AccountId: 011433970860
ContactId: fd3912e6-9a80-4471-82c2-49ab2c8f09f2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 740710 ms
Total Talk Time (AGENT): 412189 ms
Total Talk Time (CUSTOMER): 337778 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/03/fd3912e6-9a80-4471-82c2-49ab2c8f09f2_20250303T17:51_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], um, my name is [PII], and the reason I'm calling is I made a claim and um got a letter back from you guys and not really understanding, um, the reason that.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] The uh claim is not being paid because it's a it's a claim for a uh hospital um co-pay so the letter I got in response said um office visits are not covered but it wasn't an office visit so I just wanted to clarify that with somebody.
[AGENT][NEUTRAL] OK, [PII], so we, you filed a claim for yourself and the claim has been reviewed, but you have a question regarding the decision on the claim, is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][POSITIVE] Yes, ma'am. I can help you with that. And what is a good callback number for you please?
[CUSTOMER][NEUTRAL] Sure. My cell number is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And your policy number, please?
[CUSTOMER][NEUTRAL] Sure, my policy number is 0229.
[CUSTOMER][NEUTRAL] 859-5
[AGENT][NEUTRAL] OK, thank you. So give me just a couple of moments please to get all of your information pulled up. Once I do, then I will need to verify several things with you, Miss [PII] first for security purposes, and also any information that I provide for you will be a verification of benefits and not a guarantee of payment. So first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][POSITIVE] Thank you and also your home mailing address.
[CUSTOMER][NEUTRAL] Uh, my home mailing address has recently changed. It's now [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm. No, go ahead.
[CUSTOMER][NEUTRAL] Uh, uh
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Thank you. The phone number that we have on file for you is the same as the one that you gave me, so that is the best contact number that we should have, is that correct?
[CUSTOMER][NEUTRAL] Yes it is.
[AGENT][NEUTRAL] OK, thank you. And lastly your email address please?
[CUSTOMER][NEUTRAL] Uh yeah, my email address is [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. So Miss [PII], what is the date of service that you're calling in about, excuse me, calling in regards to today?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Sure it was um [PII], hold on a moment, I have to pull up, pull it up um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You're fine.
[CUSTOMER][NEUTRAL] I, I should be on the paper that I uploaded to you guys already, but it was, I believe it was [PII].
[CUSTOMER][NEUTRAL] No, it wasn't [PII]. It couldn't have been. Hold on.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Do you have your claim number, Ms. [PII]?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, yeah, so the claim number is 356.
[CUSTOMER][NEUTRAL] 853-3.
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so Miss [PII], the, I can see on that particular claim number, it had
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Two different dates of service.
[AGENT][NEUTRAL] There was a [PII].
[AGENT][NEUTRAL] And I can see that um you are set up in the online service center. Do you actually have your explanation of benefits? OK. So if you'll notice on page two.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It has all of the remarks that go along with the codes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So for example, on one of them, your primary paid everything. Um, the other code states that receipt of the claim is acknowledged, however, in order to provide further consideration of this loss.
[AGENT][NEUTRAL] Under this policy, we will need supporting documentation to evidence the accident sickness. Supporting documentation may include that it is not limited to itemized bills with the diagnosis codes, super bills, office notes, hospital admission and discharge summaries, and or other excuse me, and or diagnostic testing results.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So that has to do with your data of service 1226.
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] It yep, OK, and I did see that on the paper uh when I uh entered the last information I uploaded, I only put the face the hospital face sheet because I wasn't, I didn't know that I needed to provide the whole medical record, but I actually have the whole medical record because I got a copy of my medical record, um, just for this claim.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I can send the entire medical record to you guys, do you want me to upload it into.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You can, you can upload it into your portal. Now, you may have to break it down depending upon how many pages it is, but don't worry about that. You may just have to upload several sections at a time, but the system will know to tie all of that together. Now, the one where it said office visits are not covered, that was for [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, OK, yeah, um.
[AGENT][NEUTRAL] It's for that data service.
[CUSTOMER][NEUTRAL] Yeah, I'm not even sure what that was for, but the only, the only, the only thing I was doing the claim for was for the emergency room visit co-pay.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] OK. And so, we will, right, this was for, that was for a Doctor [PII] on [PII]. But anything that's included, when we receive information, Ms. [PII], it will get reviewed.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Oh, OK, yeah, unfortunately the um explanation of benefits from my insurance company Aetna, they don't have them separated, they have them all together on one page.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm. Mhm.
[AGENT][NEUTRAL] Yeah, so, and you know, just for future reference if you're gonna file your claims because I can see you've filed several things and now you know, I'm assuming that you know, but you may not. When you, with this policy that you have, you can present your APL ID card along with your primary insurance card.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] To your providers. Most providers will file both of your insurances, so that cuts down on some of the work that, you know, you have to do in trying to get all of this together. But if for any reason they either don't file it or you just want to file it yourself, then that's perfectly fine as well.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] Yeah, I actually when I went into the emerg when I went to the hospital, I gave them uh my APL card along with my insurance card, but they didn't they never did anything with it they didn't try to do anything so that's why unfortunately that's why I'm following up.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] OK. Well, and I only, I only say that because some people, they think that they have to file their supplemental themselves, um, but, you know, most of the time the providers will do it and they have to wait until it's been filed with your primary insurance because we always will have to have the explanation of benefits from your primary insurance carrier when we review a claim.
[CUSTOMER][NEGATIVE] I wish they had.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So, you know, sometimes I guess maybe it falls through the cracks, maybe they do file, but for whatever reason, again, it just slips through. But um yes, ma'am, just upload the information into your portal. You won't be able to add it to this existing claim number that you have, but our system will know that this was, you know, additional information we were needing.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, yeah, I just, uh, I'm sorry I didn't put it in there before because I thought that you guys only needed the diagnosis so I only put the, um, I only put in the face sheet but I'll put the entire thing and I'm, it's not that many pages I think it's only like 14 pages or something.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It probably will um be that will probably upload by itself but if for some reason you get an error message, you know, just try to break it down into smaller sections now has anyone ever emailed you, um, Ms. [PII] the user guide for the portal?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It is
[CUSTOMER][POSITIVE] Um, no, but I think I actually know how to do. I actually was able to access the user guide from the web page from you guys' portal, you know, from the portal because I can get in there usually, um, yeah, but you know I, it's kind of minimal, the directions honestly so so I kind of winged it and just put in there what I thought was right so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Oh, OK, excellent.
[AGENT][NEUTRAL] OK. Sure.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Well, I think you did a good job because it lets you set it up. And so, in the future, if you have to file another claim yourself, if you go to our main website at [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] There's a tab at the top that says claims and forms.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And if you click there, that's where you can get your Medlink claim form and that top section of the claim form, Ms. [PII], it has bullet points with instructions, so I always recommend to use that as a checklist of what you need when you file a claim on this type of policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK, sounds good, yeah, so I'll go ahead and I'll I'll go ahead and get that information uploaded and um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, it was just for the copay, um, and the only reason I went to the emergency room was because I couldn't urinate at all and only blood was coming out so I had like I, I would have definitely tried to just go to my provider, you know, my doctor's office, but yeah, but.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Sure. Sometimes, right. Sometimes we can't though, I mean.
[AGENT][NEUTRAL] Sometimes our circumstances don't allow for that.
[CUSTOMER][NEUTRAL] Yeah, I have to go.
[CUSTOMER][POSITIVE] Yeah, OK, well thank you so much for your help. I'll go ahead and upload that and then just wait and see, um, I, my coverage actually is gonna be ending soon because I changed insurance companies, so that was another reason I was concerned about getting this taken care of, uh, before my coverage ends, you know what I mean? So, um, yeah, so I'll go ahead and upload that today.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] And, and just.
[AGENT][NEUTRAL] Just so you're aware too, on that note, um, Ms. [PII], APL does not have a timely filing limit. So even if you, if you find a claim that's, you know, had not been filed with us, even once your policy is no longer active, as long as the data service was with them when your policy was active, you could still file that.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Oh, OK, very good. OK, good to know. Thank you so much for that.
[AGENT][NEUTRAL] With us.
[AGENT][POSITIVE] OK. All right. Well, you are certainly very welcome. So is there anything else that I can help you with today?
[CUSTOMER][POSITIVE] No, that, that was it. Thanks, thanks so much.
[AGENT][POSITIVE] You are certainly very welcome. It was my pleasure and thank you again for calling [PII]. I hope you have a very nice afternoon.
[CUSTOMER][POSITIVE] Thanks you too take care bye bye.
[AGENT][POSITIVE] Yes ma'am. You too. Bye bye.