AccountId: 011433970860 ContactId: 348a14ba-d897-451f-a0f7-ec1ef9258a88 Channel: VOICE LanguageCode: en-US Total Conversation Duration: 1897260 ms Total Talk Time (AGENT): 666583 ms Total Talk Time (CUSTOMER): 569324 ms Interruptions: 3 Overall Sentiment: AGENT=0.3, CUSTOMER=1.2 Redaction Types: PII Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/13/348a14ba-d897-451f-a0f7-ec1ef9258a88_20250113T20:26_UTC.wav -------------------------------------------- [AGENT][NEUTRAL] Calling APL, this is [PII]. How may I help you? [CUSTOMER][NEUTRAL] Yes, I was wanting to try to find out, um, I'm supposed to be getting a certain type of test. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] And the place I, I'm supposed to be getting it told me that APL, which is my secondary insurance. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEGATIVE] Uh, was not, would not cover it. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] And so trying to figure out where it would cover. [AGENT][NEUTRAL] OK. Let me get your um name and your policy number. [CUSTOMER][NEUTRAL] All right, the name is [PII], last name [PII] [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] And the policy number is 01828789. [AGENT][NEUTRAL] What's a good phone number, uh, [PII], in case we're disconnected or [PII]? [CUSTOMER][NEUTRAL] [PII] [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] OK. Can you verify your date of birth and mailing address? [CUSTOMER][NEUTRAL] [PII] address [PII]. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] And what's your email address on file? [CUSTOMER][NEUTRAL] [PII]. [AGENT][NEUTRAL] Thank you for that information and you said that uh the provider's office called and that we informed them that. [CUSTOMER][NEGATIVE] The the place where I'm supposed to get the imaging done it done called to set up my appointment and said that my secondary insurance, which is APL is not going to cover the imaging. [AGENT][NEUTRAL] Uh-huh. [AGENT][NEUTRAL] Let's see. [CUSTOMER][NEUTRAL] And I asked when that changed because when I had surgery in [PII], it did cover and she said it looks like it changed. She said it looks like it. [AGENT][NEUTRAL] Yeah, I'm not showing a call. I'm not showing a recent. [CUSTOMER][NEUTRAL] Changed in [PII]. [AGENT][NEUTRAL] No, you have the same policy. Um. [CUSTOMER][NEUTRAL] But she's saying APL doesn't cover it anymore. [AGENT][NEUTRAL] You [AGENT][NEUTRAL] Yeah, that's what I'm saying. You said it's an outpay, is it a diagnostic test being done in a diagnostic facility or a hospital? [CUSTOMER][NEUTRAL] And it's being done at a hospital. [AGENT][NEUTRAL] OK. I don't see a recent call from a provider. Do you know when they called? [CUSTOMER][NEUTRAL] I don't know that they did call. I don't know. [AGENT][NEUTRAL] OK, yeah, I'm not showing a call for benefits since [PII] and you do have an outpatient benefit under this policy. Um, it's up to $5000 per calendar year, but you also have a $1000 deductible that may be satisfied first. Maybe that's what they were saying. I don't know. [CUSTOMER][NEUTRAL] No, she said that you were out of network. [AGENT][NEUTRAL] Well, there is no network because this policy is secondary to your major medical policy. It's a sup a supplemental policy. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] To your, to your primary. [CUSTOMER][NEUTRAL] I guess I'll call him back then. [AGENT][NEUTRAL] Yeah, do you have their phone number? [CUSTOMER][NEUTRAL] I do. [AGENT][NEUTRAL] What is it? [CUSTOMER][NEUTRAL] [PII] [AGENT][NEUTRAL] And who have you been speaking with? [CUSTOMER][NEUTRAL] Oh, she didn't give me her name. [AGENT][NEUTRAL] OK. Now, you do have a cal. [CUSTOMER][NEUTRAL] I made an appointment though. [AGENT][NEUTRAL] OK, you do have a calendar your deductible that you'll need to satisfy. [AGENT][NEUTRAL] Um, under this policy. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] And I believe it's per calendar year. Let me verify that. And so before we can pay out the $5000 benefit, you'll need to satisfy the $1000 deductible. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] Yeah, I think it is. [CUSTOMER][NEUTRAL] Right, OK. [AGENT][NEUTRAL] Let me see something. [AGENT][POSITIVE] But you do have a benefit once that's met. [AGENT][NEUTRAL] Yeah, the deductible is per calendar year. [AGENT][NEUTRAL] Yeah, so I don't know if it was a play on words because technically we wouldn't cover it until you satisfy the $1000 outpatient deductible at which time we'll then begin to pay out the $5000 benefit this year. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] So do you want to go ahead and conference in with them to just clarify? OK, give me one second. [CUSTOMER][POSITIVE] That would be great, yeah. [CUSTOMER][NEUTRAL] All right. [CUSTOMER][POSITIVE] Thank you. [AGENT][POSITIVE] You're welcome. [CUSTOMER][NEUTRAL] Thank you for calling the BJC Healthcare centralized outpatient scheduling department. If this is a medical emergency, please hang up and dial [PII]. To better serve you, please listen carefully to our menu options. If you're a provider or provider office, press 1 now. If you are a patient or patient representative, press 2. [CUSTOMER][NEUTRAL] Please note for quality purposes this call may be recorded. If you're calling to schedule an X-ray or blood work, no appointment is needed. Simply visit the BJC hospital of your choice to have that taken care of at a time that is convenient for you. For information about our notice of privacy practices, which explains how we handle your healthcare information, press one. All other callers remain on the line to be connected to our outpatient scheduling team. [CUSTOMER][NEUTRAL] To help us serve you better, please have your insurance card available. [CUSTOMER][NEUTRAL] Hi, this is BJC Centralized scheduling department. My name is [PII] and how can I help you? [AGENT][NEUTRAL] Hi [AGENT][NEUTRAL] Hi, [PII]. This is [PII] with American Public Life Insurance Company. How are you? [CUSTOMER][NEUTRAL] I'm fine. [AGENT][NEUTRAL] Good. I have a [PII]. She's holding on the other line. I haven't conferenced her in yet. Um, do you need to verify with her date of birth? [CUSTOMER][NEUTRAL] Yes, how do you spell her last name? [AGENT][NEUTRAL] [PII] [AGENT][NEUTRAL] [PII] is [PII] [CUSTOMER][NEUTRAL] And when is her birthday? [AGENT][NEUTRAL] I'm showing [PII]. [CUSTOMER][POSITIVE] Got it. And how can I help you with her? [AGENT][NEUTRAL] OK, so American Public Life is her secondary payer. Um, it's secondary to her major medical policy, don't know who she spoke with, she couldn't remember, but they told her that she did not have coverage under the APL policy, which is incorrect. She said that she scheduled for, I think an outpatient diagnostic test. [CUSTOMER][NEUTRAL] OK, hold on one second. [AGENT][POSITIVE] OK, thanks. [CUSTOMER][NEUTRAL] Um, yes, I do see that, but I'm not seeing a secondary coverage. [AGENT][NEUTRAL] Yeah, it's [CUSTOMER][NEUTRAL] Um [AGENT][NEUTRAL] It's with American Public Life. [CUSTOMER][NEUTRAL] Um, hold on one second. [AGENT][NEUTRAL] OK. [CUSTOMER][POSITIVE] Thanks for holding. We appreciate your time and patience. Please stay on the line. OK, so I did find the insurance but it looks like we are out of network with that coverage. [AGENT][NEUTRAL] There is no network because it's a, it's a gap policy, so we follow the major medical whatever amount the uh primary insurance applies towards her deductible co-insurance and her co-pay amounts, we'll pick up those, those charges. It's like a supplemental gap plan. [CUSTOMER][NEUTRAL] OK, um, hold on one second, let me reach out to my lead. This definitely goes past me. Hold on one second. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] OK, OK. [CUSTOMER][POSITIVE] Thank you for holding. We look forward to talking with you soon. Please hold the line. We'll be right back with you. [CUSTOMER][POSITIVE] Thank you for holding. We look forward to talking with you soon. Please hold the line. We'll be right back with you. [CUSTOMER][POSITIVE] Thank you for holding. We sincerely appreciate your patience. Please stay on the line. We'll be back in a moment. [CUSTOMER][POSITIVE] Thank you for holding. We sincerely appreciate your patience. Please stay on the line. We'll be back in a moment. [CUSTOMER][POSITIVE] Thank you for waiting. Your patience is appreciated. Please hold the line. We'll be right back with you. [CUSTOMER][POSITIVE] Thank you for holding. We look forward to talking with you soon. Please hold the line. We'll be right back with you. [CUSTOMER][POSITIVE] Thank you for holding. We sincerely appreciate your patience. Please stay on the line. We'll be back in a moment. [CUSTOMER][NEUTRAL] Thank you for calling BJC pre-arrival. If this is a medical emergency, please hang up and dial [PII]. Please listen carefully as our menu options have recently changed. If you're a patient or patient representative calling for pre-registration, please press [PII]. If you are a physician office. [CUSTOMER][NEUTRAL] Thank you for calling the BJC pre-registration department. This call may be monitored for quality assurance. Registrars are available Monday through Friday [PII] to pre-register patients for hospital services. Federal law requires BJC to provide you with an opportunity to receive a copy of our notice of privacy practices, which explains how we handle your health information. [CUSTOMER][NEUTRAL] If you would like an electronic copy, please inform the register handling your call. All representatives are currently assisting other callers. If you would like to pre-register online, please utilize MyChart eCheck in within 7 days of your service. Please remain on the line, and our next available representative will be with you shortly. [CUSTOMER][NEUTRAL] Thank you for calling BJC's pre-arrival department. This is [PII]. How can I help you? [AGENT][NEUTRAL] Hi, [PII]. This is [PII] with American Public Life. I was speaking with a [PII]. [AGENT][NEUTRAL] And I've been on hold for about 10 minutes. [AGENT][NEUTRAL] Um, I have a, a [CUSTOMER][NEUTRAL] Um, [AGENT][NEUTRAL] I'm with American Public Life, and I have a, a patient that's scheduled for an outpatient diagnostic test at this location. And she said that the uh the provider of the facility said that they called us and said that this isn't covered under her policy, which is not correct. So I was calling to clarify the benefit. [CUSTOMER][POSITIVE] Alrighty [CUSTOMER][NEUTRAL] What's the patient's name? [AGENT][NEUTRAL] Um, her first name is [PII] [AGENT][NEUTRAL] And last is [PII] [CUSTOMER][NEUTRAL] And what's your last name? [AGENT][NEUTRAL] And her date of birth? [AGENT][NEUTRAL] It's [PII]. [AGENT][NEUTRAL] [PII]. [CUSTOMER][NEUTRAL] Alrighty, well they have their insurance on file and it's active and everything and it's not showing a balance so I'm not sure. [AGENT][NEUTRAL] She has an upcoming diagnostic test. She has a primary insurance and American Public Life, which is who you're speaking with. We're the secondary pair. [CUSTOMER][NEUTRAL] What was the appointment? [AGENT][NEUTRAL] And so, [AGENT][NEUTRAL] I'm sorry? [CUSTOMER][NEUTRAL] What was the appointment she has coming up? [AGENT][NEUTRAL] I have her on the line if you want me to conference her in. [AGENT][NEUTRAL] Uh, [PII] located the, the, the future appointment. [CUSTOMER][NEUTRAL] Oh [AGENT][NEUTRAL] I don't know what the date is. [CUSTOMER][NEUTRAL] Alrighty, the policy number, do you have the policy number for that, that secondary coverage? I just wanna verify, is it the 182-8789? [AGENT][NEUTRAL] Uh-huh. [AGENT][NEUTRAL] OK. It's [AGENT][NEUTRAL] Yes. [CUSTOMER][NEUTRAL] OK, yes ma'am, we have that loaded as well for secondary and verified as well. [AGENT][NEUTRAL] OK. All right. I'm not sure then what she was referring to, um, but I just wanted to call to confirm because she said that she had a scheduled appointment, uh, coming up soon. [AGENT][NEUTRAL] Do you have the benefit information? [CUSTOMER][NEUTRAL] No ma'am, I wouldn't have the benefit information we just upload the insurance and we call you guys to verify that it's active and then we mark it as active. [AGENT][NEUTRAL] OK. All right. So do you have her effective date? [CUSTOMER][NEUTRAL] And we just have it as active. [AGENT][NEUTRAL] OK. Is that all you need? [CUSTOMER][NEUTRAL] Yes ma'am. [AGENT][NEUTRAL] OK. Spell your first name for me? [CUSTOMER][NEUTRAL] [PII] [AGENT][POSITIVE] OK, thank you so much, [PII]. Have a good day, OK? [CUSTOMER][POSITIVE] Not a problem, you as well. [AGENT][POSITIVE] All [PII]. Bye bye. [CUSTOMER][NEUTRAL] Bye bye. [AGENT][NEUTRAL] [PII]. [CUSTOMER][NEUTRAL] Yes. [AGENT][NEUTRAL] Thank you so much for holding. OK, spoke with uh [PII] and ended ended up speaking with [PII]. They actually had the policy number on file. Um, she said this was like the registration team. um, they showed your policy active with American Public Life, so they are aware that you do have a secondary coverage, um. [AGENT][NEUTRAL] And I asked her if she needed the benefit, and she said, no, they just verify whether the policy is active. [AGENT][NEUTRAL] So she said you're good to go. They showed your appointment date, future scheduled appointment date. [AGENT][NEUTRAL] So whenever you go. [CUSTOMER][NEUTRAL] I wonder why the lady told me that. [AGENT][NEUTRAL] I know. [AGENT][NEUTRAL] Yeah, and so I, I don't. [CUSTOMER][NEUTRAL] And then when I when the lady transferred me to the other department to get an cost estimate. [AGENT][NEUTRAL] Uh-huh. [AGENT][NEUTRAL] Uh-huh. [CUSTOMER][NEUTRAL] Uh, she told the, the first lady told me to tell the second lady that she transferred me to that my secondary was showing wouldn't cover it and to ask if it should be taken off because it might slow down the pre-certification. [CUSTOMER][NEUTRAL] And she said she took it off. [AGENT][NEUTRAL] OK, so they, so, so [PII], she actually gave, she actually verified your policy number, so she gave it to me to verify that it was correct, your policy number with APL and I told her that it is, that is the correct number, so they have it in their system. [CUSTOMER][NEUTRAL] Hm. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] And so just be, you know, just know that, you know, there is a $1000 outpatient deductible under our policy. Um, so you may be required because you have a major medical deductible to satisfy too, right? [CUSTOMER][NEUTRAL] Mhm [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] I think overall our deductible for total insurance is 5000. [AGENT][NEUTRAL] OK. All right. And. [CUSTOMER][NEUTRAL] I honestly don't know. I hardly ever use my insurance. [AGENT][NEUTRAL] I know, I know. And by it being the the [CUSTOMER][NEUTRAL] I'm lucky that I'm in it, but I don't. [AGENT][NEUTRAL] Yeah, by it being the beginning of the year. [AGENT][NEUTRAL] Um, you know, you'll, you'll have to satisfy your major medical deductible, um, so they'll submit the claim to your major medical first and then, uh, submit it to American Public Life. I mean, they have our information. [AGENT][NEUTRAL] Um, and so that may be something that you verify to make sure that they submit the claim over to American Public Life after sending it to the major medical carrier. [CUSTOMER][NEUTRAL] So do I have to satisfy my deductible with the major medical before AP before? [AGENT][NEUTRAL] Yeah, cheap, so just, so it's. [CUSTOMER][NEUTRAL] The deductible with APL comes into play. [AGENT][NEUTRAL] Yeah, so it's two separate policies, so treat it as so you won't get, I won't confuse you. So I don't, if, if let's say, you know, whatever your major medical deductible is, you will have to meet that deductible before they pay out any benefits. [AGENT][NEUTRAL] So, [CUSTOMER][NEUTRAL] So meaning I will have to pay whatever my deductible is. [AGENT][NEUTRAL] Right, but the gap policy, that's why you have this supplemental gap policy. [AGENT][NEUTRAL] Um, because we, we assist with whatever is applied towards your major medical, uh, your major medical deductible, co-insurance and or co-pay amounts, and so the, the caveat is that you also have an outpatient deductible under your APL policy as well. So, um, and this is just a hypo. [CUSTOMER][NEUTRAL] So it says my network individual deductible with United Healthcare is 5000. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] And so and so depending on how much they, how much the service is, how much they charge, um, let's say that they apply just hypothetically, I don't know how the major medical is gonna process it, but just to give you an example of how it works. So let's just hypothetically say if you've not met your major medical deductible that they apply, just say 5000 towards your major medical deductible, OK? [CUSTOMER][NEUTRAL] And then [CUSTOMER][NEUTRAL] Uh-huh. [AGENT][NEUTRAL] And so then the hospital will then submit their bill and then your, your major medical EOB to American Public Life, and then we'll um add a deductible, but once you meet our 1000, which you will, then we'll start paying out the rest of that benefit. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] Of that 5000. [AGENT][NEUTRAL] Because your maximum outpatient benefit under our policy is 5000 per calendar year. [CUSTOMER][NEUTRAL] Mm. [AGENT][NEUTRAL] I know that probably confused you, so let's say your primary applies 5000 towards their deductible. [CUSTOMER][NEUTRAL] Meaning I have to pay 5000? [AGENT][NEUTRAL] No, not yet, because then they then they have to send it to APL. [AGENT][NEUTRAL] Right. [CUSTOMER][NEUTRAL] Well she told me that my cost was gonna be 165825. [AGENT][NEUTRAL] Is that 16,000 or 1,658? [CUSTOMER][NEUTRAL] I'm sorry, $1,658.25. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] Like 25,000 for that, I mean 16,000 for that, OK, and so it's just kind of hard to gauge because we, we have to have the primary EOB to adjudicate the claim. I mean that's the only way we'll know, you know, how to process the claim. [CUSTOMER][NEUTRAL] Uh [CUSTOMER][NEUTRAL] No. [AGENT][NEUTRAL] But I know that you [CUSTOMER][NEUTRAL] So if let's just say that it let's just say it costs $1600. I mean that's not correct, but let's just say it costs $1600. [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] Uh-huh. [CUSTOMER][NEUTRAL] Then you know then I then United Healthcare will use that amount. [CUSTOMER][NEUTRAL] Towards my deductible? [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] And that's what I would pay. [AGENT][NEUTRAL] And so, so then they would send the claim to. [CUSTOMER][NEUTRAL] But then if APL kicks in. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Then I would really only have to pay 1000 because they would pick up the remaining. [AGENT][NEUTRAL] Mhm, so you have a $1000 deductible under our policy as well. [CUSTOMER][NEUTRAL] That's how it works. [AGENT][NEUTRAL] So we would subtract the 1000 which you would owe because you have to satisfy our deductible and then we would pay the 600 based on your scenario we would pay 600. [CUSTOMER][NEUTRAL] Right. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] Got it. [CUSTOMER][NEUTRAL] I guess that's why I'm confused because with UnitedHealthcare, my deductible is 5000. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] And if you're saying I have to satisfy my deductible first. [CUSTOMER][NEUTRAL] With United, then why wouldn't I have to pay 5001st? [AGENT][NEUTRAL] Yes, that's what this gap policy with APL is. [CUSTOMER][POSITIVE] Got it. OK, got it. [AGENT][NEUTRAL] We pick up the, the deductible or if they applied it towards your co-insurance, we'll pick up that co-insurance. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] So technically our deductible is 4. [AGENT][NEUTRAL] You can look at it that way and you're out. So although, so, yeah, I get it, it is confusing. And so although you have a $1000 deductible under our policy, your maximum outpatient benefit is up to $5000. [CUSTOMER][NEUTRAL] OK, I'm just trying to figure it out in my head. [CUSTOMER][NEUTRAL] So once, so let's just say I don't exceed that $5000 with APL, does that mean I literally would only pay $1000? [AGENT][NEUTRAL] Yeah [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] Yeah, so using the scenario that you gave, uh, $1600 applied towards your major medical deductible, um, because you have a $1000 deductible under our policy, you would, you would owe the $1000 and we would pay the $600. So then we would subtract the $600 from your outpatient benefit of $5000. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] And that means if you had any other service. [AGENT][NEUTRAL] This year, your $1000 deductible would be satisfied and then you would have a remaining balance of $54,400 for the year. [AGENT][NEUTRAL] So if you went and had another diagnostic test done after this one, you've already satisfied your $1000 deductible with APL. So let's say your coinsurance was $4000 we would be able to pay it because you have a remaining balance of $5400. [CUSTOMER][NEUTRAL] Got it. [AGENT][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] Got it. [AGENT][NEUTRAL] And these are all scenarios because it depends on, you know, how it's processed by your primary. Yeah. [CUSTOMER][NEUTRAL] Right now. [CUSTOMER][NEUTRAL] So as long as I stay under 5000, I'm only paying 1000. [AGENT][NEUTRAL] Based on your scenario of 1600, yes. [CUSTOMER][NEUTRAL] Yeah. [CUSTOMER][NEUTRAL] I mean based on any scenario, right? I mean, really. [AGENT][NEUTRAL] Yeah, yeah, yeah, so, exactly. [CUSTOMER][NEUTRAL] I'm just I'm not holding in any of this. I know we're all we're just trying to figure this out the numbers aren't real, but. [AGENT][NEUTRAL] Yeah [AGENT][POSITIVE] Yeah, right. Exactly. [CUSTOMER][NEUTRAL] Mm. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] Well, [CUSTOMER][NEUTRAL] I guess I'll see what they do. [AGENT][NEUTRAL] Yeah, and so make sure you, you know, you may want to reach out. When is your appointment? [CUSTOMER][NEUTRAL] But [CUSTOMER][NEUTRAL] The [PII]. [AGENT][POSITIVE] OK. Yeah, that's cool. You may wanna reach out to him again, maybe tomorrow or today, whichever you prefer, just to confirm. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] Um, I talked with the, uh, the pre-registration department and all they basically do is verify your policy number, which they have, and then they verify if your your policy is active, which we confirmed that yes it is. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][POSITIVE] All right, that sounds good thank you for checking. [AGENT][NEUTRAL] OK. Anything else I can help with today, [PII]? [CUSTOMER][POSITIVE] Nope, that is it. I appreciate your um your help. [AGENT][NEUTRAL] Oh. [AGENT][POSITIVE] You're welcome and thank you for calling APL. Have a good day. [CUSTOMER][POSITIVE] You have a good day bye bye. [AGENT][NEUTRAL] Uh, you too. Bye-bye.