AccountId: 011433970860
ContactId: 0a336e91-3cb6-4f34-a11e-ac6d0e258555
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 694789 ms
Total Talk Time (AGENT): 298364 ms
Total Talk Time (CUSTOMER): 256740 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/17/0a336e91-3cb6-4f34-a11e-ac6d0e258555_20250417T21:19_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, I have a question. I, my son recently broke his toe over the winter and now we're getting all the bills and I just um
[CUSTOMER][NEUTRAL] I need help understanding.
[CUSTOMER][NEUTRAL] Um, all of my claims.
[AGENT][NEUTRAL] OK, I can help you with your policy. Do you have a good policy number?
[CUSTOMER][NEUTRAL] Yes, let me find my card. Here it is. um.
[CUSTOMER][NEUTRAL] What number would that be? Oh, there it is. 01828792.
[AGENT][NEUTRAL] OK. And can I get your name and your date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] OK. And what is the address on the account?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and um what uh family member was that for?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And his birthday?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you, and do you have a good callback number, Miss [PII], just in case the call gets disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] OK, so it has, it looks like, so this is a meddling policy where this process is a secondary, it'll potentially pick up co-pay, deductible and co-insurance after your primary insurance pays. Um, so has everything processed through the primary?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEGATIVE] Uh, yeah, so it's like on his X-rays if my insurance didn't chip anything in, then you guys aren't gonna chip anything in.
[AGENT][NEUTRAL] Yeah, well, if they, if they just flat out denied the claim, then then we wouldn't uh consider it but it's like it went towards the deductible um then potentially it could.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Because all of it like I just got off the phone with them and they don't chip in and they don't put anything in um towards the X-ray um until I meet the deductible so it did go towards the deductible but then like all the claims that I've gotten from APL has nothing.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Um, it's been $0 as well, so I'm just trying to figure out, it feels like I'm paying for insurance and no one's insuring me.
[AGENT][NEUTRAL] OK, let me see what.
[CUSTOMER][NEUTRAL] If that makes sense.
[AGENT][NEUTRAL] Yeah, I can see it.
[AGENT][NEUTRAL] OK, um, let me look at your policy. So this is not a guaranteed payment, it's a basic outline of the policy. So it looks like, let's see, policy that you're on, let me get that.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so give me one moment, pulling that up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so this policy, there is a maximum benefit payable of 5000 per calendar year, but
[AGENT][NEUTRAL] That also has a $1000 deductible that has to be met on our side before it starts paying.
[AGENT][NEUTRAL] So once that's satisfied, it starts to pay, um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that's again based on a calendar year, so was he seen in like the ER or?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] No, we went to, no, we didn't go to an ER, we went to like um.
[CUSTOMER][NEUTRAL] I don't really know what you call it, uh.
[CUSTOMER][NEUTRAL] It was like the it was in it was at [PII]. It was like a wash you facility like uh it was open on a Saturday but it's not an ER so it wasn't an ER visit.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I don't know what it, I don't know what you would call that maybe an urgent care for broken bones.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, yeah.
[AGENT][NEUTRAL] OK, um, yeah, because I see some claims in here. It looks like they were applied towards the deductible, um, let me see.
[CUSTOMER][NEUTRAL] Do you know how like where I'm at on my deductible?
[AGENT][NEUTRAL] Uh, let's see, I tell you what they, where we're at.
[CUSTOMER][NEUTRAL] So I feel like I gotta be close.
[CUSTOMER][NEUTRAL] To $1000.
[AGENT][NEUTRAL] So from what we've received,
[AGENT][NEUTRAL] So far, um, all the claims that we've received, we've applied 32072 towards the 1000.
[AGENT][NEUTRAL] And then, um,
[CUSTOMER][POSITIVE] Oh wow.
[AGENT][NEUTRAL] Yeah, it looks like we're quite a bit of a ways off from that 1000 and then I guess there was some durable medical equipment we applied 7738 towards the deductible, so roughly over 400 has been met.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So what classify what goes, how do you decide? I know it's not you, but how, what's the decision on what goes towards the deductible and what does not.
[AGENT][NEUTRAL] So, basically, for this policy,
[AGENT][NEUTRAL] Um, outpatient services are gonna be applied towards the deductible. That's gonna be hospital emergency room, um, urgent care facility. That'll be surgery in a hospital, um, or surgery center, diagnostic testing in a hospital, um, outpatient treatment for mental or emotional disorder, physical therapy, uh, ambulance. Also, what goes towards it.
[CUSTOMER][NEUTRAL] So like
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, we've got an office treatment, so treatment that is performed in the office, like procedures or treatment in the office goes towards that.
[AGENT][NEUTRAL] Um, it looks like that an independent life.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] With an X-ray.
[AGENT][NEUTRAL] Yeah, X-ray.
[CUSTOMER][NEGATIVE] Do X-rays go towards it at all? So then like because I'm just, I'm just looking at like right now because we have 3 visits and each visit was an X-ray and so I only have 2 out of the 3 billed to me so far and um I'm exceeding $600 in X-ray bills and that didn't go towards it.
[AGENT][NEUTRAL] They do, yeah.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] What date were the X-rays?
[CUSTOMER][NEUTRAL] Um, I have his first set was on [PII] or [PII] and his second set was on [PII] and then I think the other one that I haven't gotten a bill for was on [PII].
[AGENT][NEUTRAL] Is this for [PII] or [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let's see what was that? And, and you've already submitted those to us, is that right?
[CUSTOMER][NEUTRAL] Yes, yes.
[CUSTOMER][NEUTRAL] I have the claim that said that it was applied to the deductible.
[CUSTOMER][NEUTRAL] But I mean, I feel like that.
[AGENT][NEUTRAL] OK, yeah, so what I've got so far.
[AGENT][NEUTRAL] I've got 111.
[CUSTOMER][NEUTRAL] I don't have a claim for, yeah.
[AGENT][NEUTRAL] 1 11 2025 looks like this might be the, it looks like the physician's reading of the X-ray we applied $31.53.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, and then the X-ray on the same day for 2:48?
[AGENT][NEUTRAL] That one.
[AGENT][NEUTRAL] I'm trying to read these. Let's see department of durable medical equipment.
[AGENT][NEUTRAL] It's 2:14.
[AGENT][NEUTRAL] Yeah, looks like the hospital charge, same date for [PII].
[AGENT][NEUTRAL] That went towards the deductible.
[AGENT][NEUTRAL] There's 248.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] The first amount that was 3153.
[AGENT][NEUTRAL] So there's
[CUSTOMER][NEUTRAL] Yeah, I see those.
[CUSTOMER][NEUTRAL] Do you see one for one.
[CUSTOMER][NEUTRAL] 30 for it was.
[CUSTOMER][NEUTRAL] My insurance made an adjustment so it's coming to me at 48,240.
[AGENT][NEUTRAL] What date was that?
[CUSTOMER][NEUTRAL] Uh, 1:30.
[AGENT][NEUTRAL] 1:30? Let me see.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 30, let's see.
[AGENT][NEUTRAL] 2
[AGENT][NEUTRAL] OK, I see that one. Let's see now there was an office visit on that date, and the actual office visit is not covered, so that was 150 that was.
[CUSTOMER][NEUTRAL] OK, I see that I have that claim.
[AGENT][NEUTRAL] OK, let me see what this other one was. We've got uh looks like 4119.
[AGENT][NEUTRAL] Maybe we're missing something. Let's see.
[CUSTOMER][NEUTRAL] I don't know that one. I don't have that bill.
[AGENT][NEUTRAL] And we've got Department of Radiy. This one looks like another X-ray reading for 13025.
[AGENT][NEUTRAL] I think we, it looks like.
[CUSTOMER][NEUTRAL] I haven't gotten that bill yet.
[AGENT][NEUTRAL] OK, looks like we don't have the hospital claim or the facility claim for that date.
[AGENT][NEUTRAL] So if there was a facility charge.
[CUSTOMER][NEUTRAL] For 1:30.
[AGENT][NEUTRAL] Uh-huh, for 1:30.
[AGENT][NEUTRAL] We have one for 1/11.
[CUSTOMER][NEUTRAL] OK, then I will make sure they ran that through the right.
[CUSTOMER][NEUTRAL] OK, so, all right, um, sorry, another question.
[AGENT][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] When on the claim for 1:30, um, the one that got is that says it's an uncovered service, the doctor visit, do you know why that's uncovered?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] If this policy just doesn't pay for actual office visits. It will pay for services, yeah, it, it does pay for services rendered in the office like treatment procedure but not the actual office visit charge.
[CUSTOMER][NEUTRAL] Oh got you OK.
[CUSTOMER][NEUTRAL] Got you, got you, got you. OK, alright, that makes sense. OK, alright, well I will call them about this other X-ray and see why it didn't come to you yet, so you don't see a charge for 48,240 yet?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I do not, I don't see that yet.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK then I will call them and make sure they're doing this right. OK, thank you so much.
[AGENT][POSITIVE] Hey, well, thank you for calling APL. Have a good evening.
[CUSTOMER][NEUTRAL] You too bye.