AccountId: 011433970860 ContactId: 440a29e3-b21b-487d-87b9-5a777d389622 Channel: VOICE LanguageCode: en-US Total Conversation Duration: 1436310 ms Total Talk Time (AGENT): 565217 ms Total Talk Time (CUSTOMER): 643372 ms Interruptions: 4 Overall Sentiment: AGENT=0.4, CUSTOMER=0.3 Redaction Types: PII Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/440a29e3-b21b-487d-87b9-5a777d389622_20250103T16:35_UTC.wav -------------------------------------------- [AGENT][POSITIVE] Thank you for calling [AGENT][NEUTRAL] PL this is [PII]. How may I help you? [CUSTOMER][NEUTRAL] Hi [PII], can you hear me OK? [AGENT][NEUTRAL] Yes, sir. [CUSTOMER][NEUTRAL] OK great um I wanted to check, I wanted to check something uh with you guys if you cover um something do you need to validate me before we go on? [AGENT][NEUTRAL] Can I get your name and your call back number just in case the call is dropped I can call you back. [CUSTOMER][NEUTRAL] OK, my number at home is [PII] [PII]. [AGENT][NEUTRAL] OK, [PII], and what is your policy number? [CUSTOMER][NEUTRAL] I'm sorry, the what number? [AGENT][NEUTRAL] The policy number? [CUSTOMER][NEUTRAL] Well, I see coverage group number plan. [CUSTOMER][NEUTRAL] In hospital and outpatient certification numbers so I'm not sure which number you need. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] Uh, you can give me either the inpatient or the outpatient certification number. [CUSTOMER][NEUTRAL] OK, so the inhospital benefit here is 0196. [CUSTOMER][NEUTRAL] 0211 M like Mary L like Lisa, 7 or 8, both of those. [AGENT][NEUTRAL] Oh. [AGENT][POSITIVE] OK, alright, and let me get your benefits for you, um, and pulling your policy, you're very welcome. [CUSTOMER][POSITIVE] Thank you. [AGENT][NEUTRAL] OK, [PII], what is your date of birth, sir? [CUSTOMER][NEUTRAL] [PII]. [AGENT][NEUTRAL] Thank you. And then what is your address, phone number and email address that we have on the policy for you? [CUSTOMER][NEUTRAL] Uh, [PII]. I give you the number already that we discussed earlier for a call back and then the, uh, and then it should, I think I have a couple emails. I think you've got the [PII], is that the one you're showing? [AGENT][NEUTRAL] Yes, sir. I see that. [AGENT][NEUTRAL] Yes. [CUSTOMER][POSITIVE] OK, good. [AGENT][NEUTRAL] Absolutely, yes, sir, that's it. OK, so. [CUSTOMER][NEUTRAL] Did I validate everything for you? [AGENT][POSITIVE] Yes, sir, you validated everything. Thank you. I appreciate that. So, um, [CUSTOMER][POSITIVE] OK, sure, absolutely. [AGENT][NEUTRAL] This is to verify benefits it's not a guarantee of payment. This policy is a supplemental insurance policy that is secondary to your primary, and it helps with deductible, co-pay and co-insurance. [CUSTOMER][POSITIVE] Correct. [CUSTOMER][NEUTRAL] OK, so [AGENT][NEUTRAL] Yes. [CUSTOMER][NEUTRAL] Doctor B. [AGENT][NEUTRAL] Deductible, co-pay. [CUSTOMER][NEUTRAL] Deductible, co-pay and co-insurance. [AGENT][NEUTRAL] Yes, and you have an inpatient benefit amount of $2000 per calendar year. [AGENT][NEUTRAL] And then you have an outpatient per calendar day amount of $1000. [CUSTOMER][NEUTRAL] Right. [CUSTOMER][NEUTRAL] OK, so here's the question I have for you, um, my wife has to go for her mammogram. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] And um the insurance covers a mammogram as a, as a, you know, once a year verification and a woman's right to make sure that. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Everything's OK, but because my wife has, um, very dense breasts, she always has to get an ultrasound after the mammogram to verify, I don't know, whatever they do, but she's done this for the past 15 years. [AGENT][NEUTRAL] Right. [CUSTOMER][NEGATIVE] Now with the new insurance that I have with my new employer, they're saying that the ultrasound is gonna be a deductible, part of your deductible. They're not covering that. I'm not quite sure because it is a wellness check and I don't understand why they're getting a little technical with what's wellness and not wellness, but mammogram, if someone needs a mammogram and an ultrasound, then that's the wellness check, but they're saying no, the ultrasound is not covered, so. [AGENT][NEUTRAL] Yes sir. [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] I've used uh APL for um emergency room and ambulance transport in the past. I've used it for uh MRIs and CT scans, X-rays. Do you guys cover ultrasounds? That's what I wanted to know. [AGENT][NEUTRAL] OK, let me look at your schedule of benefits real quick to see if ultrasound is, is covered. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] Um, [AGENT][NEUTRAL] It's gonna be just a second while the computer pulls it in. It's a pretty large policy and I have to scroll through it and find, find out exactly, you know. [CUSTOMER][NEUTRAL] Sure. [CUSTOMER][POSITIVE] No worries appreciate your patience. [AGENT][NEUTRAL] What it, what it may help her with. [CUSTOMER][NEUTRAL] Mhm [CUSTOMER][NEUTRAL] And also after you look up the ultrasound, I wanted to know a little bit more of what you were talking about with uh deductible copay and coinsurance please. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] All right. So looking at the policy, um, [AGENT][NEUTRAL] She has outpatient benefits, um. [CUSTOMER][NEUTRAL] Uh [AGENT][POSITIVE] And it says outpatient benefits we will pay the out of pocket amounts for treatment in a hospital emergency room without subsequently being considered an inpatient treatment in an urgent care facility. [CUSTOMER][NEUTRAL] Right. [AGENT][NEUTRAL] Physical therapy performed in a physical therapy facility. Surgery performed in a hospital outpatient facility, a freestanding outpatient surgery center. Um, diagnostic testing performed in a hospital outpatient facility or a magnetic an MRI imaging center or uh. [AGENT][NEUTRAL] Also mental health and emotional. So if it's uh. [AGENT][NEUTRAL] Ambulatory center MRI imaging center ER urgent care center. [CUSTOMER][NEUTRAL] Right, but this wouldn't be, this would be, this would be at a place that does mammograms. I don't know what kind of place I think mam I don't know. I don't know what those who, who, I don't know what kind of these imaging places are that do mammograms. [AGENT][NEUTRAL] And she's having her, her [AGENT][NEUTRAL] OK, so, um [CUSTOMER][NEUTRAL] So if we're, if she's at a place that does a mammogram. [CUSTOMER][NEUTRAL] And that's already part of the regular health insurance to get the mammogram as a yearly check. That's not a problem. The big question is this ultrasound that they need to do on her breasts every time after the mammogram because there's, I don't know, she has dense breasts and they can't see through well enough with the mammogram so they always have to do an ultrasound and now with this new insurance, my main insurance, they're saying we don't cover the ultrasound so that's why I wanna check with you guys so. [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Is it so can you see ultrasound specifically or that's not listed? I wasn't like you're talking about ER and diagnostic places and this, but I, I don't, I'm not sure I'm getting a clear answer if, if you have that, yeah. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] Yes, let me, let me keep looking and see if I see anything that specifically says ultrasound for her. [CUSTOMER][NEUTRAL] Oh, uh-huh, and this would be an outpatient. This is not, she's not going to be in the hospital, obviously she's going to, uh, you know, an ultrasound, not an ultra um, she's going to a place where they do mammograms. I think that's, I don't know what those places are they're. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] I guess they do MRIs and all kinds of things like that, it's that kind of place. [AGENT][NEUTRAL] OK, so if it is performed for her outpatient benefits, um, if it's performed. [CUSTOMER][NEUTRAL] Uh-huh. [AGENT][NEUTRAL] She has an office treatment writer which is treatment in an office, um, but these are the outpatient places that will, the insurance will help with, um, and hospital emergency room, urgent care facilities, uh, surgery or outpatient facility that's free standing, a diagnostic testing in a hospital. [AGENT][NEUTRAL] Um, [AGENT][NEUTRAL] An outpatient facility or an MRI facility. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] Are the facilities that cause it's not the procedure. [AGENT][NEUTRAL] That [AGENT][NEUTRAL] The insurance is covering because the insurance is for deductible co-pay or co-insurance. It's for the facility where it's performed at. [CUSTOMER][NEUTRAL] So if I got, how, how about this? I have an idea. If I find out where the facility is, can I call you guys back and you guys can verify? Oh yeah, that is, you know, that's one of, yeah, that's a free standing facility or it's an MRI facility. Could you then say further further to what you're saying here, yes, that would be a facility where the um public life would would assist in covering up to $1000 of outpatient help. [AGENT][NEUTRAL] And those are the [AGENT][NEUTRAL] Right. [CUSTOMER][NEUTRAL] Is that something that we can do? [AGENT][NEUTRAL] Yes, that is something that you can do um to see if it's a free standing facility or if it's a ambulatory center. [CUSTOMER][NEUTRAL] Uh-huh. [AGENT][NEUTRAL] So you'll need to know. [CUSTOMER][NEUTRAL] So can I get the name of where she would be going, and you guys can check to see that? How do I move forward with this to try and clarify it a little bit better? [AGENT][NEUTRAL] Right, so it's not um. [AGENT][NEUTRAL] It's not by the name of the facility we don't have a way to check that um by the name of the facility. It would have to be the type of facility that it is uh, is it an office visit? Is it a, uh, ambulatory center? [CUSTOMER][NEUTRAL] It will not be an office visit. No, it's not an office visit. She already saw her gynecologist as her yearly, you know, office check, and the gynecologist said you need to get your, your breast scanned like you do every year. So now she goes on to a place that does mammograms. So are places that do mammograms one of those outpatient free standing things that you're referring to? That, I guess, is what we need to answer. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] Right. OK. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] Yes, it sounds like that that's the type of place that she needs to go to would be a freestanding um. [AGENT][NEUTRAL] Outpatient [CUSTOMER][NEUTRAL] Yeah, cause she's not going to the hospital. I know she, there's a place where that they do these. [CUSTOMER][NEUTRAL] Mammograms and I, I'm pretty sure that's like an MRI kind of center. They have a place where you can go do your MRI's and they have a place where you do your mammogram. It's like it's different, you know, it's all part of the same building. [CUSTOMER][NEUTRAL] So [AGENT][NEUTRAL] Right [CUSTOMER][NEGATIVE] To your point, if it's that freestanding building that does these diagnostic tests, the APL will come in to cover if the main insurance doesn't, because our main insurance is covering the MRI. They just won't cover the ultrasound for someone who has dense breasts, which doesn't make sense, doesn't seem fair. [AGENT][NEUTRAL] And [AGENT][NEUTRAL] OK. OK. [AGENT][NEUTRAL] Right, right, I understand that. [CUSTOMER][NEUTRAL] Is there anyone you can check with on that? [AGENT][NEUTRAL] Uh, yes. [CUSTOMER][NEUTRAL] Is there any further verification you can you can do? [AGENT][NEUTRAL] Well, reading your policy. [CUSTOMER][NEUTRAL] Hm. [AGENT][NEUTRAL] Um [AGENT][NEUTRAL] Reading the policy, um. [AGENT][NEUTRAL] Let, let me see, there's your policy is very large, so I'm trying to read anything that says outpatient that will help you. Um, it says outpatient covered charges are those charges that are incurred by a covered person because of an accident or sickness. [CUSTOMER][NEGATIVE] Sorry, your, your, your, your connection is very poor. I guess you're, I guess you're on a Bluetooth headset or something and you're, you're just breaking up terribly. I can't hear you well. Um, is there any way you can switch to a regular phone? Your, your headset or something is breaking up terribly. I, I can't hear what you're saying. [AGENT][NEUTRAL] Oh. [AGENT][NEUTRAL] Oh, no. OK. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] OK, let me see if I can fix that for you. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] OK sir, can you hear me any better now? [CUSTOMER][NEUTRAL] Well, I'm hearing you now, just when you started to talk quite a bit. [AGENT][POSITIVE] OK, good. [CUSTOMER][NEUTRAL] We'll see what happens as you proceed. [AGENT][NEUTRAL] Yes, sir. [AGENT][NEUTRAL] Yes, sir. OK, so, um, the outpatient services are covered for injury, or I'm sorry, for accident or sickness. [AGENT][NEUTRAL] Um, [CUSTOMER][NEUTRAL] So this is not an accident or a sickness. This is like, um, so then therefore, it's not covered? [AGENT][NEUTRAL] Right. [AGENT][NEUTRAL] I'm going to keep on looking to see if it specifically mentions mammogram or ultrasound of mammogram. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] Oh, it's gonna take just a second. I'm trying to. [AGENT][NEUTRAL] Read through it. [CUSTOMER][POSITIVE] Thank you. [CUSTOMER][NEUTRAL] It's a very big policy yeah. [AGENT][POSITIVE] You've got a great policy. It has a lot of stuff on it, um, a lot of benefits. [CUSTOMER][POSITIVE] I, I've used it extensively, yeah, I've used it extensively it's been very helpful. [AGENT][NEUTRAL] Yes. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] OK, so basically what it's saying is if, if it's done in. [AGENT][NEUTRAL] A free standing facility, MRI imaging center or an ambulatory center and you even have office visits, even if it's done in the doctor's office. Um. [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] So it looks like all your outpatient is covered as far as facilities go. Um. [AGENT][NEUTRAL] It doesn't specifically say ultrasound, but if it's performed in one of those facilities, it should be covered under the deductible co-pay or co-insurance. [CUSTOMER][NEUTRAL] Uh-huh. [CUSTOMER][NEUTRAL] So talk to me a little bit about deductible copay and coinsurance because um. [CUSTOMER][NEUTRAL] As I said, the actual mammogram is covered as a yearly benefit from my insurance. They're just squandering here with the ultrasound, but they're saying the ultrasound, I do have a $250 deductible. [AGENT][NEUTRAL] Mhm. Yes. [AGENT][NEUTRAL] Right. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Um, so there's a $250 deductible and then there's some coinsurance, I think they said. [AGENT][NEUTRAL] So [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Uh, I'm not sure they're not very clear or specific about it, maybe 80 or 90%. [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] OK. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] Is covered, but there's like a remaining 10 or 20%. So let's say that hypothetically speaking, the mam the the ultrasound is $500. They're saying we have to pay $250 as a deductible and then some other portion, you know, 10 or 20% of the rest of our co-insurance or something. So as far as your reading, you feel that these amounts. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Could be covered by APL uh based on the fact that it's a free standing facility. [AGENT][NEUTRAL] Right. [AGENT][NEUTRAL] Right. [CUSTOMER][NEGATIVE] That's doing it's not, it's not in the doctor's office. If it was, it would still potentially be covered because you, you do cover things like that as well, you're saying in the doctor, but this is definitely not. Doctor farms it out to the right places to do these mammograms. [AGENT][NEUTRAL] Yes. [AGENT][NEUTRAL] Right. [AGENT][NEUTRAL] Right, that's correct, um, by the way that I'm reading it. So everything that this policy covers is based on the explanation of benefits from your primary insurance. So when they file their claim, they can file a claim with us for the deductible co-pay or co-insurance. [CUSTOMER][NEUTRAL] Uh-huh. [AGENT][NEUTRAL] You can give them that card so that they can um. [CUSTOMER][NEUTRAL] Right. [AGENT][NEUTRAL] File a claim for us to pick up the deductible co-pay or co-insurance for the procedure. [CUSTOMER][NEUTRAL] Right after they find out what the primary covers or doesn't cover then they follow up with you guys. [AGENT][NEUTRAL] Right. [AGENT][POSITIVE] Exactly. [CUSTOMER][POSITIVE] And that's what I typically do. I typically bring in my, my insurance card and the APL card, and I always make sure that's on file just in case there's something that is not covered by the primary that you guys can, you know, slip in and, and cover, which is help tremendously. [AGENT][NEUTRAL] Yes. [AGENT][POSITIVE] Exactly. Yes, sir. Sounds like you, you have a very good um understanding of it. [AGENT][POSITIVE] And how it works. That's, that's good. [CUSTOMER][NEUTRAL] Yeah, so let me ask you another question if you don't mind. I see that something was processed. [CUSTOMER][NEUTRAL] On just a couple of days ago on uh [PII], can you look at that claim number if you don't mind? Can I give you the claim number or do you see that one? [AGENT][NEUTRAL] Yes. [AGENT][NEUTRAL] Let me look. [AGENT][NEUTRAL] OK, what is the claim number? [CUSTOMER][NEUTRAL] 354-567-4 [AGENT][NEUTRAL] OK, let me pull it up. [AGENT][NEUTRAL] OK, it looks like that we paid for you for Beacon respiratory Services. The claim was $44.01 and we paid the $44.01. [CUSTOMER][NEUTRAL] Uh-huh. [CUSTOMER][NEUTRAL] Right. [AGENT][NEUTRAL] To [CUSTOMER][NEUTRAL] Beacon [AGENT][NEUTRAL] The facility, yes, sir. [CUSTOMER][NEUTRAL] OK [CUSTOMER][NEUTRAL] Um, I don't know why they did this, but this was durable equipment. I know you guys cover also durable equipment, but for some reason these folks split it up over monthly payments. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEGATIVE] I have asked them for a one time bill, but they just keep on sending these, these, these in these incremental things and it looks like you've paid the 4401 a number of times, at least 3 times, but that's only covering a portion of the durable equipment. [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Um, if I can get you guys the full. [AGENT][NEUTRAL] OK. [CUSTOMER][NEUTRAL] Bill [CUSTOMER][NEUTRAL] Would that be [CUSTOMER][POSITIVE] More helpful to actually see. [CUSTOMER][NEUTRAL] Like I don't know [AGENT][NEUTRAL] I am. [CUSTOMER][NEUTRAL] And I've been asked [AGENT][NEUTRAL] That might be a question that I'm, I'll need to transfer you over to a claims uh examiner for because I'm unsure if it'd be helpful or not. Um, it looks like I'm looking at your history here and it looks like that, you know, as you said they are paying the 4401 they've paid it several times, um. [CUSTOMER][NEUTRAL] Looks like they all did it at the end of the year actually. Number of uh invoices I guess were submitted throughout [PII] in June, July and August. Looks like you guys covered it at the end of the year. [AGENT][NEUTRAL] Oh. [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] Uh-huh. [AGENT][NEUTRAL] Right, I see that. [AGENT][NEUTRAL] Right, I do see that, um. [CUSTOMER][NEGATIVE] I'm not sure why it was just at the end of the year. Do you have any idea why it would have taken a couple of months? Maybe they didn't supply you with information you guys needed. I don't know. [AGENT][NEUTRAL] I do know that once we receive the claim and we have to get the claim from the facility first and once we receive the claim, it takes 7 to 10 business days to process it so that might be where your gap is coming in from the facility sending it in compared to the amount of days it takes to process it. [CUSTOMER][NEUTRAL] Mhm. [CUSTOMER][NEUTRAL] Uh huh. [CUSTOMER][NEUTRAL] Yeah, because they kept on calling me. I said you need to send this to APL. APL covers my durable equipment. They're like, OK, we will, but I don't know. There's another one here if you don't mind 343-849-4. Can you tell me what that is? [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] Mhm. [AGENT][NEUTRAL] 343-849-4. Let me look. [CUSTOMER][POSITIVE] Thank you. [AGENT][POSITIVE] You're very welcome. [AGENT][NEUTRAL] South Miami Hospital. [AGENT][NEUTRAL] Um, [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] It was paid $433.50. [CUSTOMER][NEUTRAL] Right, what was that though at the hospital? What were they charging? Do you see that? Because I don't see the details here. I see that it was covered 433, but. [AGENT][NEUTRAL] Um, [CUSTOMER][NEUTRAL] I don't know what I don't know if that was an MRI or. [AGENT][NEUTRAL] It was for [AGENT][NEUTRAL] I will not be able to see the actual paperwork that came in um I can like I said, the claims examiners can they have access to that they can see that um but I do so see that um. [CUSTOMER][NEUTRAL] Oh [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] OK. [CUSTOMER][NEUTRAL] Mhm. [AGENT][NEUTRAL] There was a Doctor [PII]. [AGENT][NEUTRAL] I [CUSTOMER][NEUTRAL] OK. [AGENT][NEUTRAL] That it says it could be critical care. Let me see. [CUSTOMER][NEUTRAL] I don't remember, yeah. [CUSTOMER][NEUTRAL] Oh, well this is an urgent care one then or something? [AGENT][NEUTRAL] Um, [AGENT][NEUTRAL] It doesn't tell me. Uh, there's only so much I'm allowed to see. [CUSTOMER][NEUTRAL] OK, that's OK. [AGENT][NEUTRAL] Um [CUSTOMER][NEUTRAL] Yeah, no, I understand. All right, well, what I'll do is I appreciate the information. uh, let me share that with my wife, and if I have any further questions I'll, I'll call again. What, uh, what are you guys' hours typically? I know you're in [PII], but you're in Central time, but what are your hours normally every day? [AGENT][NEUTRAL] Yes, sir. [AGENT][NEUTRAL] Yes, sir. [AGENT][NEUTRAL] Yes. [AGENT][NEUTRAL] We're open from [PII]. [CUSTOMER][NEUTRAL] OK, central, right? [AGENT][NEUTRAL] Yes, sir. [CUSTOMER][NEUTRAL] Yeah, because right now it's [PII] here, so it's [PII] for you, OK. [CUSTOMER][POSITIVE] Well that's great thank you so much for your for your help I really appreciate your time today. [AGENT][POSITIVE] You're so very welcome, [PII]. I hope her procedure goes well and everything just goes so easily for you. [CUSTOMER][POSITIVE] Thank you, thank you so much. [AGENT][POSITIVE] You're welcome. Thank you for calling APL. You have a good day, sir. [CUSTOMER][NEUTRAL] All right. You too, bye-bye. [AGENT][NEUTRAL] Bye-bye.