AccountId: 011433970860
ContactId: ea4def86-1958-4029-a161-b1d6e26f080d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 780780 ms
Total Talk Time (AGENT): 325597 ms
Total Talk Time (CUSTOMER): 406582 ms
Interruptions: 1
Overall Sentiment: AGENT=1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/18/ea4def86-1958-4029-a161-b1d6e26f080d_20250218T15:40_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII], and my husband has gap insurance through APL, um, and I was calling to follow up on a claim that was submitted as well as ask a question about whether or not another service is eligible for benefits under the plan. I have our ID. That's helpful.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, Ms. [PII], so are you also covered under this policy?
[CUSTOMER][NEUTRAL] I am.
[AGENT][NEUTRAL] OK, and you have a question regarding a claim that was submitted and also an additional benefit question, is that correct?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][POSITIVE] Yes, ma'am. I can help you. And what is your callback number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And your policy number please, Ms. [PII]?
[CUSTOMER][NEUTRAL] 01893557
[AGENT][POSITIVE] Thank you one moment.
[AGENT][NEUTRAL] OK, and Miss [PII], I will have to verify several pieces of information with you first for security and then also any information that I do provide for you today would be a verification of benefits and not a guarantee of payment. So if you could first please verify your husband's name and date of birth and then your date of birth.
[CUSTOMER][NEUTRAL] [PII] [PII] [PII] 72558.
[AGENT][POSITIVE] Thank you. Also your home mailing address, please.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. The phone number that we would have on file uh for Mr. [PII]?
[CUSTOMER][NEUTRAL] Hm, good question. We have [PII] [PII]?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, which is also the, OK, that is also the one you gave me, so you're saying that is one of the numbers that we have on file. OK, so that'll be the last piece of information that I need to verify. Give me just one moment please.
[AGENT][NEUTRAL] OK, so how can I help you today, Ms. [PII]?
[CUSTOMER][NEUTRAL] I have a confirmation of a claim submission made on [PII].
[CUSTOMER][NEUTRAL] Uh, with the confirmation help you? Do you need that number?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, is the claim for you or for Mr. [PII]?
[CUSTOMER][NEUTRAL] This one is for Mr. [PII].
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, do you have the claim number?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hold on 1 2nd, hold on 1 2nd. I'm not sure if it's, oh no, this is for me. I'm so sorry. Yes, this is for me.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Um, and the confirmation number is Oscar Sam Charlie 92574.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, now I don't have a claim on file for you for that.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] This is this is a claim submission confirmation that came from APL, so I don't know why you would not have that.
[AGENT][NEUTRAL] OK. OK. So what is the last number again? What is, you said, give me that number one more time, please, Ms. [PII].
[CUSTOMER][NEUTRAL] That's the number or the letters as well?
[AGENT][NEUTRAL] You don't have to give me the OSC part, just the numbers will be fine.
[CUSTOMER][NEUTRAL] 92574
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, now, we share that claim to be for Mr. [PII], not for you.
[CUSTOMER][NEUTRAL] That's bizarre because it's for my um lumpectomy that happened on [PII].
[CUSTOMER][NEUTRAL] So I don't know why that would be. I'm, I'm looking at the claim form submitted section B about the patient has my name.
[AGENT][NEUTRAL] Yes, ma'am. It appears that this was submitted through the portal. It was uploaded in the online service center.
[AGENT][NEUTRAL] So it looks like it was submitted under his name and instead of your name.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So maybe that was what the glitch was and why I haven't heard.
[AGENT][NEUTRAL] I can see this claim was reviewed and it does state in order to provide further consideration to this claim, please submit the following items explanation of benefits from the primary insurance carrier for this data service, and the second remark states the diagnosis for which treatment was provided on this date of service. Once we have received this information, we will resume processing this claim.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, um, and United Healthcare has, uh, uh, made me jump through 10 hoops to get that explanation of benefit.
[AGENT][POSITIVE] Oh goodness.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Um, because 23, however, the bill that I paid that you have a copy of came to me on like last month.
[CUSTOMER][NEGATIVE] So they made it very difficult for me to access a statement date. Sorry, it says [PII], so I probably got it during the holidays and um didn't get around to submitting this until January. So I'm just uh um kind of between a rock and a hard place because it was breast cancer surgery that was um completed and.
[AGENT][NEUTRAL] Sorry.
[CUSTOMER][NEGATIVE] I don't have a way to get the explanation of benefits from United Healthcare, despite the fact that they probably paid out over $20,000 for this surgery, um.
[CUSTOMER][NEUTRAL] So I'm just trying to navigate what to do or how to do it since I have claims and copy of claims from [PII] but I don't have any of the information from [PII] um because like I said they they either archive well I don't know what they do with it, but they told me I have to go through an appeal process to get a copy of my coverage of my EOB.
[AGENT][NEUTRAL] Oh, OK. Um,
[AGENT][NEUTRAL] OK, so they, so United Healthcare told you that you must go through an appeals process to get a copy of an explanation of benefits from [PII].
[CUSTOMER][NEUTRAL] Isn't that crazy?
[AGENT][NEUTRAL] Um, I mean, honestly, Mr. [PII], I've never heard of that before.
[CUSTOMER][NEUTRAL] I mean, it's, it's my.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Figures.
[AGENT][NEUTRAL] Yes, I mean
[CUSTOMER][NEUTRAL] I'm just looking to
[AGENT][NEUTRAL] And do you have access, I mean, you know, like we have our portal that you all have been submitting claims through. Do they have a portal?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That you can log into and and have get the.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] Information there.
[CUSTOMER][NEUTRAL] Yes, and I went
[CUSTOMER][NEUTRAL] Get out. Hang on a second. Look out, look out, move.
[CUSTOMER][POSITIVE] OK, we're gonna get her.
[CUSTOMER][NEUTRAL] Um, I'm just gonna look one other possible place because I kept a record of.
[CUSTOMER][NEGATIVE] All of the medical stuff for my breast cancer somewhere if I can find that and then maybe in there I have something that'll show no that's not it, something that'll show what was done um so I guess I'm just gonna have to either I mean I already paid this bill obviously since it was from.
[CUSTOMER][NEUTRAL] A while ago and I didn't want any credit, you know, issues, um, fortunate.
[AGENT][NEUTRAL] Yes, ma'am. Sure.
[CUSTOMER][NEUTRAL] So, um, now it's just a question of whether or not it's a.
[AGENT][NEUTRAL] Now,
[AGENT][NEUTRAL] Let me ask you this. I can see that this particular claim was for Boca Raton Regional.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, have you contacted the facility? See, they should have received, I mean, the way our process works is we send the explanation of benefits to the provider and to you, OK? Even though you have access to your information online as well. But the hospital, I would think, would have received some type of explanation of benefits showing.
[AGENT][NEUTRAL] You know, what your primary insurance had taken, had paid or applied, you know, I mean, I would assume that they would have received.
[AGENT][NEUTRAL] A copy of that. You may want to reach out to them to see if they have a copy of that. If you're saying UnitedHealthcare is going to make you go through an appeals process.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] Just to get a copy of an explanation of benefits again, I'm sorry for all the confusion, Ms. [PII], but I've just never heard of that.
[CUSTOMER][NEUTRAL] I know, I know, and, and trust me, I, I have like 8 different types of insurance besides GAP, and I've been doing, you know, submitting claims and doing everything I know I'm supposed to do.
[AGENT][NEUTRAL] Mhm, right.
[CUSTOMER][NEUTRAL] Uh, since [PII], so I'm pretty savvy about what needs to be done and how it needs to be done and when it needs to be done. I was just really taken by surprise when I got a bill 18 months after a procedure, you know, like what the what the delay was, I have no idea.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, but in any case, I'm just looking through some paperwork that probably I received after the procedure that, that, but none of it has, I, I don't, I didn't attach the explanation of benefits. It was all just stuff from the hospital that they provided to me.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Yeah, um, and I'm pretty sure like when I get my explanation of benefits I put it in the file and the next year I put it like in archive so maybe maybe I can find that file in my garage but. OK, so that's.
[AGENT][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] You know, thank goodness that's only 221, but the next one is 1500, and that one is for my out of pocket deductible, um, for an outpatient procedure that my husband had, and I wanted to know whether or not, um, it was something that, um, his gap insurance covers.
[AGENT][NEUTRAL] OK, so on this policy, there is an outpatient benefit maximum of $500 per covered person per calendar day for covered outpatient services, Ms. [PII], with no outpatient deductible per covered person per calendar day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So what do I need to submit for um consideration for this uh procedure? What, what do?
[AGENT][NEUTRAL] OK, so the the easiest way, Ms. [PII] is for me to give you the website, our website, because we have the specific claim form for this Medlink policy.
[CUSTOMER][NEUTRAL] I have the
[CUSTOMER][NEUTRAL] Yeah, I have that form in front of me.
[AGENT][NEUTRAL] OK, all right, so on page one at the top there are specific instructions for completing the form and then also what other documents are needed.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I need an EOB on this one and I need an itemized bill with diagnosis from the hospital.
[AGENT][POSITIVE] That is correct. Yes, ma'am.
[AGENT][NEUTRAL] And then you all can upload that just like you did before directly into the, into our portal for review. But just use that and those instructions as your checklist. That's what I call it a checklist for what you need to provide us.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, very good. Well, thank you for your help and.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Appreciate it.
[AGENT][POSITIVE] Well, you, oh, well, you're certainly welcome. So is there anything else at the moment that I could help you with, Miss [PII]?
[CUSTOMER][POSITIVE] No, ma'am, I, I think you've given me everything I need for now thank you so much.
[AGENT][POSITIVE] Well, you are certainly very welcome and thank you again for calling APL. I hope you have a very nice day.
[CUSTOMER][POSITIVE] Thank you you too bye bye.
[AGENT][POSITIVE] Yes, ma'am. Thank you. Bye bye.