AccountId: 011433970860
ContactId: 4d390e71-de3d-4fc2-b000-899827ed6af6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1116719 ms
Total Talk Time (AGENT): 533021 ms
Total Talk Time (CUSTOMER): 379812 ms
Interruptions: 4
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/28/4d390e71-de3d-4fc2-b000-899827ed6af6_20250528T15:12_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Um, yes, uh, good morning, [PII]. Uh, this is [PII].
[CUSTOMER][NEUTRAL] Hi. Um, I wanted to, uh, check to see, um, how much is left in the maximum for my account. Um, I've been, uh, I'm going to the doctor regularly and I know that I've been, um, using up the, the max up to the maximum of, uh, of my account, and I just don't know where it's up to at this point.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Yes, Ms. [PII], absolutely I can help you with your benefits. May I please get your callback number just in case the call is dropped.
[CUSTOMER][NEUTRAL] College
[CUSTOMER][NEUTRAL] OK. It's [PII].
[AGENT][NEUTRAL] Thank you. And then Miss [PII], what is your policy number?
[CUSTOMER][NEUTRAL] Excuse me.
[CUSTOMER][NEUTRAL] OK, it's 02510864.
[AGENT][NEUTRAL] OK, let me look that up real quick.
[AGENT][NEUTRAL] OK, Miss [PII], can you please verify your date of birth for me?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you ma'am, and then what is the address, phone number and email address that we have on the policy?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's um address [PII].
[CUSTOMER][NEUTRAL] Um, phone number, probably my husband's [PII].
[CUSTOMER][NEUTRAL] Um, I have to think.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] [PII]. And then
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Email address. I'm not sure which one he would use.
[AGENT][NEUTRAL] That's OK. We, we've got the rest of it. That's fine.
[CUSTOMER][NEUTRAL] Uh-huh, yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Let me look real quick.
[CUSTOMER][NEUTRAL] He has like 4 emails.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] I like, I don't know which one.
[AGENT][NEUTRAL] I'm checking right now.
[AGENT][NEUTRAL] OK. So you have used.
[CUSTOMER][NEUTRAL] Sorry if I cough from time to time.
[AGENT][NEUTRAL] That's OK.
[AGENT][NEUTRAL] Um, I'm showing that you have used the amount of $401.50.
[AGENT][NEUTRAL] Of your, and that is your outpatient.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the outpatient benefit per calendar year is [PII].
[CUSTOMER][NEUTRAL] A calendar year is [PII].
[CUSTOMER][NEUTRAL] OK. And what was that for?
[AGENT][NEUTRAL] And that's just
[AGENT][NEUTRAL] And that's just to verify your benefits it's not a guarantee of payment.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh, it looks like you had a claim paid for.
[AGENT][NEUTRAL] A day service of [PII] for Baptist surgery and endoscopy.
[CUSTOMER][NEUTRAL] OK. All right. That was, that was a colonoscopy thing. OK.
[CUSTOMER][NEUTRAL] So it still hasn't been paid out for my physical therapy, which is another 400.
[CUSTOMER][NEUTRAL] Which I, we provided all of the documentation that was requested.
[AGENT][NEUTRAL] OK, what was the date of service?
[CUSTOMER][NEUTRAL] Um, for the physical therapy.
[AGENT][NEUTRAL] Yes, so, uh, you've already sent in the claim?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The all of the documentation for the physical therapies. Yeah, we sent in all the documentation for that already. That was a while ago, um.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Um, jeez.
[CUSTOMER][NEUTRAL] There were 4 dates.
[AGENT][NEUTRAL] Let me look real quick.
[CUSTOMER][NEUTRAL] I don't know if I put it in the PT.
[AGENT][NEUTRAL] I'm just gonna go down the line and um.
[AGENT][NEUTRAL] Just read off the data service and maybe that'll.
[AGENT][NEUTRAL] Uh, it's for [PII].
[CUSTOMER][NEUTRAL] Yeah, I think it was uh [PII], [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] The [PII]
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII] and then [PII].
[AGENT][NEUTRAL] The [PII], OK, alright, let me see what this claim says. There's a remark on it, so let me read the remark.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] We provided every single bit of documentation that was requested.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, OK, so it's got 3 remarks on it.
[AGENT][NEUTRAL] One of them is office visits are not covered by the policy.
[AGENT][NEUTRAL] One of them is insured's primary insurance provided full benefits. There are no benefits payable.
[AGENT][NEUTRAL] And then I do see that original um.
[AGENT][NEUTRAL] No diagnosis code was provided on the documentation that was sent.
[AGENT][NEUTRAL] So they'll need a diagnosis code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then let's go down to the next one and see if there's anything on it.
[AGENT][NEUTRAL] And this was submitted on [PII].
[AGENT][NEUTRAL] For
[AGENT][NEUTRAL] Kindled neurology.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Day of service is [PII].
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][NEUTRAL] Uh, let me look at back at it again.
[CUSTOMER][NEUTRAL] That's weird.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] No, [PII]. I'm, I'm sorry, wait a minute, it's the they've got the numbers.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEGATIVE] Um, um, that doesn't make sense.
[AGENT][NEUTRAL] The date is from [PII].
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] [PII] and it's Kindle Neurology.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] Yeah, I did have an appointment that day, but I had you guys during that time.
[CUSTOMER][NEUTRAL] I guess.
[AGENT][NEUTRAL] Let me look and see what, let me look and see what it says there's a remark on it.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] It just says that um benefits payable under this certificate are limited to those outlined in the policy schedule of benefits and this is not a covered loss under the plan, therefore no amount is payable for this expense and it's for the procedure code that they gave.
[CUSTOMER][NEUTRAL] It's just
[AGENT][NEUTRAL] On the EOB.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the charge amount was $299.
[CUSTOMER][NEUTRAL] OK, I didn't expect anything from that one, so that, that, that's fine.
[AGENT][NEUTRAL] OK. Looks like, OK, let's go on to the next one.
[AGENT][NEUTRAL] Which was sent in on [PII].
[AGENT][NEUTRAL] For physical therapy now.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] There's the same remark for the dates of service.
[AGENT][NEUTRAL] Which is, in order to provide further consideration of the claim, uh needs the uh explanation of benefits with the diagnosis. And that's the one that I think we previously looked at, that you need to send in the diagnosis codes for that.
[CUSTOMER][NEUTRAL] So, I did send them the explanation of benefits. So the diagnosis code, where do I get that from?
[AGENT][NEUTRAL] That the diagnosis code should come from the itemized statement with the diagnosis and procedure codes from the facility itself.
[CUSTOMER][NEUTRAL] From the
[CUSTOMER][POSITIVE] from the facil facility, OK.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] And that wasn't on the receipt that they gave me.
[AGENT][NEUTRAL] No, ma'am. That's what they're asking for.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, which they didn't ask for.
[AGENT][NEUTRAL] And if you
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] I know it's a lot.
[CUSTOMER][NEUTRAL] It's back in back.
[CUSTOMER][NEUTRAL] Yeah, why didn't A APL ask for it originally?
[CUSTOMER][NEUTRAL] Instead of having me go back and forth, back and forth.
[AGENT][NEUTRAL] Uh, uh, I'm not sure. Yes, ma'am. And that looks like the ones that you were in question about, that looks like that's everything that, um,
[CUSTOMER][NEUTRAL] I'm like, OK.
[AGENT][POSITIVE] That, that we needed at that time. That looks like it's gonna knock them all out.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] For your therapy.
[CUSTOMER][NEUTRAL] There's
[CUSTOMER][NEUTRAL] Um, that, um, have been going through, and I just wanna know if I'm gonna go over with these recent ones from my neurologist.
[CUSTOMER][NEGATIVE] Um, I'm kind of worried because they're starting to send me like a bill for like $300 something dollars.
[AGENT][NEUTRAL] Right. I can't, um,
[CUSTOMER][NEUTRAL] And they think.
[AGENT][NEUTRAL] I can't confirm that because until it's paid.
[AGENT][NEUTRAL] You know, I just
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I just don't know.
[AGENT][NEUTRAL] Until we get all the documentation and see what the amounts that are paid.
[CUSTOMER][NEUTRAL] You won't be able to
[AGENT][NEUTRAL] According to your policy.
[CUSTOMER][NEGATIVE] Yeah, because I'm like having back to back every week I'm seeing them, and I'm, I'm like afraid that if I keep seeing them all of a sudden I'm gonna get this surprise bill that
[AGENT][NEUTRAL] So and
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] I go over my allotment, you know, my $2000 limit.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEGATIVE] And I'm scared about that. You know what I'm saying.
[AGENT][NEUTRAL] Yes, ma'am. I understand. Yes, I understand.
[CUSTOMER][NEGATIVE] And then um they sent me for blood work and now all of a sudden I'm getting from the um the blood work company a $700 bill that was not covered by my insurance.
[CUSTOMER][NEUTRAL] And they're saying it's part co-insurance part deductible. So my other question to you is, uh, the deductible part, is that something that APL covers?
[AGENT][NEUTRAL] That is, um,
[AGENT][NEUTRAL] What this policy is about is deductible, co-pay, and co-insurance. Now, let me look at your policy certificate.
[AGENT][NEUTRAL] Uh, do you have a copy of that so that you know what your benefits are?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, my husband does, I think.
[AGENT][NEUTRAL] OK, good. Yes, if you guys can get that out and look at your schedule of benefits, there's a, there's a um table of contents in the front of it and look at your schedule of benefits. I'm gonna look right now, but um that will tell you.
[AGENT][NEUTRAL] What your policy pays.
[AGENT][NEUTRAL] And then it also breaks it down into um definitions of what's paid and what isn't paid according to how your policy is written.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] All he gave me was, it, it said in hospital policy, outpatient policy, but it doesn't say specifics, anything about blood work or anything like.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] It, it doesn't get into the nitty gritty of it.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So I, I have no idea if something like blood work would be part of it.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So it would be, it would fall under lab, um, which would be.
[AGENT][NEUTRAL] Under your outpatient um.
[AGENT][NEUTRAL] Let me look at your outpatient benefits and see.
[AGENT][NEUTRAL] It's gonna be just a minute because the computer is pulling it up for me and I'm scrolling through and trying to find it for you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] So what I would do is I would just call the um Quest Diagnostics and give them the APL information and have them put it through with you guys.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Um, and see if it goes through and then wait on that.
[AGENT][POSITIVE] Yes, ma'am. That's correct. Yes, ma'am.
[CUSTOMER][NEUTRAL] Do it that way, OK.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] It's gonna be just a second. I'm still, this is a big policy, so I'm still trying to, um, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][POSITIVE] Thanks I appreciate your, your, your help with this.
[AGENT][POSITIVE] Oh, it's no problem at all, no problem at all. OK.
[CUSTOMER][NEUTRAL] I, I, I'm just, I was so worried about getting the $70 something dollar bill. I'm like, what? For blood work?
[AGENT][NEUTRAL] Uh yes. OK, so this policy, your outpatient benefits go by facility.
[CUSTOMER][NEUTRAL] This is.
[AGENT][NEUTRAL] And it's towards deductible, co-pay or co-insurance. And again, this is just to verify your benefits, it's not a guarantee of payment, um.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] You have, OK. So the, this is considered an approved outpatient facility. Hospital emergency room, urgent care facility.
[AGENT][NEUTRAL] Surgery in a hospital outpatient facility or a freestanding outpatient surgery center.
[AGENT][NEUTRAL] Diagnostic testing in a hospital.
[AGENT][NEUTRAL] Outpatient facility or MRI facility.
[AGENT][NEUTRAL] Outpatient treatment for mental or emotional disorder in a hospital outpatient facility.
[AGENT][NEUTRAL] A physical therapy facility and then ambulance.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] That's what those are the um facilities that this policy covers for treatment.
[AGENT][NEUTRAL] And then this policy is your secondary so it.
[AGENT][POSITIVE] Excuse me, it does help with um deductible, co-pay and co-insurance and those approved facilities.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] So it's not specifically saying a uh uh blood work like.
[CUSTOMER][NEUTRAL] Facility
[AGENT][NEUTRAL] Let me see, let me keep going down because it does say you have a writer for independent lab facility.
[AGENT][NEUTRAL] So that's been added on for independent lab.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] Which, let me tell you, um,
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] Yes, independent lab facility, we will pay the out of pocket amounts for diagnostic testing in an independent lab facility.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is what your policy states.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so we should, I should try to put it through and see what happens.
[AGENT][POSITIVE] Yes, ma'am, definitely. And always, I mean, if you ever have any questions as to whether or not your insurance is gonna cover it, always send it because there may be something in there that is written in your policy that you may be unaware of that might be covered and if it's not, then of course, you know, they'll send you a letter letting you know why it wasn't covered.
[CUSTOMER][NEUTRAL] Yeah, because
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah, I, I, I know that my daughter had dental work that they sent it to Quest and then they didn't cover it for her, but that was dental, and that was a different, this is me.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] So it's a different situation so hopefully.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] And it's, and this one is, is really different.
[AGENT][NEUTRAL] Because everything is based on what your primary insurance carrier pays also. So the two of them together is how this correlates and works.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] OK. All right. All right. Thank you for your patience and your help with this. I, I really appreciate it.
[AGENT][POSITIVE] You're very welcome.
[AGENT][POSITIVE] You're so very welcome. Well, I'm glad I was able to.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Help you and get some things cleared up for you so that you understand it better and we definitely appreciate you being an APL customer and I hope you have a blessed rest of your week, Ms. [PII].
[CUSTOMER][POSITIVE] Thank you. You as well.
[AGENT][NEUTRAL] All right, bye-bye.
[CUSTOMER][NEUTRAL] OK. Bye-bye.
[AGENT][POSITIVE] Thank you