AccountId: 011433970860
ContactId: 246aaa30-3301-4c70-9989-9f92fb6a3e79
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 884260 ms
Total Talk Time (AGENT): 289786 ms
Total Talk Time (CUSTOMER): 448290 ms
Interruptions: 3
Overall Sentiment: AGENT=0.5, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/23/246aaa30-3301-4c70-9989-9f92fb6a3e79_20250123T20:37_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], good afternoon, uh.
[CUSTOMER][NEUTRAL] Let's see what am I looking for? Um, first of all, I guess I need to identify myself. Do you need the group number or the benefit certification number?
[AGENT][NEUTRAL] Are you the policy holder?
[CUSTOMER][NEUTRAL] I am.
[AGENT][NEUTRAL] OK, the certification number?
[CUSTOMER][NEUTRAL] OK 019.
[CUSTOMER][NEUTRAL] 602-11.
[CUSTOMER][NEUTRAL] Uh, Mary, Lisa, and then there's a 7 for inside in the hospital and 8 for outpatient.
[AGENT][NEUTRAL] OK, and what's your name?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] [PII], OK, and what's a good phone number, [PII], in case we're disconnected?
[CUSTOMER][NEUTRAL] I'm calling from my home line here that's [PII].
[AGENT][POSITIVE] OK. And how can I help you today?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I wanted to go through what kind of um.
[CUSTOMER][NEUTRAL] Things you guys cover. I know I've used you in the past for um emergency room costs. I've used it for ambulance charges. Have you've used you guys to cover MRI's and uh X-rays. My son has some belly pain which we saw a specialist yesterday. He's ordering, um, he's ordering him an ultrasound. Is that something you guys cover?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Um, I can check for you. Let me pull up your information, get you there.
[CUSTOMER][NEUTRAL] I have like a diagnostic. I'm sorry, what's that?
[AGENT][NEUTRAL] Yeah, let me pull up your information, get you verified, and then we can proceed.
[CUSTOMER][POSITIVE] Oh, OK, sure, absolutely, whatever you need, sure.
[AGENT][NEUTRAL] 11 moment.
[CUSTOMER][NEUTRAL] Do you need the group plan also? I have a group number on the card.
[AGENT][NEUTRAL] No, I don't. The policy number is fine.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] On the phone
[AGENT][NEGATIVE] Almost there system it's a little slow.
[CUSTOMER][POSITIVE] No worries, no worries appreciate it.
[CUSTOMER][POSITIVE] I'm looking for your help so I'm really patient, no worries.
[CUSTOMER][POSITIVE] You're busy all day taking people's call and helping people.
[AGENT][NEUTRAL] Let's see
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] [PII], verify your date of birth, mailing address, and email address for me?
[CUSTOMER][NEUTRAL] Of course, [PII], we're at [PII], and do you have a Gmail or a Yahoo account on file for me?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So that would be [PII].
[AGENT][POSITIVE] Perfect, thank you.
[CUSTOMER][POSITIVE] I passed the test. Good.
[AGENT][POSITIVE] That was funny.
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. And so you said that your son reported to the doctor's office?
[CUSTOMER][NEUTRAL] Yeah, I went to see a specialist yesterday for his abdomen, and he's having pain on the lower right side so the doctor said he's, he would like to get an ultrasound of his gallbladder, and I have like the, the codes for that, but I just wasn't sure. I know my insurance, my primary insurance, um, they don't cover ultrasounds that comes out of my deductible for the year, um, just like other things like X-rays and MRI.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right. Mhm.
[CUSTOMER][NEUTRAL] And I've used you guys um for for those kind of tests. I just wasn't sure. I don't think we've ever had an ultrasound thankfully recently and I wasn't sure if you guys covered ultrasounds.
[AGENT][NEUTRAL] OK, I can check for you. Um, what's your son's name?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] And OK, thank you.
[CUSTOMER][NEUTRAL] And he's uh [PII], date of birth if you need that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So there is an outpatient uh benefit under your policy. Um, where would the diagnostic tests be done? Uh, in a diagnostic setting, facility setting, or imaging center?
[CUSTOMER][NEUTRAL] That's the, that's the plan. I would go somewhere where, like, I don't want to go into a hospital. I just want to go like, like my wife went to get a mammogram recently, you know, she went to Baptist Health. It's like a free standing, but there's also a Baptist Health hospital, so I don't know if they bill from the hospital or if it's free standing billing like that's that I'm not sure. So let me ask you that question. If we went to that Baptist Health.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] And they billed us from the hospital. Does that mean it's not covered when you're talking about this? You're talking about, you know, quote unquote free standing.
[AGENT][NEUTRAL] Yeah, if it's in a hospital setting that's considered outpatient and that can be considered under your the outpatient benefit of the policy.
[CUSTOMER][NEUTRAL] I guess that's
[CUSTOMER][NEUTRAL] OK, so outpatient, so there is a there is coverage for outpatient.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I think you said facility.
[AGENT][NEUTRAL] So if it's, if it's done in a diagnostic facility, it's, it can be considered. If it's done in a hospital setting, um, and then, you know, to me, hospital facility is the same thing, but
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] In my eyes, but technically, you know, a hospital is separate than a facility. I don't know what the difference is, but if it's done in a hospital, a freestanding facility, um, you know, I believe that like an imaging center would be considered a free-standing facility. So it's apart from a hospital, OK? All three are, are can be considered no matter where they are. If it's those three locations can be considered under your outpatient benefit.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Which is up to $1000 per calendar day, which is a really nice benefit, a daily benefit of $1000.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] It is. We've used it. We've used it a lot and it's very, very helpful, absolutely wonderful. So it's not the actual MRI or X-ray or CT scan or ultrasound. It's the fact that something is in a freestanding imaging facility. That's really the the focus here, is that right?
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Absolutely. Mhm.
[AGENT][NEUTRAL] Uh, not necessarily both cause some procedures could possibly be not covered, but a diagnostic test is.
[CUSTOMER][NEUTRAL] Oh OK.
[AGENT][NEUTRAL] Yeah. And then you also, you also have a treatment writer under your plan. So let's say uh some specialist office are designed to do this type of testing in their office.
[CUSTOMER][NEUTRAL] OK, yeah, because it, yeah.
[AGENT][NEUTRAL] So because you have a treatment writer under your policy, if it was done in a setting such as that, it would, we can also consider it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, so if, if this doctor happened to do the ultrasounds in his office, that is potentially or it is covered because it's in the office setting?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now, you have an you have an office treatment writer and so yes, we can consider it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, under the policy, which is 1000 per calendar day.
[CUSTOMER][NEUTRAL] So I have, I have to ask you when you say you you seem to be tacking on we can consider everything it sounds like there's no.
[CUSTOMER][NEUTRAL] Guarantee because you're not allowed to guarantee you're just not sure or you're just not allowed to guarantee.
[AGENT][NEUTRAL] Yeah, any
[AGENT][NEUTRAL] Yeah, any, any insurance company can't guarantee it because we have to receive the itemized bill, you know, sometimes we get calls and we provide a benefit based on what's asked of us, but then when we get the claim, it could be something different than what we quoted or than what they asked for when they call for the benefits.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh, well, OK, so let me ask you a question. Can you look up these codes that the doctor put on here for the order? Do you have that?
[AGENT][NEUTRAL] Well, if it's an, did you say it's an X-ray?
[CUSTOMER][NEUTRAL] It's an, it, it says, well, there's a bunch of codes. It, it's an ultrasound of the gallbladder. It says US. What's that?
[AGENT][NEUTRAL] Yeah, that's covered.
[AGENT][NEUTRAL] Yeah, that's fine.
[AGENT][NEUTRAL] Yeah, that's a covered service.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Oh, OK, because then there's like codes ICD-10 and R 10.13 like I I don't know if.
[AGENT][NEUTRAL] That, that's the diagnosis code. That's what they've diagnosed him with. And the the treatment is the ultrasound. They're gonna see what's going on. Mhm.
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] He wants to see what's going on, yeah, exactly, before doing, you know, something more now, now there's another test if he's saying if, um, you know, because he wants to do a stool on him, he wants to do a blood test, he wants to do this ultrasound and if none of those things show any kind of reason why he's having this pain, he's saying he might have to, well, he, he's saying he's gonna have to have like a.
[AGENT][NEUTRAL] Yeah. Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Oh jeez, what is it they have to like put a scope down his throat, like put him out and look, look actually up, you know, into his stomach. Uh do you guys cover that stuff too again if it's in a um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] In a diagnostic facility.
[AGENT][NEUTRAL] Yeah, they'll probably have to do that on an outpatient basis at a at a hospital.
[CUSTOMER][NEUTRAL] Right, and is that something that APL does cover as well?
[AGENT][NEUTRAL] It is.
[AGENT][NEUTRAL] It, it is because it's, it's outpatient hospital, so yes, we can consider that as well.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, alright.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Well, very good, um, I appreciate that because I, yeah, because I called my primary and I have like a $500 deductible for an ultrasound. I'm like, oh my god. So that's when I turned to the APL and I'm like, oh wow, it's like phenomenal. It's a great plan. I have another question for you, and I don't know if you can answer this.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right. OK.
[CUSTOMER][NEUTRAL] So, um, I left the company that um that I was with for the APL coverage, but because of COBR I kept the APL. Um, can I renew that myself with APL afterwards, or is it only like a a thing that you can get through an employer? Do you know?
[AGENT][NEUTRAL] I can look at it. Who is your employer?
[CUSTOMER][NEUTRAL] It was advisors
[AGENT][NEUTRAL] OK. And when did your COVR begin?
[CUSTOMER][NEUTRAL] Oh,
[AGENT][NEUTRAL] You've been on it for a while.
[CUSTOMER][NEUTRAL] Yeah, I think [PII]. 0 jeez, you know what? I'm not, no, no, no, I'm sorry, no, [PII] I think it was.
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] And I know the COR goes 18 months. I know it's getting, it's com it's gonna complete. It won't go past May this year.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I wasn't sure if I can purchase APL as an individual for my family or it has to be through an employer that's what I'm not sure.
[AGENT][NEUTRAL] You know, we do not sell individual policies, but on some of our policies we do, we can convert them, um, and I don't believe that this is one of those policies. Give me a second.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Let me place you on a brief hold, OK, [PII]?
[CUSTOMER][POSITIVE] Absolutely thank you.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] f er ring
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[AGENT][NEUTRAL] Hi [PII], this is [PII]. How are you?
[CUSTOMER][POSITIVE] I'm doing good. How are you?
[AGENT][NEUTRAL] Good, can you look at something with me? Um, we're always asked to call customer service if someone is inquiring about whether the policy can be ported.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Although I don't think it can, I need somebody to check it. The policy number is 1960211. It's a Metlink policy.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 196
[AGENT][NEUTRAL] 011.
[CUSTOMER][NEUTRAL] 02
[AGENT][NEUTRAL] For [PII]. Uh-huh.
[CUSTOMER][NEUTRAL] 0211.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, give me just a second.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] OK, that is a long lasting.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, let me look at it really quick.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, I'm not sure if he can afford it, but he's already enrolled with, so he should still be covered. Uh-huh, he's still.
[AGENT][NEUTRAL] Yeah, yeah, he's on Cobra.
[AGENT][NEUTRAL] He is. He's on Cobra.
[CUSTOMER][NEUTRAL] All right, so his coverage won't end until um let's see, we have.
[CUSTOMER][NEUTRAL] [PII] of this year.
[AGENT][NEUTRAL] Yeah, so it's only 18 months and he was wondering after his cover expires could he convert.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, I believe he can't. I'm not quite familiar after Cobra.
[CUSTOMER][NEUTRAL] Enrollments
[AGENT][NEUTRAL] But just in general the port, the support the policy, what's the rule? Would it not have to be in the policy? I don't see anything in the policy document talk that talks about it.
[CUSTOMER][NEUTRAL] Uh, no, I don't think so.
[AGENT][POSITIVE] OK. All righty. Thank you, [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Uh-huh, bye-bye.
[CUSTOMER][POSITIVE] Have a nice day. Bye-bye.
[AGENT][NEUTRAL] You too. Bye bye.
[AGENT][NEGATIVE] OK, thanks for holding, uh, [PII]. Unfortunately, this policy cannot be ported. You can't continue the coverage after your COR.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][POSITIVE] I see. OK, well, I have all the answers I was looking for. Uh, thanks so much for verifying that as well for me. So, uh, you have a great afternoon. Thanks.
[AGENT][POSITIVE] Absolutely.
[AGENT][POSITIVE] You too [PII], and if no other questions, thank you for calling APL. Have a good day.
[CUSTOMER][POSITIVE] Thank you bye bye.
[AGENT][NEUTRAL] Bye bye.