AccountId: 011433970860
ContactId: 0bf952e3-0271-4b00-a7b9-955106cbaebe
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 659469 ms
Total Talk Time (AGENT): 216551 ms
Total Talk Time (CUSTOMER): 351890 ms
Interruptions: 2
Overall Sentiment: AGENT=1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/14/0bf952e3-0271-4b00-a7b9-955106cbaebe_20250114T20:46_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APS. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] Did you say Hammer?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII], hey, [PII], this is [PII]. How you doing?
[AGENT][NEUTRAL] Mhm. Hey.
[AGENT][POSITIVE] I'm doing good. How are you?
[CUSTOMER][POSITIVE] Good and I need, I wanna run something by you quick, OK?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, so you, you guys getting ready to see a claim come through on one of my own clients.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So this let me just give you the broad view of it and I want you to go through this claim with me, OK?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you might want to write it down. You want to write to jot this down on a little piece of paper?
[AGENT][NEUTRAL] Oh yeah, I'm waiting. I, I have my note ready.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Alright, so my client has got a $5000 deductible on the primary, OK?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] They have a 9100 max out of pocket, OK?
[CUSTOMER][NEUTRAL] We see a spread of 4100, OK?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'll bring you in my client's got Medlink 6 with a $6000 outpatient benefit, OK?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So let's just make the numbers simple here. So I'll bring you in as a 6 that satisfies the deductible of 5 and gives one extra 1000, OK?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Oh, OK. The primary pays fifty-fifty coinsurance for the deductible.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So really,
[CUSTOMER][NEUTRAL] You got $4100 after the deductible. $5 deductible plus $4100 remaining at your $9100 out of pocket, OK?
[CUSTOMER][NEUTRAL] The company, the primary is going to pay 50% of that $4100 which is $20,050 OK?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So of the claim, of the claim.
[CUSTOMER][NEUTRAL] If 2050 is paid by the insurance carrier and 2050 is paid by my client, then that has satisfied the max out of pocket with the primary. Is that correct?
[CUSTOMER][NEUTRAL] Do they count what portion?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Is that right?
[AGENT][NEUTRAL] That's, I mean, yes, that's correct, and then once we get the claim, that's when the reimbursement starts.
[CUSTOMER][NEUTRAL] Yeah, and you're gonna pay 6 of that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So, really, what's left is the, uh, 3 $9100 minus 6 is $3100. But if the primary co-insurance was 50% and they pay $20,050 you got to subtract $20,050 off the $3100. That's what the client's gonna have to pay. Is that right?
[AGENT][NEUTRAL] You're trying to see what the patient responsibility would be?
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah.
[AGENT][NEUTRAL] Roughly from from how you're saying it, yes, but now we don't know what all has been from the 6000 because just because there's a 6000 max doesn't mean that that all is going to go to the deductible. So it depends on what's being applied to what.
[CUSTOMER][NEUTRAL] Because
[AGENT][NEUTRAL] That's where all the gray areas come in at, but from what you're saying, yes, that's how it goes, but
[AGENT][NEUTRAL] We don't know what all, what all is going to be applied to what, just because there's a 6000 max for outpatient.
[AGENT][NEUTRAL] And there's a $5000 deductible, doesn't mean that full 60 would go to that or $50,000 that full 6 would go to the 50. It depends on how it comes in.
[CUSTOMER][NEUTRAL] OK. I mean, uh, I mean, you guys, I mean, that, that $6000 benefit that we bought, that's gonna pay deductibles, co-insurance, and any other little small expenses. That, that's what the Medling 6 pays because the Medli 3 used to pay that. It pays deductibles and co-insurance. So you guys are gonna spend that whole 6.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I mean, it's, you know, you're gonna spend that regardless.
[AGENT][NEUTRAL] But what if they had a co-pay too, like that's 6000 for the year. What if, what if they have other claims, like there's too many.
[CUSTOMER][NEUTRAL] 00, yeah, yeah, yeah. No, no, no, right, right. No, the max, that's correct. The max you guys pay is 6. Now, she dipped into that bucket with previous claims, yes, I agree, it's not gonna be 6 there. I agree with that.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I agree with that. As a matter of fact, if you don't mind, dear, can I'm gonna get my assistant on the line. Can you pull up my client and tell me how much does she actually have left?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, sure. Mhm.
[CUSTOMER][NEUTRAL] OK, one minute let me get [PII] on the line. One minute please.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Yes, I'm here.
[CUSTOMER][NEUTRAL] She, she saw me calling and she's gonna call right back. She saw me calling in, um, just bear with me quick. Her name, uh, mhm, go ahead.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, while he
[AGENT][NEUTRAL] While we're waiting on her, um, what's the group number and then the member's name so I can pull up the policy.
[CUSTOMER][NEUTRAL] I can give you her name. It's [PII] I think it's [PII] or [PII] [PII], something like that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then,
[AGENT][NEUTRAL] But for the most part, yes, without all the other variables, how you explained it, yes, is how it works. I just, I don't want to say yes and then there's other, you know, things that are determined, like we said, the co-pays if they dipped into it or anything like that, but yeah, that's how it works. If, if they had that full 6000 and of that deductible bill came in, then um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, they could apply it all to that deductible or the co-insurance, you know.
[CUSTOMER][NEUTRAL] It just depends on, yeah, yeah, depends on if she has any previous things that you guys paid.
[AGENT][NEUTRAL] But yes sir, that
[AGENT][POSITIVE] Exactly, but yes, how you explained it, if nothing else was affected, yes, that's, that's exactly right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got you, man. Got you. I thought too.
[AGENT][NEGATIVE] I just didn't want to get hope and like what if they use something.
[CUSTOMER][NEUTRAL] Yeah, yeah, if we just deal with the numbers, OK, wait, hold on, hon, here she is, hold on, hold on.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sorry. Mhm. I have [PII] on the line with us from American Public. Can you give um [PII]'s Clayba's uh number please, her uh member ID and such? Sure, uh, policy number 2180309.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] All right, and I have her here.
[AGENT][NEUTRAL] And um,
[AGENT][NEUTRAL] I'm just waiting for everything to come up here.
[AGENT][NEUTRAL] And then [PII], I just need you to um verify your email address and then you've already uh gave the
[AGENT][NEUTRAL] Group name and everything.
[CUSTOMER][NEUTRAL] Yeah, Triple B fencing company, um, my, uh, my email is [PII].
[AGENT][NEUTRAL] Alrighty, and then let me see what she's used for the year. Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, that's what I wanna know.
[AGENT][NEUTRAL] This is for, you want me to check for 25 or 24?
[CUSTOMER][NEUTRAL] Oh no, 25 because she's getting ready to have a surgery done.
[AGENT][NEUTRAL] 25, OK.
[CUSTOMER][NEUTRAL] So that doesn't go from policy period, policy period starts over with the year, right, calendar?
[AGENT][NEUTRAL] Right, I just wasn't sure if it was an old claim or something happening soon.
[CUSTOMER][NEUTRAL] No, it's getting ready to happen in 2 days, Thursday.
[AGENT][NEUTRAL] OK. So I'm pulling everything now.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And hey [PII], but I explained to [PII] and we'll we'll go over it one more time.
[CUSTOMER][NEUTRAL] [PII], did you said I was what, right or wrong?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, just going over the numbers, yes, that's how it works without any other variables or anything.
[AGENT][NEUTRAL] Can you hear me?
[CUSTOMER][NEUTRAL] Oh yeah, ho, yeah go ahead I'm sorry I don't wanna interrupt you, mhm.
[AGENT][NEUTRAL] Oh, no, you're fine. Um, so for [PII], there's been, um, she hasn't used any of the benefits.
[CUSTOMER][POSITIVE] Excellent, so she's gonna have a whole $6000 to pay toward this.
[AGENT][NEUTRAL] For outpatient, yes, there's a full 6000 for the year. Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Beautiful, beautiful. OK. um.
[CUSTOMER][NEUTRAL] So [PII], you wanna run that by [PII] real quick because she's actually in claims. I talked to [PII] and [PII] said, [PII], you just need to talk to claims. So [PII], you run it by [PII] and let's see, what's that?
[AGENT][NEUTRAL] Whoa, hold on, hold on. I'm not in claims. I'm in customer care.
[CUSTOMER][NEUTRAL] Oh, yeah, I thought you was in claims.
[AGENT][NEUTRAL] No, I just have a degree in this, but no, I'm not in claims.
[CUSTOMER][NEUTRAL] No, and what we were discussing wouldn't even involve APL. It's involving the co-insurance of her primary plan.
[AGENT][NEGATIVE] I was like, wait, no.
[CUSTOMER][NEUTRAL] You've seen enough of these, [PII]?
[AGENT][NEUTRAL] Yes sir.
[CUSTOMER][NEUTRAL] give it to her, [PII]. You, you go from your perspective and let's see what she says. OK. OK, so if the, if her primary plan has 50% co-insurance.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What the insurance carrier pays in their portion of co-insurance does not count towards the member's maximum out of pocket, correct?
[AGENT][POSITIVE] Correct. Mhm.
[CUSTOMER][POSITIVE] See, that's what I'm telling you, [PII]. OK, OK, OK, alright, OK, alright, we're gonna call Allstate now we're gonna check that out. We're gonna make sure we're good with them. We're gonna give them a quick call. Um, well, [PII], you verified what we needed, dear. I appreciate it very much.
[AGENT][POSITIVE] Well, you're very welcome. Was there anything else I can help you out with today?
[CUSTOMER][POSITIVE] No, you did good. Um, we'll just start these claims together and I appreciate you.
[AGENT][POSITIVE] Thank you.
[AGENT][POSITIVE] All right. Well, [PII] and [PII], thanks for calling APL. I hope you all have a good evening and [PII].
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][POSITIVE] You too thanks.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.