AccountId: 011433970860
ContactId: 18cc6fd9-4ee5-4d38-847a-b7ffc524edf3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 778119 ms
Total Talk Time (AGENT): 257369 ms
Total Talk Time (CUSTOMER): 445374 ms
Interruptions: 5
Overall Sentiment: AGENT=1.2, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/02/18cc6fd9-4ee5-4d38-847a-b7ffc524edf3_20250102T20:24_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APL. My name is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] in customer care. How are you?
[AGENT][POSITIVE] Good how are you?
[CUSTOMER][NEUTRAL] Hey, I'm good. I have an insured on the line. Her name is [PII] Doctor, and she has some questions on her meddling plan. I'm wondering if you could help her with.
[AGENT][NEUTRAL] OK, what's the policy number?
[CUSTOMER][NEUTRAL] It is 01866983.
[AGENT][POSITIVE] OK, I'm ready.
[CUSTOMER][NEUTRAL] Alright, and specifically what she's asking for is she was asking about like outpatient cover charges and she wanted to know for copay at an urgent care facility would be covered.
[CUSTOMER][NEUTRAL] Um, I told her that physician's office visits are not covered, and then she was asking about a hospital. Um, she wasn't really confident in my answer, so then she had asked to speak to somebody else, so.
[AGENT][NEUTRAL] I'm sorry.
[CUSTOMER][POSITIVE] No, that's OK. I mean, look, I'm new, so I made him and hall a little bit. I read the policy, do the best I can do, you know, so, uh, no, no, no worries.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, I'm ready.
[CUSTOMER][POSITIVE] All right, thanks. Here she comes.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Hi, Miss [PII]?
[CUSTOMER][NEUTRAL] Yes, hello.
[AGENT][NEUTRAL] Hi, this is [PII] with APL claims department. How are you?
[CUSTOMER][POSITIVE] Oh hi I'm good thank you how are you doing?
[AGENT][NEUTRAL] I'm good. I understand you have some questions in regards to your policy and urgent care benefits and office visit benefits.
[CUSTOMER][NEUTRAL] Uh, urgent care or hospital, let me explain, um, I need an I need to go for an X-ray of my knee, OK? Um, and what I found out so far was that, um, through my insurance, I have to pay $100 in that network at urgent care just to get in the door and the X-ray is free that, that I understand. My question was, would I get reimbursed by.
[CUSTOMER][NEUTRAL] APL for the urgent care and [PII] pretty much said no, which I understand. Uh, and I think that's correct and I wanna verify that. But if I go to the hospital for an X-ray to emergency.
[CUSTOMER][NEUTRAL] Um, will they?
[CUSTOMER][NEUTRAL] Will you reimburse me if they charge me to walk in the door on that? That's my main question.
[AGENT][NEUTRAL] OK, well, let me apologize, you do have benefits for urgent care facilities.
[AGENT][NEUTRAL] So if you did go to the urgent care um and we received a claim from the urgent care and the EOB that shows your patient responsibility of $100 we would pay that $100 up to let me look at your daily maximum oh and I'm sorry, please be advised that a verification of coverage is not a guarantee of payment uh so for your outpatient.
[AGENT][NEUTRAL] Per day maximum is 500 so.
[AGENT][NEUTRAL] Yes, if we received the claim from the, I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] On my card it says in hospital benefits.
[CUSTOMER][NEUTRAL] Then outpatient benefit. So I, from what I understand, this is for hospital coverage. So that's separate from urgent care, which I'm sure you know.
[CUSTOMER][NEUTRAL] So, uh, on the urgent, if I went, we're talking about urgent care, right? We're talking about urgent care, not the hospital. So if I go to urge
[AGENT][NEUTRAL] Right, I, I know the difference between the ear.
[CUSTOMER][NEUTRAL] Pardon?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, I know the difference between the urgent care and the hospital. How about this? I'm gonna read directly from your policy where what your outpatient benefits entail.
[AGENT][NEUTRAL] The first one is hospital emergency room visit.
[CUSTOMER][NEUTRAL] No, no. I, no, listen, listen. I, excuse me. I, I have confidence that you know what you're talking about. I wanna make sure I understand it because [PII] seemed to be 100% that I wasn't gonna be covered. She read me the same thing, OK? So, um,
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] So she read urgent care facility and then still told you that you wouldn't be covered.
[CUSTOMER][NEUTRAL] I don't wanna get her in trouble, but yeah.
[CUSTOMER][NEUTRAL] Well, now, wait, wait a minute.
[CUSTOMER][NEUTRAL] Let me back up. It was the hospital one. It was a hospital one.
[CUSTOMER][NEUTRAL] I, I can't remember, honey. I can't remember. She.
[AGENT][NEUTRAL] OK, well let's start fresh. I, I work in the claims department and I work in a department that pays the claims, OK?
[CUSTOMER][NEUTRAL] OK, OK, OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You are covered for hospital emergency room, urgent care facility, surgery and hospital outpatient facility, a free-standing outpatient surgery center, a diagnostic testing in the hospital, outpatient facility, or MRI facility, outpatient treatment for mental or emotional disorder in a hospital or outpatient facility, a physical therapist, the physical therapy facility, and ambulance.
[AGENT][NEUTRAL] And at a doctor's office, let me also clarify, at a doctor's office, you are covered for any treatment and procedures that you receive, not the co-pay that's associated with the physician's charges.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK, but I am covered for co-pay with urgent care. Is that correct? That's not.
[AGENT][POSITIVE] Tha[PII] correct.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Now to do that, I need
[CUSTOMER][NEUTRAL] To do that I need to pay them when I go in and present my insurance card and my APL card to them is this.
[CUSTOMER][NEUTRAL] Am I right?
[AGENT][NEUTRAL] OK, let me.
[AGENT][NEUTRAL] Break that up because if you're going to pay them upfront I'm sorry.
[CUSTOMER][NEUTRAL] Because some, some urgent care places, some, sorry, some urgent care places are not very cooperative. I'm just saying, I have found, I haven't been to a slew of them, but when it comes to stuff like this, so.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] OK, but I was saying if you're going to pay up front, then there's no purpose in giving them your insurance because what what's the point of them filing? You can file yourself and have the money come straight to you.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] You would present the card to them if they're going, I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Right, but what, what I'm, uh, uh, uh.
[CUSTOMER][NEGATIVE] They're gonna ask to see my insurance card when I first walk in the door, and some places, they don't care about whatever you've got. They want the money up front.
[CUSTOMER][NEUTRAL] So that's been my experience. So my, my goal is to get an X-ray. So when I walk in, I'm gonna give them my card. So,
[CUSTOMER][NEGATIVE] Then they're not supposed to charge me. They're supposed to just send it directly to the to to you guys, right? Is that it's the song?
[AGENT][NEUTRAL] So find out, so you're gonna find out, do you file gap insurance or do you file secondary? If their answer is yes, then you would you would hand them their card, they call us, verify that you're covered, and then they should not ask you to pay.
[CUSTOMER][POSITIVE] OK, let me write this down because that's helpful and I remember this from years ago so what you're saying. All right, I appreciate it. Thank you so much. Let me write this down.
[CUSTOMER][NEUTRAL] Oh, OK. This has been an experience. I have been
[CUSTOMER][NEUTRAL] On the phone with Starbucks corporate today. I can't tell you how much I walked into a store yesterday. I fell on their floor in front of boxes, tripped over a boxes that they had laying there, OK? And I hopefully didn't break anything in my knee. So that's what got this tobaccle started.
[AGENT][POSITIVE] Oh wow.
[CUSTOMER][POSITIVE] Fun facts. So,
[CUSTOMER][NEUTRAL] Uh, that's why I'm trying to make sure, and they said, well, somebody will call you in a few days. They didn't tell me not to go to the hospital urgent care. They said, save your receipt, save your receipt, save your receipt, so.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, so that's what's going on with me. Um, today is [PII]. What was your name again?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII] in claims. Are you at a certain extension, [PII]?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Uh, no, I don't have a direct extension, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I just, I'm in the like, but if you dial when you dial the number you came to me from the care line I'm not sure what number you dialed to get to them, but there's a prompt for Medin claims and then it'll bring you to the call center that I work in.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Prompt for claims. OK. All right. So I am to ask them if they file secondary insurance or gap insurance. Is that what you said?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Do you file secondary or gap insurance? Now, if they don't, and I wanna go to them.
[CUSTOMER][NEUTRAL] That's OK because I can save the bill and send it to you, is that right?
[AGENT][NEUTRAL] Let me alter that.
[AGENT][NEUTRAL] If they don't, that is OK. You can file with us directly by sending us the EOB explanation of benefits from your primary insurance after they file and the diagnosis information from that visit.
[CUSTOMER][NEUTRAL] And diagnosis. So in other words, um,
[CUSTOMER][NEUTRAL] When my insurance company sends me the EOB.
[CUSTOMER][NEUTRAL] Um, in the mail, which they will do, then I make a copy of that. I send it to you, and I also send you a copy of the diagnosis from urgent care. Is that correct?
[AGENT][POSITIVE] Yes, that is exactly correct. Yes.
[CUSTOMER][NEUTRAL] Do I need, can I just put claims on it? Do I need to fill out a form that I don't have? Do I?
[AGENT][NEUTRAL] You can just um you can you can just put attention claims department.
[CUSTOMER][NEUTRAL] Uh, so I don't need to get a copy of the claim sheet and blah blah, OK.
[AGENT][NEUTRAL] Now if you would like to fill out the claim form and submit it along with that, you're you're welcome to do that.
[CUSTOMER][NEUTRAL] Attention claims department.
[CUSTOMER][NEUTRAL] Are you the only [PII] there or are there 50 like you?
[AGENT][NEUTRAL] Oh, no, no, no, no. I'm the only [PII].
[CUSTOMER][POSITIVE] Oh, you're so helpful. Thank you so much for your efficiency.
[CUSTOMER][POSITIVE] And you're making this procedure easy for me. If if I understand something, it just takes the any anxiety out of it for me, you know?
[AGENT][POSITIVE] Right, right, exactly.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, but you're saying now if I go to the hospital, I don't have to mess with anything really, or no, if I go to the hospital.
[CUSTOMER][NEUTRAL] If I went to the hospital emergency, which I really don't wanna do that, um,
[CUSTOMER][NEUTRAL] Then
[CUSTOMER][NEUTRAL] They won't charge, they they probably will file.
[CUSTOMER][NEUTRAL] Secondary, right at the hospital?
[AGENT][NEUTRAL] They normally do and urgent cares as well we get a lot of urgent care claims as well.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK. Well, good to know. Thank you so much.
[CUSTOMER][NEUTRAL] And um
[CUSTOMER][POSITIVE] I appreciate it.
[AGENT][NEUTRAL] OK, was there anything else I can assist with today?
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] We're good. I wonder on my insurance, maybe this is stretching it to ask you this with uh United Healthcare. I probably have to contact them again.
[CUSTOMER][NEUTRAL] Or the uh agency that stands in the gap for us there um.
[CUSTOMER][NEUTRAL] Do you know if
[CUSTOMER][NEUTRAL] The hospital charges you to walk in the door.
[CUSTOMER][NEUTRAL] With them.
[AGENT][NEUTRAL] That would be a question directly for the hospital, their billing practices.
[CUSTOMER][NEUTRAL] A deductible?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Cause every hospital is probably different, right?
[AGENT][NEUTRAL] Right. Yeah, I don't think United Healthcare would know the billing practices of whatever.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Um, institution you go to or facility that you go to, so you would have to contact the facility directly to see um.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, sounds good.
[CUSTOMER][POSITIVE] Thank you very much.
[AGENT][POSITIVE] Well thank you for calling APO you have a good day.
[CUSTOMER][POSITIVE] You too. And a happy New Year.
[AGENT][POSITIVE] Happy New Year to you, thank you.
[CUSTOMER][POSITIVE] Thanks. Bye.
[AGENT][NEUTRAL] Mhm bye bye.