AccountId: 011433970860
ContactId: 032bc6a5-9237-41bc-a656-5cd94bb8dbe0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1453380 ms
Total Talk Time (AGENT): 692992 ms
Total Talk Time (CUSTOMER): 767769 ms
Interruptions: 41
Overall Sentiment: AGENT=0.3, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/032bc6a5-9237-41bc-a656-5cd94bb8dbe0_20250219T14:33_UTC.wav
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[CUSTOMER][NEUTRAL] Um.
[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]. I was calling to inquire that um I was covered correctly for an emergency room visit back in [PII].
[AGENT][NEUTRAL] OK, so are you the insured and you're wanting to see if we received a claim for you for data service?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, it, it said that a claim was received and paid by you all, but it says it was only paid $150 and so I just wanted to call and make sure that was correct because I got a $10,800 bill, so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, [PII], yes, ma'am, I can help you with that. And what is your last name, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you. And a good callback number for you?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And your policy number please, Ms. [PII]?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Um, I don't, do they change you every year or do they stay the same?
[AGENT][NEUTRAL] It would only change if there, if you received an excellent, did you receive an explanation of benefits from APL?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, it did change. I have the old one. The old one is um the policy number is 02334602.
[AGENT][POSITIVE] OK, thank you. So give me.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Sure
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] I'm sorry, I was just making sure that was the right one. Yes, correct, sorry.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][POSITIVE] Moving forward
[AGENT][NEUTRAL] This is for dental
[CUSTOMER][NEGATIVE] Mm, no, it should have been medical.
[AGENT][NEUTRAL] And that policy number you just gave me is a dental number. OK, so just.
[CUSTOMER][NEUTRAL] And to.
[CUSTOMER][NEUTRAL] How about 02587994?
[AGENT][NEUTRAL] OK, so, um, first off, let's verify your information and then we can determine which policy I need to look at, OK? So first off, any information that I do provide for you, Miss [PII] would be a verification of benefits and not a guarantee of payment. So first off, what is your date of birth?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and your home mailing address please?
[CUSTOMER][NEUTRAL] Um, currently or at the time?
[AGENT][NEUTRAL] Uh, what we have on file, so I don't know what that is.
[CUSTOMER][NEUTRAL] OK, sure, [PII].
[AGENT][NEUTRAL] OK, thank you. The phone number that we have for you is the same as the one you gave me, so that is your best contact number, is that correct?
[CUSTOMER][POSITIVE] It is correct mhm.
[AGENT][POSITIVE] Thank you. And lastly, your email address, please?
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] OK, thank you very much. Now, is your address still the [PII]?
[CUSTOMER][NEUTRAL] It is, yeah, but at the time in [PII] it would have been different. That's why I just wanted to make sure, but yeah, that's correct.
[AGENT][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] OK. And what is the data service that you're calling about? Because I'll need to have that first.
[CUSTOMER][POSITIVE] Thank you. Yeah, [PII].
[AGENT][NEUTRAL] OK, so the policy number that would have been effective during that time is the 2,334,600.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so give me just one moment to get that information pulled up.
[CUSTOMER][NEUTRAL] Mar
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Send him over.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] accepted.
[CUSTOMER][NEUTRAL] Chinese.
[CUSTOMER][POSITIVE] It's funny.
[CUSTOMER][NEUTRAL] So he see that he.
[CUSTOMER][NEUTRAL] He
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, I, I try to fish it out of them and, uh, you know, it's breakfast.
[AGENT][NEUTRAL] And again, the data service is [PII]. Do you have a total bill amount for that data service? OK.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Yep
[CUSTOMER][NEUTRAL] Yeah, total charges was $11,262. I paid a, um, I guess.
[AGENT][NEUTRAL] 262.
[AGENT][NEUTRAL] Or 252.
[CUSTOMER][NEUTRAL] I'm sorry? 26262, yeah.
[AGENT][NEUTRAL] Oh, OK, thank you. Alright, give me a moment to locate that claim.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And like I said, I think, I think that.
[AGENT][NEUTRAL] And again, do you have the uh what was the bill amount?
[CUSTOMER][NEUTRAL] The bill amount was $11,262.
[CUSTOMER][NEUTRAL] I paid a $250 co-pay when I was there.
[CUSTOMER][NEUTRAL] And then it says that you all paid 150.
[AGENT][NEUTRAL] And you're saying, uh-huh.
[AGENT][NEUTRAL] OK. So, yes, ma'am, I do see that this is on claim number 3343639. Is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, I'm not sure what the claim number would be on y'all's side. I, I don't have that number, but mm mm.
[AGENT][NEUTRAL] Oh, OK. You don't have that 10, OK, OK. So this was for [PII]'s New Braunfels, is that correct?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII] mhm yeah, Crystal Center Rose Emergency Center.
[AGENT][NEUTRAL] OK, so yes ma'am, that is correct. There was a benefit paid in the amount of $150 on this claim to the provider, um, on the on the ER portion.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So [PII].
[AGENT][NEUTRAL] It shows that with that payment of the $50
[CUSTOMER][NEUTRAL] With.
[AGENT][NEUTRAL] Because it was broken down into 2.
[AGENT][NEUTRAL] Two charges. So there was $50 paid on that and it states with this check the maximum benefit payable for this data service has been met.
[AGENT][NEUTRAL] And with the $100 payment for the imaging portion of that, it states the calendar year max for this benefit has been exhausted with the payment of this claim, because this was a limited benefit plan that you had with APL at the time.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] That is the maximum for those two.
[AGENT][NEUTRAL] Proceed or to events.
[CUSTOMER][NEUTRAL] So for.
[AGENT][NEUTRAL] On this limited benefit plan.
[CUSTOMER][POSITIVE] Wow.
[AGENT][NEUTRAL] Mhm. It's not major medical insurance.
[CUSTOMER][POSITIVE] Wow.
[CUSTOMER][NEGATIVE] So what was the point of me paying a $250 co-pay then really?
[AGENT][NEUTRAL] Now
[AGENT][NEUTRAL] I'm not sure as far as what the providers require of you to pay. Um, we don't have anything to do with that.
[CUSTOMER][NEUTRAL] So yeah.
[AGENT][NEUTRAL] Ms. [PII], so that would be a question, you know, for the facility if that's.
[AGENT][NEUTRAL] Who you pay that to.
[CUSTOMER][POSITIVE] Wow.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] That's absolutely insane. Um.
[CUSTOMER][NEUTRAL] So I, I have a so I had insurance but I now have a bill for $10,862 is really what you're saying.
[AGENT][NEUTRAL] Yes, because on the ER portion that bill was $7530 according to what we show, and yes, $50 was the benefit for that and the other charge was $3732. That is the one that we paid the $100 benefit on. But again, with this being a limited benefit plan, it only pays certain amounts for certain services. It's not major medical insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] just
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] Wow.
[CUSTOMER][NEUTRAL] So I signed back up for.
[CUSTOMER][NEUTRAL] This coverage I guess through APL is so the coverage that I have that's currently in effect, it's pretty much the same thing. So if I like had a heart attack or something, I, I basically be putting the whole bill by myself.
[AGENT][NEUTRAL] I can pull up your current policy information to see what your benefits are on that. Uh, do you need any other information on this plan though before?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] No, I mean there's nothing else that you guys can do to help, right? There's like you can't like.
[CUSTOMER][POSITIVE] Get caught the the cost lowered on the all the stuff they charged me.
[AGENT][NEUTRAL] No, ma'am. That would be, no, ma'am, we can't. Mm mm.
[CUSTOMER][NEUTRAL] I didn't assume so, but I figured I'd ask, OK.
[AGENT][NEUTRAL] Oh, absolutely, um, now I do wanna ask you though before I get out of this policy, have you ever set up your profile in our online service center so you can have access to all of your information and your explanation of benefits ID cards online through APL?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] What.
[CUSTOMER][NEUTRAL] She's
[CUSTOMER][NEUTRAL] I'm not sure I have no I don't I don't think so.
[AGENT][NEUTRAL] OK, what I'll do is I will email you a user guide for how to set that up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, so that you can have access online, so give me one moment.
[CUSTOMER][POSITIVE] Which probably be a better candidate for this week.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Um, so for [PII].
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] In.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I see internal. I don't know that, uh.
[CUSTOMER][NEUTRAL] That.
[CUSTOMER][NEUTRAL] My
[CUSTOMER][NEUTRAL] That.
[AGENT][NEUTRAL] OK, so I have just emailed that to you, Miss [PII], and the email that I just sent it's gonna come from [PII] [PII], and I did put APL online service center in your subject line for you so that that's easy for you to recognize, OK?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Exactly
[AGENT][NEUTRAL] Just a moment for me to get this other policy information pulled up that's currently active.
[CUSTOMER][NEUTRAL] Ted mission plan last week.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] for
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] OK, so let's see.
[CUSTOMER][NEUTRAL] What.
[AGENT][NEUTRAL] It's taking a moment. I'm sorry, Miss [PII] for this information to load for me.
[CUSTOMER][NEUTRAL] No, that's OK.
[CUSTOMER][POSITIVE] No, no worries.
[CUSTOMER][NEUTRAL] Yeah, I, I, yeah, it's, you know, uh, people don't care and I think too, you know.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] right.
[AGENT][POSITIVE] I am, I am so sorry about the delay. It's just, I, I don't know.
[CUSTOMER][NEGATIVE] No, no, no, no need to apologize. So now you, I know you can't give advice, but this is still not anywhere near major medical. I, and I should probably if I was wise get a plan that was major medical.
[AGENT][NEGATIVE] Why it's taking so long.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Yes, this is not major medical insurance. Again, with the limited benefit plans, Ms. [PII], they pay specific amounts.
[CUSTOMER][NEGATIVE] crumble.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] For a certain number of day or days per calendar year.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, for specific services that's, you know, listed under your schedule of benefits. So, for example, if you were admitted as an inpatient into the hospital,
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] It's pretty good, you know, we have more yeah.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The benefit on this plan, you have a hospital admission benefit of $1000 per day and a maximum of 1 day per calendar year.
[CUSTOMER][NEUTRAL] Yeah yeah
[CUSTOMER][NEUTRAL] One day.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Then there's also, in addition to that, a hospital confinement benefit.
[AGENT][NEUTRAL] That is $100 per day and a maximum of 30 days per calendar year per covered person. Now the hospital admission benefit and combinement benefit are not payable for the same day.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So like if you were admitted, you would get that $1000 then your confinement benefits, so hypothetically, if you were there for 5 days.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] You know, the confinement benefit would start on that.
[CUSTOMER][NEUTRAL] 2nd day.
[AGENT][NEUTRAL] That next day, not your admission date.
[CUSTOMER][NEUTRAL] What's the, what was the confinement benefit amount?
[AGENT][NEUTRAL] Mhm. For up to 30 days.
[AGENT][NEUTRAL] $1000 per day and a maximum of 1 day per calendar year.
[CUSTOMER][NEUTRAL] I get all.
[CUSTOMER][NEUTRAL] That was the inpatient.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What's the confinement per day?
[AGENT][NEUTRAL] $100 per day, maximum of. Mhm.
[CUSTOMER][NEUTRAL] $100.
[CUSTOMER][POSITIVE] 30 days great OK.
[AGENT][NEUTRAL] Mhm. Now, when you set up your profile in that portal, Ms. [PII], there, you, you will see which policy is active, and you can download, it's in a PDF format. You just click on it and it will download and you can go to your schedule of benefits page and it gives you all of the benefits under your policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] And the benefit amounts.
[CUSTOMER][NEUTRAL] No
[AGENT][NEUTRAL] You know, and for how many days?
[AGENT][NEUTRAL] You have that. There's also definitions in your policy certificate that explains what is considered a hospital admission, um, you know, what diagnostic testing are covered under this plan, things like that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I I understand.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got you. OK, I do have two more questions. Um, I got went to the dentist at the towards the end of last year, and they sent me a bill saying I guess my, my, it was just, you know, a regular routine cleaning, and they said it wasn't covered and I owed $150. Is that are you somebody I can talk to about that?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, I can pull up your dental policy and see if we ever received a claim on that, but I'll need to finish making my note on this one before we can move on to the next one, OK? All right, so do you have any other questions on this policy at the moment?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, on this one I have, yeah, I have one more. So this, this bill at the time I think I had um Tricare as a secondary insurance. Do you then send the, the rest to TriCare or does um [PII] send it, send it to TriCare?
[AGENT][NEGATIVE] No, ma'am, we would not send it.
[CUSTOMER][NEUTRAL] They do OK alright that was my last question about this specific.
[AGENT][NEUTRAL] Mhm. OK. Oh, sure. OK. So, all right, so give me just a moment, please.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Check
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Actually it's much bigger than mine yeah I gotta do that.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] me.
[AGENT][NEUTRAL] OK. Now, on the dental claim that you have a question about, OK, you've only had one dental policy, so give me just a moment to get that information pulled up.
[CUSTOMER][NEUTRAL] I think.
[CUSTOMER][NEUTRAL] Well.
[CUSTOMER][NEUTRAL] Oh OK.
[CUSTOMER][NEUTRAL] yeah.
[CUSTOMER][NEUTRAL] Oh I would say it's probably.
[CUSTOMER][NEUTRAL] OK bye bye.
[AGENT][NEUTRAL] OK, and same thing with this one any information this line that I provide would be a verification of benefits and not a guarantee of payment. What is the data service on your dental policy that you're inquiring on?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I am not entirely sure. I don't have that. I I don't have anything in in front of me regarding that. It would have been last year in [PII]. I think I only went, it was towards the second half of the year.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Doctor [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so there's
[AGENT][NEUTRAL] Again, I mean, I have more than one claim for you for last year for dental.
[CUSTOMER][NEUTRAL] Doctor [PII].
[AGENT][NEUTRAL] So do you think it was, what was the doctor's name again?
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] Did you only see him once last year?
[CUSTOMER][NEUTRAL] Yeah, I did only once mhm.
[AGENT][NEUTRAL] OK, so,
[CUSTOMER][NEUTRAL] like.
[AGENT][NEUTRAL] We show that to be an [PII] data service.
[CUSTOMER][POSITIVE] Yeah, that sounds about right.
[AGENT][NEUTRAL] OK, so, yes, I do show that the
[CUSTOMER][NEUTRAL] My.
[AGENT][NEUTRAL] The claim that we received was for $215.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] And there was a benefit paid to the provider.
[AGENT][NEUTRAL] In the amount of $59.
[CUSTOMER][NEUTRAL] Then I.
[AGENT][NEUTRAL] And give me one moment to get all of the information pulled up.
[CUSTOMER][NEUTRAL] uh.
[CUSTOMER][NEUTRAL] the box.
[CUSTOMER][NEUTRAL] Oh yeah, yeah, yeah, that's like a.
[AGENT][NEUTRAL] OK, so on one of the codes submitted there were two different codes submitted again, you will be able to see this explanation of benefits as well in your portal, Ms. [PII]. The claim number for that claim for him for that provider was 354-034-4.
[CUSTOMER][NEUTRAL] I feel you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah maybe.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That right now like some of the buzz between us.
[CUSTOMER][NEUTRAL] 0344.
[AGENT][NEUTRAL] Yes, ma'am. Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and so the
[CUSTOMER][NEUTRAL] That so that the little bug and I'm trying to get flowers and.
[CUSTOMER][NEGATIVE] You got it no.
[AGENT][NEUTRAL] The benefit paid on one of the codes again was the $59.
[CUSTOMER][NEUTRAL] Cross that it kills them.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And with that, the calendar year max for this benefit was exhausted with the payment of this claim.
[CUSTOMER][MIXED] That's great but it's.
[CUSTOMER][POSITIVE] It's you favorite.
[AGENT][NEGATIVE] And then on the other amount for $100 that one was denied because the policy max for this benefit has been met.
[CUSTOMER][NEUTRAL] and it's so
[CUSTOMER][NEUTRAL] I got it.
[CUSTOMER][NEUTRAL] You gotta check.
[CUSTOMER][NEUTRAL] What was the code for the one that was denied?
[AGENT][NEUTRAL] 0150.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] But what does that mean?
[AGENT][NEUTRAL] That was a comprehensive oral evaluation.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] There were other claims that have previously been processed that matched your benefit. You would, there was an appointment back in March with the Doctor [PII].
[CUSTOMER][NEUTRAL] Well, I mean it's not that.
[CUSTOMER][NEUTRAL] But that I.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] In which we pay a $200 benefit. Do you see your calendar, your maximum on this policy is $500.
[CUSTOMER][NEUTRAL] it's like like right it's like that like winter.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] Per calendar year per covered person.
[CUSTOMER][NEUTRAL] So, but in the year only $259 was paid.
[CUSTOMER][NEUTRAL] Are you all.
[AGENT][NEUTRAL] Let me look at all of these claims. Give me just a.
[CUSTOMER][POSITIVE] Absolutely.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It was supposed to be a preventative visit, you know, there was just a cleaning and an examination.
[AGENT][NEUTRAL] Right, but they did not, but the codes that they were not, did not fall under your preventative codes on your policy.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Is there any way to know what that code would be so they can resend it?
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Please turn on the.
[AGENT][NEUTRAL] No, ma'am, we can't tell them how to code their procedures.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Yeah yeah you did.
[AGENT][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] Uh, hey, [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So it shows you used your max and your deductible.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, so, on [PII], we paid a $240.01 dollar benefit to Doctor [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] That was for data service 131 2024.
[CUSTOMER][NEUTRAL] that.
[CUSTOMER][NEUTRAL] Mm, OK. And then the 200 for Dr. [PII], so that was 1559. OK, that makes sense.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] And then the balance was paid on the most recent claim.
[CUSTOMER][NEUTRAL] Are you
[CUSTOMER][NEUTRAL] So even if I called and said hey you, you um you put it that probably incorrectly doesn't matter well no it wouldn't matter because it was found under the preventative or just the $500 max um trumps the preventative 100%.
[AGENT][NEUTRAL] Because
[AGENT][NEUTRAL] Uh
[AGENT][NEGATIVE] The maximum, the max does not, I mean, the preventative services do not fall under your calendar, your max.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I actually call them and say, hey, is there a different code that you could use since this wasn't prevented physics.
[AGENT][NEUTRAL] Again, we can't do that because that would be insurance fraud, so we can't do that. We can't tell.
[CUSTOMER][NEUTRAL] No, not you. I'm saying me. I'm saying I, I can call him and say, hey, is there, is there a proper better code that you can put that under because it was sincerely a preventative visit, OK.
[AGENT][NEUTRAL] Yeah, um, we can't tell them.
[CUSTOMER][NEUTRAL] Every 3.
[AGENT][NEUTRAL] But we also pay, oh, that was for a [PII]. I'm sorry, we received a claim in [PII], but that claim was for [PII].
[CUSTOMER][NEUTRAL] For Doctor [PII] or Doctor [PII]?
[AGENT][NEUTRAL] So yes, we've, [PII], so we processed two claims for him this past calendar year and then the remaining benefits that were available were processed on with that $59 payment to Doctor [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Mm, OK, OK, that makes sense.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] OK, I appreciate it very much. Alright, thank you.
[AGENT][POSITIVE] OK. Oh, well, you're certainly very welcome. Yes, and is there anything else I can help you with?
[CUSTOMER][POSITIVE] No, have a great rest of your day.
[AGENT][POSITIVE] OK, well, thank you so much. And again, that email I have sent it to you and you should have it by now. And again, it's coming from care team at [PII].
[CUSTOMER][NEUTRAL] I think I
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] OK. You're welcome. And thank you again for calling APL. Yes, ma'am.
[CUSTOMER][NEUTRAL] Bye.