AccountId: 011433970860
ContactId: 0ccbdb6d-5fd9-4723-bb4f-40d5f888a19d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 636619 ms
Total Talk Time (AGENT): 169431 ms
Total Talk Time (CUSTOMER): 203113 ms
Interruptions: 1
Overall Sentiment: AGENT=1.1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/05/0ccbdb6d-5fd9-4723-bb4f-40d5f888a19d_20250505T14:52_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] on the care team. How you doing?
[AGENT][POSITIVE] I'm good. How are you?
[CUSTOMER][POSITIVE] I'm doing good. I have an insured um on the other line. She wants to talk about her claim. Um, the policy number is.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 261
[CUSTOMER][NEUTRAL] 663 9.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's part 2.
[CUSTOMER][NEUTRAL] Um, both of the claims there. It's the same date of service, but she forgot to submit the surgical bill, which is that last one there.
[CUSTOMER][NEUTRAL] We applied, we paid the 1st 1 $600. She's wanted to know how did we come up with that because we didn't have the surgical bill at the time. And is there anything applied to anesthesia? I'll let her know these are all the same codes and we applied it to the first claim, but she wants to know why we didn't pay anything to anesthesia and how we came up with the amount if we didn't have the surgical bill.
[AGENT][NEUTRAL] One second, let me pull it up
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So these are the surgery center charges, but you can send her on over.
[CUSTOMER][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Hello, Ms. [PII].
[CUSTOMER][POSITIVE] Yes. Thank you so much for holding. I have [PII] on the line and she'll be assisting you further, OK?
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Good morning Miss [PII]. Thanks for calling APL. How are you today?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][POSITIVE] I'm doing well thanks for asking.
[AGENT][NEUTRAL] OK, she stated, did you have a question about your claim?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] I did. OK, so maybe I'm gonna write this down so can you explain to me so.
[CUSTOMER][NEUTRAL] Um, what portion or what percentage do, um, we get back for the facility bill?
[CUSTOMER][NEUTRAL] This will, this will help me better understand it so what percentage of payment do we get back for the facility?
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] So it looks like they are, they paid the um these are the facility charges that we paid you $600 for the surgery.
[CUSTOMER][NEGATIVE] OK, so if that $600 is just for the facility bill, why do we, why are we told to send in the anesthesiologist and the surgeon's bill but uh we not get any percentage back off that because I didn't get any percentage back from the anesthesiologist bill which was 1310 and the surgeon's bill which was 3242.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let me pull your policy up because it looks like it states that the only the largest uh.
[AGENT][NEUTRAL] Whenever the procedure is done on the same day.
[AGENT][NEUTRAL] So of course all these are done on the same day. The only the largest one is paid, so give me one second to pull your policy up to see how it reads.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, OK, let's
[AGENT][NEUTRAL] OK, so it looks like your policy would pay 6%.
[AGENT][NEUTRAL] Um, of the surgical benefit for the repair of a tendon.
[AGENT][NEUTRAL] And so that's how and your benefit is up to $10,000 and so that's how they came about with the $600.
[CUSTOMER][NEUTRAL] OK, 6% for the total of the whole surgery.
[AGENT][NEUTRAL] Well, no, ma'am, of your surgical.
[CUSTOMER][NEUTRAL] And and are you saying that's including oh.
[AGENT][NEUTRAL] Of your surgical benefit with APL and your surgical benefit with
[CUSTOMER][NEUTRAL] What do you mean surgical?
[AGENT][NEUTRAL] You have a surgery and anesthesia benefit with American Public Life.
[CUSTOMER][NEUTRAL] Like what
[CUSTOMER][NEUTRAL] Oh,
[AGENT][POSITIVE] And that benefit
[CUSTOMER][NEUTRAL] OK, got you.
[AGENT][NEUTRAL] Yeah, pays up to $10,000.
[CUSTOMER][NEUTRAL] Up, up to 10,000. OK, so, um, are, so when you say surgical, does that mean the facility and the surgeon?
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] It would be the facility, the surgeon, the anesthesiologist.
[AGENT][NEUTRAL] It would include our
[CUSTOMER][NEUTRAL] No, that's why I said that's when I said total, so the total of those three bills definitely is more than 10K.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] No ma'am, maybe I'm not explaining it correctly.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] Your total, your surgical benefit with APL is up to $10,000 per calendar year.
[CUSTOMER][NEUTRAL] Mhm right.
[AGENT][NEUTRAL] So, whenever you have a surgery performed, we look at the surgery that you have performed in the schedule of benefits. And so with this one, for the repair of a tendon.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yep.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, the percentage that we will pay is 6% of the maximum surgical benefit, and your surgical benefit with APL is $10,000. So 6% of that $10,000 would be $600.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And so that's how we determine what we're gonna pay.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEGATIVE] So then why do we even need do you do you guys when we send all this paperwork in.
[CUSTOMER][NEGATIVE] Like, why do we even need it then? Like that doesn't make sense. Why do you guys is it just to prove that we had surgery because why do we need to do the facility anesthesiologist and surgeon [PII] if you already know automatically what you're going to give back for each surgery? Is it just to prove that we had surgery?
[AGENT][NEUTRAL] No, ma'am. Um.
[AGENT][NEUTRAL] We have to have the codes. And so if the benefit is less, so if you send in your surgeon, your surgeon's charges and, you know, it's less, then, you know, we probably could have paid.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] With the surgeon's bill, we probably, if we hadn't paid like the whole $600 to the surgeon, then there possibly could have been more benefits that we could have paid on the anesthesiologists charges. But uh the facility bills are usually the larger uh bills. So that one came in first, so that one exhausted all of the benefits.
[CUSTOMER][NEUTRAL] Mhm. Mhm.
[CUSTOMER][NEUTRAL] Got you. I, yeah, I, I didn't know that. OK.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] That's not very much at all, you know, but you know this isn't my insurance plan, so.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Anyways, alright, well thank you so much for explaining that.
[AGENT][POSITIVE] You're welcome. Was there anything else I can help you with on today?
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] Alright well thanks for calling APL and you have a great rest of your day.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][NEUTRAL] Alright bye bye.