AccountId: 011433970860
ContactId: 4b8909ae-7dfb-46f6-91f2-4801462af02b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 578330 ms
Total Talk Time (AGENT): 282657 ms
Total Talk Time (CUSTOMER): 227097 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/05/4b8909ae-7dfb-46f6-91f2-4801462af02b_20250305T18:32_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. I have a quick question. So, um, I had insurance with API or APL, um, and then I canceled that insurance after I got my C-section done, but I had to pay out of pocket for my C-section. I had to pay $2000 out of pocket, um, because they bill on a global scale. So I let you guys know, I started a claim for the refund and I got the check.
[CUSTOMER][NEGATIVE] And it is only $600 refund. So I am just trying to figure out what happened to the other portion of that, like why was that not refunded?
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, what's your policy number?
[CUSTOMER][NEUTRAL] Um, let me check here.
[CUSTOMER][NEUTRAL] Let me go back to where it was. Um, the policy number is 025.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 77511
[AGENT][NEUTRAL] And can you spell your first name for me?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you, [PII]. What's a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] [PII] thank you for that one moment.
[AGENT][NEUTRAL] And [PII], verify your date of birth, your mailing address, and an email address on file please.
[CUSTOMER][NEUTRAL] [PII] mailing address is uh [PII]. Um I'm not sure what email you have on file. It's probably [PII].
[AGENT][POSITIVE] Mhm, that's the one we show thank you for verifying that for me.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so is your delivery [PII]?
[CUSTOMER][NEUTRAL] Yeah, it was [PII].
[AGENT][NEUTRAL] Oh, not the [PII]? Oh, I see the, OK, so in several dates of service then I see [PII].
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so are you specifically asking about the September, I mean the [PII] data service?
[CUSTOMER][NEUTRAL] No, so when I was.
[CUSTOMER][NEUTRAL] Like right before I was about to have my baby, we had to complete the um.
[CUSTOMER][NEUTRAL] What is it called, like prenatal appointment um with my doctor. And those appointments, I had to pay out of pocket for that. It was like $2000 to do that. And they did let me know that once
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The delivery was completed, then they, in my one postnatal appointment was complete, then they would then send the claim out to um the insurance. So they did that. So insurance paid for dates from October until I had my son. And then just the one date after that, which I think was like [PII] or something. Um,
[CUSTOMER][NEGATIVE] And and they only paid $600 out of the $22,000 that I paid.
[AGENT][NEUTRAL] OK. And so when you were talking about your prenatal visit, so that, that was with your OB doctor, kind of like an office visit?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And what day did you have those prenatal visits?
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Well, let me just show you what I have or what was sent in by you. So I'm showing uh a $50 benefit which is the maximum benefit when you go to the doctor's office.
[AGENT][NEUTRAL] Um, PC, uh, let's see.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] Bear with me one second. Alright, so for your physician's office benefit for your policy, it's up to, it's up to $50 per day and then you have a maximum of 3 days per calendar year per covered person, so I show that we paid the $50 benefit for.
[AGENT][NEUTRAL] Uh, date of service of.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] So for each of those states of service there were 2 procedure codes on the claim for each claim, but the maximum that we can pay is 50 because that's your maximum per day.
[AGENT][NEUTRAL] Um, so I'm showing the two office visits paid and then I'm showing the, um, looks like this could have been your OB doctor's fee.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, on [PII] or [PII], it's a $500 benefit, so that would have been a surgeon's fee on an outpatient basis. Let me look at your benefits, one moment.
[CUSTOMER][NEUTRAL] So for the 18, is that the like because the bill was like 20,000 for that and then I know you guys came in and paid like I think 2 or 3000 or something like that. The bill that I owe is 18,000.
[CUSTOMER][NEUTRAL] Because you guys paid that.
[CUSTOMER][NEUTRAL] Is that why I'm not getting the full part of the 2000?
[AGENT][NEUTRAL] OK, so the 20,000, would that be the, the hospital charge or is that the surgeon's charge?
[CUSTOMER][NEUTRAL] The hospital charge.
[AGENT][NEUTRAL] OK, so the documents that I'm looking at, I don't see a hospital charge.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Um, is your OB doctor [PII]?
[CUSTOMER][NEUTRAL] Yes, that's my OB.
[AGENT][NEUTRAL] OK, so I see the OB's charge and we paid 500 on that.
[AGENT][NEUTRAL] And then $250 office visits, so that totals a $600 check that you were talking about. But now as far as the hospital charge, um, I'm not showing the hospital charge received and this is the only claim that we have. So you do have a hospital admission benefit and a hospital confinement benefit, but we would need the um the hospital itemized bill.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For review of the inpatient hospital bill.
[CUSTOMER][NEUTRAL] OK, um,
[CUSTOMER][NEUTRAL] Is that going to cover it or is it going to send me a refund?
[AGENT][NEUTRAL] So you submitted the claim, so if you submit the claim, this the hospital claim to us, the reimbursement will come to you. I will tell you what the benefit is, so.
[AGENT][NEUTRAL] The first time you were admitted to a hospital in a calendar year, there is a hospital admission benefit of $750 per day. That's just one time per calendar year, so you'll get $750 and then there's also a hospital confinement benefit which pays $200 per day for each day that you're in the hospital, um, not to exceed 30 calendar days. So how many days were you there?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] 3.
[AGENT][NEUTRAL] So that'll be 200 times 3.
[AGENT][NEUTRAL] So that's 600 plus 750.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, alright, so that makes sense OK um.
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] That's closer to the 2000.
[CUSTOMER][NEUTRAL] So I can
[CUSTOMER][NEUTRAL] Yeah, that's a lot closer to that 2000. So in the meantime, I'm able to go ahead and cash this check and then just submit another claim for the other ones and then just get those as they come.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, yes.
[CUSTOMER][NEUTRAL] Oh, OK, well then I will go ahead and do that then um I have a quick question about this check though it's, it's literally just like a check on green paper. This is the actual correct check, right?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, check number should be, well, what is the check number on that docket, the check that you have?
[CUSTOMER][NEUTRAL] 2029041
[AGENT][NEUTRAL] Yes, that's the check that we issued to you.
[CUSTOMER][NEUTRAL] OK, alright, so I will go ahead and um have that cast and then I will submit another claim with the hospital information.
[AGENT][NEUTRAL] And let me give you the let me give you the form name when you call the billing department there at the hospital because we need a specific itemized bill from that facility that captures all the information we need in order to process your claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it's um it's a it's an itemized bill and the form is U as in university, B as in boy, 04, so you're going to request the UBO4 form and they're familiar with it. It's what they'll send to the insurance companies also since I provided a benefit to you, [PII], it's just a verification on a guarantee of payment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, the information provided was simply based on the information that you gave me, such as the number of days you were there, and I'm sure you know, but we can't make a permanent decision until we get the document that itemized bill.
[CUSTOMER][NEUTRAL] Of course, OK, give me one sec.
[AGENT][NEUTRAL] I just wanted you to know that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Because I'm still trying to get the 10 out and it's not wanting to come out.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] No rush no rush.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] There we go now, OK, so the form ID that I need is.
[AGENT][NEUTRAL] U as in university.
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] B as in boy.
[AGENT][NEUTRAL] 04 that's an itemized bill for the hospital.
[CUSTOMER][POSITIVE] Itemized bill. OK, I will go ahead and reach out to the hospital and try to get that from them, and then I will, uh, send that on over. Thank you so much.
[AGENT][POSITIVE] Oh, you're welcome. Anything else I can help out with today?
[CUSTOMER][POSITIVE] Um, I think that's gonna be it. Thank you.
[AGENT][POSITIVE] You're welcome thanks for calling APL have a good day.
[CUSTOMER][NEUTRAL] Bye bye.