AccountId: 011433970860
ContactId: 3a90d687-d58c-4fd4-bc08-08f47af07861
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 735280 ms
Total Talk Time (AGENT): 258853 ms
Total Talk Time (CUSTOMER): 386293 ms
Interruptions: 5
Overall Sentiment: AGENT=0.1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/08/3a90d687-d58c-4fd4-bc08-08f47af07861_20250508T21:32_UTC.wav
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[AGENT][NEUTRAL] Calling APL, my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII], and my husband has Pella, um, employer group insurance with, uh, you guys, and we've had it in the past, and now they're switching. It's the new year to pick our new insurance. And they said they're going with the APL metalin.
[CUSTOMER][NEUTRAL] Series, which we've had APL in the past, like I had foot surgery a couple of years ago, and they said that it's not for that, it was for inpatient only. But now, his HR department sent stuff home today. And in it, it talks about
[CUSTOMER][NEUTRAL] Deductibles being in hospitals deductibles and outpatient deductibles. So what are outpatient deductible or what is the outpatient.
[CUSTOMER][NEUTRAL] Procedure or labs or X-rays with metalline.
[AGENT][POSITIVE] OK, I'd be happy to assist. I would need um.
[AGENT][NEUTRAL] A specific policy number um you said you had us before, so you should still be in the system um what is your social?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Um, well, I'd be covered under my husband's. His social is.
[CUSTOMER][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] You go?
[AGENT][NEUTRAL] OK, and
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] If you can verify your date of birth?
[CUSTOMER][NEUTRAL] [PII] and it's [PII].
[AGENT][NEUTRAL] And the mailing address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, so the policy is already active then.
[CUSTOMER][NEUTRAL] OK, is it the same type of policy?
[AGENT][NEUTRAL] Um, OK, so.
[CUSTOMER][NEUTRAL] So she, she just spend the whole with.
[AGENT][NEUTRAL] Yeah, I'm showing.
[CUSTOMER][NEUTRAL] She sent him home with a bunch of paperwork today to go over.
[CUSTOMER][NEUTRAL] And she's addressed it it's called the medical gap insurance with APL and it talks about benefit maximums and outpatient benefit maximums and then it has um.
[CUSTOMER][NEUTRAL] Emergency room deductibles. It looks like it's.
[CUSTOMER][NEUTRAL] It looks like they're trying to show the employees that yes, we do cover when you have outpatient things going on in the emergency room, but I know when I had my foot surgery a couple of years ago, I had to have um a bone removed with a cyst to make sure it wasn't cancerous. And I know when we got the claim back they said don't use that card, that's just for inpatient when you're inpatient hospital because we had the, the claim denied, so I sent it back in.
[CUSTOMER][NEUTRAL] You know, and I said, hey, you know, ask your employer and they're like, oh no, this is like, you know, catastrophic, that means, you know, if it's something big and I was like, well, outpatient usually is not big.
[CUSTOMER][NEUTRAL] But I didn't know what outpatients.
[AGENT][NEUTRAL] OK. I'm showing.
[AGENT][NEUTRAL] I'm showing we received 2 claims for you.
[AGENT][NEUTRAL] And they were only for office visits.
[AGENT][NEUTRAL] And that was for the physician's charges. It wasn't for treatment or procedures at the visit. It was just the co-pay associated with the physician's charges, which is not covered. We never received a claim for you being in the hospital or.
[AGENT][NEUTRAL] Anything like that. What, what day were you in the hospital?
[CUSTOMER][NEUTRAL] I'm getting ready to pull up my chart. It sounds terrible. I'm sorry. It, it was outpatient surgery.
[CUSTOMER][POSITIVE] Let me look real quick I'm sorry.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Looks like [PII].
[CUSTOMER][NEUTRAL] I had surgery on my foot.
[CUSTOMER][NEUTRAL] And I had it through Barnes.
[AGENT][NEUTRAL] OK, so
[AGENT][NEUTRAL] They
[AGENT][NEUTRAL] Assumed without them calling to verify your benefits they assumed because we have policies that only cover for inpatient but it's not one size fit all they assume because they ran and they called us about someone else and maybe they only had the inpatient but they didn't call about you you have outpatient coverage and that's a claim we could have paid for you but it's not too late thank goodness we don't have a um.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] We don't have a timely filing, so, um, that can still be submitted.
[AGENT][NEUTRAL] Um, but they didn't call to verify and I, and I hate that they didn't do, you know, I, I hate that they just assumed, oh, APL is only inpatient. No, we have policies like that, but we also have outpatient coverage and your company has the inpatient and the outpatient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So like if I have outpatient blood work or any outpatient testing is that fall underneath this also?
[CUSTOMER][NEGATIVE] But I'm, I just, it sounds terrible but it says.
[AGENT][NEUTRAL] So let's see, yes, you have a lab.
[AGENT][NEUTRAL] Yes, you, I see lab on here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I see durable medical equipment.
[AGENT][NEGATIVE] So I don't know why they didn't call, they just assumed and that's that's a dangerous thing to do.
[AGENT][NEUTRAL] Because now you have people paying out of pocket for stuff that they didn't have to pay out of pocket for.
[CUSTOMER][NEUTRAL] Oh, I know.
[CUSTOMER][POSITIVE] Most definitely.
[AGENT][NEGATIVE] That's awful.
[CUSTOMER][NEUTRAL] That's OK. I mean, I, the only reason I questioned it is my husband. I used to work in the medical field. I did all the coding and billing, and I was like, let me look at this thing and I was like, why are they saying that they cover it when I was told they don't, but.
[CUSTOMER][NEGATIVE] Probably would have been nice if they sent it in and get it denied.
[AGENT][NEUTRAL] Or even just call even if they even just call and ask.
[CUSTOMER][NEUTRAL] So do they require pre-op?
[AGENT][NEUTRAL] Even if they didn't want to submit the claim.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Exactly.
[CUSTOMER][NEUTRAL] So, um, I'm just trying to educate myself a little bit too because I'm not familiar with you guys so on this it talks about.
[CUSTOMER][NEUTRAL] Outpatient benefits.
[CUSTOMER][NEUTRAL] 3500 per person per calendar deductible.
[AGENT][NEUTRAL] Per year, so we pay.
[CUSTOMER][NEUTRAL] Oh no, the the emergency room was the emergency room was per per occurrence, never mind. I thought there was something that showed only 2 times. There was something that I read and that's not with you guys. I apologize.
[CUSTOMER][NEUTRAL] So yeah, I, I have no idea.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So for the outpatient is $3500 per calendar year and also $3500 per year for inpatient and outpatient includes um ER urgent care.
[AGENT][NEUTRAL] Uh, outpatient surgical facilities, MRI facilities.
[AGENT][NEUTRAL] You also have benefits for treatment in the office, and that's just the treatment. It's not the co-pay for the visit. It's just any treatment or procedures at the visit that would be covered under your outpatient benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] So like today I went to the dermatologist. This is a stupid question. I went to the dermatologist today and she found something that looked abnormal mole.
[CUSTOMER][NEUTRAL] So I paid my $75 co-pay.
[CUSTOMER][NEUTRAL] Then they're sending that biopsy off.
[AGENT][NEUTRAL] Did she just
[AGENT][NEUTRAL] So she did something. She didn't just talk to you and walk out the room. She touched you, she cut you.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] She probed, she prodded.
[CUSTOMER][NEUTRAL] Yep, she cut something off and send it.
[AGENT][NEUTRAL] We're gonna pay for the probing and the prodding.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Cause that's treatment or that's a procedure. Her talking to you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Cause that's what all that talking, how you've been, what's going on.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] That's the physician's fee and that's where your co-pay is tied to. We don't pay that.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right, the office visit, right, office visits aren't covered. A procedure, surgery or something like that is covered, and then you have a $3500 per occur, OK.
[AGENT][NEUTRAL] Right.
[CUSTOMER][POSITIVE] I, yeah, every time I've given the people APL they hand it back to me, but I gave it to them when I had my foot surgery, and they said no, they don't cover that and needs to be inpatient, so I was like, oh, OK, so [PII], if we ever go to the hospital and we need to be in this is something I covered, but it'd be nice that his employer group could go over that with everybody and explain to them, you know, hey, this is what this benefit is for.
[CUSTOMER][POSITIVE] OK, thank you so much. I appreciate you, um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Was there anything else I could assist with today?
[CUSTOMER][NEUTRAL] If, if I go back and look through and see how much we paid out, you said there is not a time limit that I could get that to you guys, how would I go about doing that?
[CUSTOMER][NEUTRAL] For my surgery in [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so,
[AGENT][NEUTRAL] Um, we will need the diagnosis for each of the treatments that you are filing for and then the EOB from the insurance for each data service and there's, um, if your husband, I don't know if he is, is he signed up for the um online service center?
[CUSTOMER][NEUTRAL] Diagnos
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Cause you can upload the documents there.
[CUSTOMER][NEUTRAL] Uh, uh, I don't.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You have been a wealth of information. What was your name?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] Uh thank you so much. I hope you have a wonderful day.
[AGENT][POSITIVE] Thank you you too
[CUSTOMER][POSITIVE] I appreciate you taking the time out and explaining everything to me. It makes things, you know, and I'm in the, uh, I'm in the medical field. I've been doing this 30+ years, and she sends this out and I'm like, I need this in layman's terms. So I wrote it out on a piece of paper and then it said we could call on the thing and I thought, well, I'm just gonna call them. They're gonna know as for going back to the girl she she needs to put this in [PII]'s terms because they said outpatient benefit maximums.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Well, what are the outpatient what are the outpatient benefits?
[AGENT][NEUTRAL] Right, right.
[CUSTOMER][NEUTRAL] You know when you just say it like that, people don't know what that is.
[AGENT][POSITIVE] Right, exactly.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right. Yes, because I've had labs, lab works done and mammograms, but that should have been covered 100% because that was routine. I didn't have any issues, but OK, awesome.
[CUSTOMER][POSITIVE] Awesome, awesome.
[AGENT][NEUTRAL] Yeah, just send us where you see um they applied something to your deductible and co-insurance and if it, if they didn't pay anything, then we're gonna deny cause if, you know, we have to follow their guidelines. So if it's not covered with them, it's not covered with us.
[CUSTOMER][NEUTRAL] Right, but if their portion went towards the deductible, you guys will probably pick up a portion of that, correct? I denied just saying they won't cover the benefit, OK, alright.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Right, meaning they're not paying nothing now applying to the deductible is not a denial, it's just, hey, you gotta pay first, but a deni I'm, I'm talking about denied meaning this is not covered under your major medical policy.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEGATIVE] Yeah, I wouldn't be seeing somebody for that.
[AGENT][NEUTRAL] Right. Right. OK.
[CUSTOMER][POSITIVE] All right, thanks [PII] have a wonderful day.
[AGENT][POSITIVE] You too, thank you for calling APL bye bye.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Bye bye.