AccountId: 011433970860
ContactId: 234c980a-8881-4105-b14a-284e44447c15
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 718460 ms
Total Talk Time (AGENT): 274397 ms
Total Talk Time (CUSTOMER): 268470 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/05/234c980a-8881-4105-b14a-284e44447c15_20250505T14:17_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I wanted to check on a claim. I had a question concerning a claim.
[AGENT][NEUTRAL] OK, Ms. [PII], I can help you with a claim.
[AGENT][NEUTRAL] OK, and what is the name of the facility you're calling from, please?
[CUSTOMER][NEUTRAL] Oh this is um I'm actually the insured.
[AGENT][NEUTRAL] Oh, you are the insured. OK, Ms. [PII]. And may I please get your callback number just in case the call is disconnected?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] Thank you, ma'am. And then what is your policy number, please?
[CUSTOMER][NEUTRAL] It's 00785108.
[AGENT][NEUTRAL] OK, let me look that up real quick.
[AGENT][NEUTRAL] OK, Ms. [PII], can you please verify your date of birth for me?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, ma'am. And then also your address, phone number and email address that we have on the policy for you, ma'am.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Place
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]. I noticed online it had a suite 100, but that's for my office, so um the the number is [PII] and the email is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK thank you Ms. [PII], I appreciate you verifying that information for me. Let me go in there real quick and get that suite number off.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, my office has a suite number 100, so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm gonna remove that real quick so there's no more confusion.
[AGENT][NEUTRAL] OK and you said that you had questions about your claim, um.
[CUSTOMER][NEUTRAL] Yeah, and it might be, it might be the coverage in itself because I mean knock on wood I've only been using my insurance for WellCare so but um I did go to an urgent care and I thought I understood where.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] APL pays 4 co-payments up to 25 each.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] A year
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEGATIVE] And I noticed a claim was filed when I went to urgent care on [PII]. The claim number is 358-6206, and it didn't pay.
[CUSTOMER][NEUTRAL] The $25 and I'm just confused why.
[AGENT][NEUTRAL] OK, let me look real quick and see.
[AGENT][NEUTRAL] And it was for West Bank urgent care, is that correct?
[CUSTOMER][POSITIVE] That's correct.
[AGENT][NEUTRAL] OK, let me look to see if there's any remarks.
[CUSTOMER][NEUTRAL] It said something like I didn't meet the deductible but.
[AGENT][NEUTRAL] Says all or part of the payable benefits applied to the policy deductible of $100.
[AGENT][NEUTRAL] And then let's see.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] Yeah, so I thought the $100 was.
[CUSTOMER][NEUTRAL] I don't know, I, I guess I understood that and I've used it in the past where.
[CUSTOMER][NEUTRAL] You didn't have to meet that $100 deductible before it paid for the 4 co-payments of $25 each.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK. Let me look at your policy real quick. Um.
[AGENT][NEUTRAL] See what it says about deductible.
[AGENT][NEUTRAL] OK, so you have a deductible for accident and sickness only on the outpatient benefit of $100 per calendar year.
[AGENT][NEUTRAL] And your major medical insurance, there was another remark on here, um, that benefits were not paid if the major medical didn't pay.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That was the other remark on this claim.
[CUSTOMER][NEUTRAL] So, but my major medical did pay.
[AGENT][NEUTRAL] It was for code.
[AGENT][NEUTRAL] Let me look at it real quick.
[AGENT][NEUTRAL] It says benefits are payable only if your major medical insurance provider provides benefits. If this claim is later paid by your major medical insurance, please send the explanation of benefits showing that they were paid, and let me tell you what the code was for that one.
[CUSTOMER][NEUTRAL] I mean
[AGENT][NEUTRAL] That would be on your um EOB and your itemized statement. It was for procedure code 87.
[AGENT][NEUTRAL] 88
[AGENT][NEUTRAL] 0.
[CUSTOMER][NEUTRAL] OK, because let me go log into my HC let's see.
[AGENT][NEUTRAL] Yes, if you have that, please send in the EOB and then we can reprocess the claim.
[CUSTOMER][NEUTRAL] Because I would just happen to be in my uh United Healthcare and that's what I think where it said that I would be liable for the 25 and then I'm like well I thought that's what.
[CUSTOMER][NEUTRAL] Let's see, let me pull this up real quick.
[AGENT][NEUTRAL] And the charge amount for that procedure code it might help you to find it easier is $26. Uh, no, ma'am, it was 2026.
[CUSTOMER][NEUTRAL] Was 166.
[CUSTOMER][NEUTRAL] Oh plan discount.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Because the total bill amount was $166 the plan discount was $26 and the plan paid $115.
[CUSTOMER][NEUTRAL] Showing I owe 25, so let me see payment breakdown, yeah.
[CUSTOMER][NEUTRAL] Yeah, the plan discount was 26 and the plan paid 115.
[AGENT][NEUTRAL] So you owed the 25 which was put towards your deductible.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And that's why I was always understanding they pay like APL always pays up to 4 $25 copays per year.
[AGENT][NEUTRAL] Yes ma'am, what I can do is I can um transfer you on over to a claims specialist and they can go over how they process the claim for you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Would you like for me to do that?
[CUSTOMER][POSITIVE] Yeah, I'm just, yeah if you could please because I'm just trying to have a good understanding of it.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I understand, yes ma'am I do. So it's gonna be a quick hold. I'm gonna transfer you on over. Is there anything else I can help you with Ms. [PII], before we go?
[CUSTOMER][POSITIVE] No, that'll be it thank you.
[AGENT][NEUTRAL] OK, it's gonna be a brief hold.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi [PII], it's [PII].
[AGENT][NEUTRAL] I've got, um, hey, I've got Miss [PII] on the phone, or B, anyway, I'm gonna destroy that last name and her her policy, her policy number is 257-8794. She's been verified. She's calling about claim number 3586.
[CUSTOMER][NEUTRAL] Hey [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 206. I read the remarks about um the part of the claim was uh paid towards the deductible and she has further questions about it. She's um wanting a better understanding.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I mean, uh, what, what more is there?
[AGENT][NEUTRAL] She said that she knows that she gets 4 visits per year and she thought that the that the visits were paid $25 each. She's not understanding that the deductible for outpatient accident or sickness needs to be paid first and then the claim pays, but she wants further understanding.
[CUSTOMER][NEUTRAL] OK, let me double check something. I mean, I don't, I don't know what else you could possibly explain.
[AGENT][NEUTRAL] You're just gonna
[AGENT][NEUTRAL] You're gonna just reiterate what I said and maybe hearing it from a second person will.
[CUSTOMER][NEUTRAL] Yeah, exactly, like, and it's just like major medical, you know, you have a deductible and until you make that deductible you have out of pocket cost.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And for this policy, um,
[CUSTOMER][NEUTRAL] Let me double check something.
[CUSTOMER][NEUTRAL] This is the office treatment router.
[CUSTOMER][NEGATIVE] And the office treatment router doesn't even pay for.
[CUSTOMER][NEUTRAL] The physician's fee.
[CUSTOMER][NEUTRAL] So, that tells me that somebody didn't do something right anyways.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Can I, is it OK to let her go?
[AGENT][NEUTRAL] Like, are you ready for the call yet?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] If the certificate deductible is on per current receive more than one covered outpatient service and only one certificate deductible will be required to be met. OK, I was just trying to make sure there wasn't any like.
[CUSTOMER][NEGATIVE] Extra something out here that I needed to be aware of. I don't see anything. They applied the deductible to the office visit fee though, and we don't pay that under this router, so that wasn't even done correctly in the first place.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] But I'm not gonna tell her that.
[AGENT][NEUTRAL] Yikes.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That'll make her flip her wig.
[CUSTOMER][NEGATIVE] I'm just gonna have to send an error to the yeah yeah it'll be even worse.
[CUSTOMER][POSITIVE] OK, yep I got you.
[AGENT][NEUTRAL] OK. All righty. Bye-bye, [PII].
[CUSTOMER][NEUTRAL] All right.