AccountId: 011433970860
ContactId: 4bd9e122-2a15-45db-8feb-5d305c579394
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1153920 ms
Total Talk Time (AGENT): 749296 ms
Total Talk Time (CUSTOMER): 329144 ms
Interruptions: 5
Overall Sentiment: AGENT=0.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/25/4bd9e122-2a15-45db-8feb-5d305c579394_20250425T15:54_UTC.wav
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[AGENT][NEUTRAL] Contacting ATO, my name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, [PII], thanks for taking my call. Um, I have a commercial policy. I mean, I belong to a company that have a policy with you guys.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I could give you
[CUSTOMER][NEUTRAL] Oh, excuse me, I'm so sorry. Um, the, the benefit pin number or group number?
[AGENT][NEUTRAL] Uh, do you have a card with you? It might be in, uh, your.
[CUSTOMER][NEUTRAL] I have, I have
[CUSTOMER][NEUTRAL] Yeah, I have a card with me.
[AGENT][POSITIVE] Great.
[AGENT][NEUTRAL] It might begin with a 01 or 02, your policy number?
[CUSTOMER][NEUTRAL] Yes, 023.
[CUSTOMER][NEUTRAL] 63.
[CUSTOMER][NEUTRAL] 02363908.
[CUSTOMER][NEUTRAL] And then I have ML7 or ML 8, but I think that is just addition.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Yes, yeah, that just tells us what, what type of plan you have and um if I could just verify your name, uh date of birth, and a phone number, please.
[CUSTOMER][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] 42675, um.
[CUSTOMER][NEUTRAL] Phone number [PII].
[AGENT][NEUTRAL] OK, I do have your policy pulled up, Miss [PII]. How may I help you?
[CUSTOMER][NEUTRAL] OK, I have a question for you. Um, I recently had some, uh, co-payments that I have to take care of myself at the moment at the doctor's office, and I would like to see if they are eligible for me to provide for reimbursement.
[AGENT][NEUTRAL] Yes, certainly, let's just to go over your benefits and and what you're talking about is the office is a co-pay, is that correct?
[CUSTOMER][NEUTRAL] One
[CUSTOMER][NEUTRAL] Uh, yes, but it was like special services. It wasn't doctor visits. It was for.
[CUSTOMER][NEUTRAL] Colonoscopy one and the other one was for vascular services.
[AGENT][NEUTRAL] Alright, OK. Um great. So let's just look at your policy. Um, so, uh, of course, first your policy went into effect on [PII]. It is active now, for the type of services that we're talking about, your policy will pick up the deductible, co-payment or co-insurance from your major medical.
[AGENT][NEUTRAL] Up to $3000 per calendar year per individual. So what would end up happening in this case is that let's just say that you do go into your doctor's office or have gone into your doctor's office, um, for these services, you would give them both your major medical card.
[AGENT][NEUTRAL] And this card, and then what they will do is they will file through your major medical first, but then they file through us and we will pick up the deductible, co-payment or co-insurance for those services in your physician's office, up to $3000. Yeah.
[CUSTOMER][POSITIVE] Correct. Yeah.
[AGENT][NEUTRAL] So that's the way your policy works.
[CUSTOMER][NEGATIVE] So that means that I will never get assistance with uh co-payments. Co-payments is always gonna be due to me.
[AGENT][NEUTRAL] Uh, it should always be, yes, you should always have that. Now, if they don't want to file the claim or they don't have the staff to or ask you to file it, you can always file it yourself. Um, we do have a way for insureds to, uh, file those claims and get the benefit to themselves. You can certainly do that, but yes, for sickness or accident, uh, treatment within the physician's office, treatment within an outpatient hospital setting, um, independent labs, you know, when you have to have lab testing.
[AGENT][POSITIVE] Those things are all included in that $3000. So, yes, that, that will certainly be taken care of um by your, your policy.
[AGENT][NEUTRAL] And this is per individual um in your family that's covered.
[CUSTOMER][NEUTRAL] No, but then I got a little bit confused. OK, so for instance, um, to just to be more practical, I have these co-payments that I did one in a gastro service and the other one in a vascular service. Can I, if I file a claim for this, is this something that is gonna be.
[AGENT][NEUTRAL] Sure, certainly.
[CUSTOMER][NEGATIVE] Applicable, I'm gonna, or because if it's not worth for me to put a claim for something that I don't have the right to do it or because it's not meeting the $3000 then I won't do it.
[AGENT][NEUTRAL] Well, you, right. Now, you can file that claim as, as long as we are not talking about the office visit co-pay. Now, when, when you go into your physician's office, they're gonna charge you 2 times, um, one just for the office visit. Now, that is not covered.
[AGENT][NEUTRAL] The office visit is not right, but treatment within the physi physician's office for anything that's like a sickness or an accident, that is covered. Now, your, your wellness checks are not covered, but if you, you did say that you had vascular work, um, did, did you say colonoscopy or did you, um,
[CUSTOMER][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, yes, OK, now those, those are, um, those are covered and so yes, uh, if you do have co-payments for those, um, what you would want to do is you would want to send, you can certainly send those in, um, and what we would need.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Is the explanation of benefits from your major medical, from your primary insurance.
[AGENT][NEUTRAL] But you should also have um what are called the walkout notes or the notes from the doctor letting us know what they did and why they did it. And, and you can certainly submit those to us.
[CUSTOMER][NEGATIVE] It's not something new, is not something new access. I have to obtain the information.
[AGENT][NEUTRAL] Yes, that's right. See your doctor's office is not going to give it to us. They, they, uh, this is something if you file the claim yourself.
[CUSTOMER][NEUTRAL] Let me ask you this, and I'm sorry to interrupt you. I received statements uh cause our primary insurance is Florida Blue. So I received statements from Florida Blue West for the services that I've been to do. Would that information, that statement be good enough?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] No, that's fine.
[AGENT][NEUTRAL] Well, no, uh, it, it's good. We want that. We do want that. Yes, we do want that. Um, but you will also have to give us the, um, uh, the information, uh, regarding why you went into the doctor, and that's, that's usually, um, when you go into a doctor's office, they usually give you that, that uh 8 by 11 piece of paper or, or a sheet that tells you what was done, who you saw that day, and why you saw them.
[CUSTOMER][NEUTRAL] But that is only on the emergency room, the hospital in the outpatient or like in the vascular plate so I didn't get anything like that.
[AGENT][NEUTRAL] OK, so your physi your physician, your regular physician doesn't give you a walkout paper. He just, he just lets you go with no, with no thing at all. OK. Well,
[CUSTOMER][NEGATIVE] No, no.
[CUSTOMER][NEUTRAL] Yeah, that's it, yeah, see you next time and.
[AGENT][NEUTRAL] You can actually request that because um it's uh
[AGENT][NEUTRAL] They are supposed to let you know what they did. First of all, who you saw, what you did, or what they did and what their, uh, what the diagnosis was or, or what their, their prognosis was, and that prognosis, but their diagnosis of your, of what you um went into the doctor for. So you may just have to ask them.
[CUSTOMER][NEUTRAL] OK, understood. I will start, I will start doing, I will start doing that from moving forward, but it's not something that here at least in in [PII] or in my town where I am at, they do not provide that. But OK, I understand I have the right to ask and I will consider that.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Absolutely.
[CUSTOMER][NEUTRAL] Take any have any mind that in order to claim for you guys I need that information directly from them. OK, perfect. Now I have a second question.
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] There's a claim that you guys paid uh already. It was for one of my dependents that was um expense based on an accident that we endured with one of my children and I already got the confirmation that it was um a partial payment to that.
[CUSTOMER][NEUTRAL] So I was in a dispute with the primary insurance for the other half and they finally gave me the final answer that was a no. Can you revisit that case again for me to see if the reason why APL used or applied 50% was because it was expecting that Florida Blue would do the other 50%.
[AGENT][NEUTRAL] Yes, we can certainly look that up and, and, um, which, which of your dependents would this be?
[CUSTOMER][NEUTRAL] Uh, Lucas.
[AGENT][NEUTRAL] [PII], OK. So, um, let's look at that. And what date of, what, what was the date of surface for [PII]? What was?
[CUSTOMER][NEUTRAL] Uh, precisely, I would say [PII], but it's [PII]. I'm sorry, it's been a time of debating with this.
[AGENT][NEUTRAL] [PII]. OK.
[AGENT][NEUTRAL] Well, let's see what we have here because I, I don't have anything in [PII] yet, so let's just see what we have.
[AGENT][NEUTRAL] What I've got for him, um.
[CUSTOMER][NEUTRAL] And, um, helicopter service that we have to make use of from the local town.
[AGENT][NEUTRAL] OK, so this is for a doctor's service in, in [PII]. Is that correct?
[CUSTOMER][NEUTRAL] No, helicopter service. Emergency.
[AGENT][NEUTRAL] A helicopter, oh, I'm sorry. OK, I see. I see. So it was an ambulance. OK. I mean, it's OK, I understand it was transport. OK. Just let me see what we've got here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, can you give me a minute while you search that up for me, please? I'll put you on hold for a second. OK.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] Yes, sorry about that.
[AGENT][NEUTRAL] OK. Uh
[AGENT][NEUTRAL] So what, um, it looks like we had Miami-Dade.
[AGENT][NEUTRAL] Fire and rescue for uh yes uh [PII]. So the um
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Let's see, from Florida Blue, uh, what we did was we processed it, we processed the payment according to the Florida Blue explanation of benefits and, and this is how they process the claim.
[AGENT][NEUTRAL] So, um,
[AGENT][NEUTRAL] What they did was they uh processed the claim for $412.94 which we paid to Miami-D Dade Fire and Rescue. But the reason that we paid that is because that is the amount that that uh Florida Blue put towards your deductible. So there is an amount, there is an amount that um whenever, uh.
[AGENT][NEGATIVE] Yeah, you have any kind of service.
[CUSTOMER][NEGATIVE] Sorry, your voice went away. Your voice went away.
[AGENT][NEUTRAL] OK, can you hear me now?
[AGENT][NEUTRAL] Can you hear me better now? OK, so the reason that we, uh, that we, um, did the claim the way that we did, uh, is because we followed the way that uh um Florida Blue.
[CUSTOMER][POSITIVE] Yes, I can.
[AGENT][NEUTRAL] Uh, process the case, yeah, so what they did was they put um $412.94 towards your deductible, and that's what we pay. So, um, because, uh, Florida Blue only put $412.94 towards your deductible, that is why that's the only amount that we pay. So what we do is we will pick up the deductible, co-payment or co-insurance from Florida Blue.
[CUSTOMER][NEUTRAL] Reported.
[AGENT][NEUTRAL] But if they, if they don't add any more money to that, I mean this is just the way that they um adjudicated this particular claim. This is, this is the way that they processed it and um and so this is something if you had any, uh, if you were in dispute over over the charge, this is something that you'd probably want to talk to Florida Blue over because we can only process it.
[CUSTOMER][NEUTRAL] I already did and and they and they said that the, the, as, as you see is dated from [PII]. I've been in dispute with them and their final answer is that that no that that um it's based on my deductible which is fine because it I mean for my dependent deductible at that time which is fine and that's why now I decided to come back to APL because my understanding is that the APL would.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Uh, cover whatever is that, um, a Florida Blue would pass along to me from my pocket.
[AGENT][NEUTRAL] No, that's, no, that's not really the, the way that it works is that um the way that that the that our program works, um, Ms. [PII] is that if Florida Blue puts something put uh if if as they um process the claim.
[AGENT][NEUTRAL] Uh, whatever they put towards your deductible, co-payment or co-insurance, that's what we'll pay. But in this particular case,
[AGENT][NEUTRAL] There's there is a certain amount of, of, of the charge that let's put it this way now that when uh Miami Dade uh charged you for this, um, they charged a certain amount of money for each service and so what they did was they charged $870 for the transportation that they provided.
[CUSTOMER][NEUTRAL] For the transportation for the ambulance.
[AGENT][NEUTRAL] Now Florida Blue has a contract with them and what they will do is they have a certain amount of money that they are willing to pay for these services and that usually has nothing to do with what um Miami-Dade or or your physician or whoever charges. So there's the charge amount from the provider of service.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then there is how much Florida Blue as your insurance company is willing to pay.
[AGENT][NEUTRAL] So there was one service that they charged $15 and Florida Blue.
[AGENT][NEUTRAL] Will only allow
[AGENT][NEUTRAL] $10 for that service. So there is a, there's a difference between what the provider is charging.
[AGENT][NEUTRAL] And what Florida Blue is willing to pay, and this is on, this is every insurance company, it's on, it's almost on every charge that you're ever going to have. There's always going to be what, what the provider charges and then what your insurance company is willing to pay.
[AGENT][NEUTRAL] On one of those charges, they charged $855. Florida Blue, uh, in their, their, their contract with Miami Dade.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] They say that for this particular service, they will only charge, they will only pay $402.94. Now, as your secondary insurance, what we will do
[AGENT][NEUTRAL] Is that and they put this towards your deductible. So as your secondary insurance, what we will do is we will pay the amount that Florida Blue.
[AGENT][NEUTRAL] Their contractual amount for these for these services, not the difference between what the provider is charging and what Florida Blue is willing to pay. What we will do is your secondary insurance is we will pay that whatever Florida Blue puts towards your deductible, co-payment or co-insurance. So in this particular case, that amount that Miami-Dade charged $870 but Florida Blue.
[AGENT][NEUTRAL] They're in their contract with Miami-Dad stated that they will only pay 40 they only I think that this service is worth $412.94 and that's what we pay. So if there's a difference between what is charged and what Florida Blue's contract contract amount is with the provider, then that's, you know, that's not something that we would have anything to do with. Um, we can only pay what they put towards your deductible, co-payment or coin.
[CUSTOMER][NEUTRAL] Understood. No.
[CUSTOMER][NEUTRAL] OK, so pretty much the gap insurance of APL is over what my primary insurance submit to me as for my uh deductible. So my, my out of pocket portion is still on me it's not something APR would assist me in any form.
[AGENT][POSITIVE] That's correct, for your, yeah, for your deductible.
[AGENT][NEUTRAL] Well, normally whenever they they have a contract like this, if, if you use an out, if you use an in-network provider, normally you're not charged again.
[AGENT][NEUTRAL] Um, so if [PII] is charging you for this, um, again, you may want to talk to, uh,
[CUSTOMER][NEGATIVE] So they are charging me, they are charging me for the other half that wasn't covered. That's what they're charging me.
[AGENT][NEUTRAL] OK, then that's the, so what they're doing is they're charging you for something that's above and beyond what they contracted with Florida Blue, and you may um
[CUSTOMER][NEGATIVE] But it was as you can see the bill was 855 you guys paid for 12 and they're charging me for the difference. So I was wondering if there's something else that APL can assist me with in this other half.
[AGENT][NEUTRAL] Yeah, mhm.
[AGENT][NEUTRAL] Well, not, not us, no, because this is the, because um this is the way that, that your, your primary insurance um uh process the claim, and that's the only, the only thing that we can do is follow what the primary insurance does. So, um,
[AGENT][NEUTRAL] If this is a, if this is the uh the amount that is uh the difference between what the provider is charging and what Florida Blue contracts them for, this is why you would need to talk to Florida Blue because in their contract, usually with these providers.
[AGENT][NEUTRAL] If you use an in-network provider, generally speaking, the provider isn't supposed to charge you the difference. So what they will do is they will, they will have a contract with, say, in this case Miami-Dade Fire and Rescue that they were only willing to pay this much for these services and normally that that balance billing.
[AGENT][NEUTRAL] Um, is not supposed to, you know, it's normally something that that you would want to talk to Florida Blue about. You would need to let them know that they're charging you above and beyond what they contracted with them for. Now, if, if, uh, Miami-Dade is not.
[AGENT][NEUTRAL] Uh, in network with, with Florida Blue, then there's not much you can do, but if they are charging you that difference between what uh Florida Blue contracted for.
[AGENT][NEUTRAL] And what they, you know, what their normal charges are, that's, you know, that's really that what you'd have to talk to your primary insurance for. But that's not something that we would do because we're only your secondary insurance. We, we pick up what you normally have out of pocket as far as your deductible co-payment or co-insurance is for. This is something completely different. This is something where the provider is charging you more than, than maybe what they contracted with, with your primary insurance.
[AGENT][NEUTRAL] So you, if, if Florida Blue is telling you that they can't help you, then I'm, I'm just not really sure what you would do at that point, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, it's OK.
[AGENT][NEUTRAL] Now, is there any other claim
[CUSTOMER][POSITIVE] OK, thank you so much for your time and all the explanation.
[AGENT][POSITIVE] OK, well thank you for contacting thank you for contacting AP have a.
[CUSTOMER][NEUTRAL] No, that's pretty much it.