what is that considered to be?
[AGENT][NEUTRAL] That's the payment that your insurance paid to that provider.
[CUSTOMER][NEUTRAL] OK, and then whenever it says you saved.
[CUSTOMER][NEUTRAL] 159,250, 72% of your service was covered by your plan discounts from your employer sponsored benefits or other amounts for which you are not responsible. So what does that what does that uh amount.
[CUSTOMER][NEUTRAL] Uh, go far.
[AGENT][POSITIVE] If you would take that amount billed, your discount, and the amount that was paid by your pro your insurance, that would give you that amount that was saved.
[CUSTOMER][NEUTRAL] OK, and so then the $610 is what I owe.
[CUSTOMER][NEUTRAL] And it says this, the portion of this amount bill that you may owe to the provider, this amount includes your deductible, co-pay, co-insurance and non-cover charges.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So is that the part that you're saying that y'all need to know about the $610 I mean breakdown?
[AGENT][NEUTRAL] Anything that your primary insurance applies to your deductible, coinsurance or co-pay, it will be indicated on pages. It looked like you only submitted the first page of that EOB.
[AGENT][NEUTRAL] This is not a completed EOB.
[CUSTOMER][NEUTRAL] That's the only page I have.
[AGENT][NEUTRAL] And did you download this from the website or they submitted this to you?
[CUSTOMER][NEUTRAL] No, this was mailed to me.
[AGENT][NEUTRAL] OK, if you have the option, you may be able to go on to your website and access that EOB because there's a breakdown that indicates if it's covered or not covered. So that even though that amount says that is the amount that is owed and it says deductible, co-insurance, or co-pay, as you can see, it also says noncovered charges. So that could be a, that amount could not be covered by your primary insurance.
[AGENT][NEUTRAL] So we can't just say that the 16 was applied to your deductible coinsurance or co-pay.
[CUSTOMER][NEUTRAL] So which part are y'all going to pay?
[AGENT][NEUTRAL] Once we receive the needed documentation and it does show that it was applied to those, those deductible co-insurance co-pay, then we will process and make a payment if it's able to be paid.
[CUSTOMER][NEUTRAL] OK, so you're saying if the if the $610 charges says that it was for my co-pay, co-insurance and.
[CUSTOMER][NEUTRAL] My deductible that y'all will pay that amount?
[AGENT][NEUTRAL] We will pay whatever amount that you're whatever amount that you have available if you have up to that $610 then you may pay up to that $610. I can't process the claim over the phone, so I don't know how much you have available for that year.
[CUSTOMER][NEUTRAL] For the year?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, this is the first time I used the services, so how much does most how I think it was uh.
[CUSTOMER][NEUTRAL] It's $1000 or something dollars for the year. I'm not sure, but I know it's more than $610.
[AGENT][NEUTRAL] Let me pull that up for you.
[AGENT][NEUTRAL] So in regards to your policy, verification of coverage does not guarantee the payment of the claim. You do have up to $2400 per calendar year that we will pay out towards your policy that will go towards the primary insurance deductible, co-insurance, or co-pay.
[AGENT][NEUTRAL] This policy is only for sickness and injury. It will not cover any type of preventative or wellness. So once we receive that needed documentation, that examiner will review that claim. If it's eligible for payment, that claim will be processed and paid.
[CUSTOMER][NEUTRAL] You said that it will go towards what?
[CUSTOMER][NEUTRAL] Illness or what?
[AGENT][NEUTRAL] Sickness or injury?
[CUSTOMER][NEGATIVE] And it won't go to
[AGENT][NEUTRAL] Preventative or wellness?
[CUSTOMER][NEUTRAL] OK, because
[CUSTOMER][NEUTRAL] It's a breakdown there. I can't, I don't have the information in front of me, but it said something about, it was different, um.
[CUSTOMER][NEUTRAL] A breakdown of how I could use my um gap benefits so I know that I could use it at outpatient services, right?
[AGENT][NEUTRAL] Yes, you do have outpatient services, those are the benefits that I just gave you.
[CUSTOMER][NEUTRAL] OK, and it also said hospital.
[CUSTOMER][NEUTRAL] One for hospital also, right?
[AGENT][NEUTRAL] You do have inpatient as well.
[CUSTOMER][NEUTRAL] OK. So what does inpatient uh cover?
[AGENT][NEUTRAL] Let me check that for you.
[AGENT][NEUTRAL] For your inpatients you have up to $4000 per calendar year.
[CUSTOMER][NEUTRAL] So that means like you have to actually be admitted to the hospital.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So I have outpatient inpatient, and wasn't there a 3rd, uh, a 3rd 1 on there?
[AGENT][NEUTRAL] You have benefits for outpatient, inpatient, and for office procedures, so procedures that is rendered within an office setting.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So, and what's my, um, what's my maximum benefits for that?
[AGENT][NEUTRAL] That will be the $2400 per calendar year.
[CUSTOMER][NEUTRAL] And what does that cover?
[CUSTOMER][NEUTRAL] Procedures rendered in an office visit, in an office setting.
[AGENT][NEUTRAL] Anything that is rendered within an office setting, not the office visit fee, just anything rendered within an office setting.
[CUSTOMER][NEUTRAL] So like if you have an ultrasound, that will be considered in an office setting, right?
[AGENT][NEUTRAL] If it's done within, within your physician office.
[CUSTOMER][NEUTRAL] Well, I don't know. I don't know how they coded it, but I will, um, let me see if I could ask them for another breakdown and I will fax it, try to fax it so I could get this bill paid for. Thank you for explaining um the different benefits because I was not sure and I can't find the information. I don't know where I filed it at.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So let me try to find this information and I'll send it to you all today.
[AGENT][NEUTRAL] OK, and is there anything else that I can assist you with today, Miss [PII]?
[CUSTOMER][POSITIVE] Thank you very much.
[CUSTOMER][POSITIVE] That's it. Thank you.
[AGENT][POSITIVE] You're welcome, thank you for calling American Public Life. Have a great day.
[CUSTOMER][NEUTRAL] OK, bye