AccountId: 011433970860
ContactId: 4ddc32c1-6a5e-4f18-8ad0-5da10cacef1e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 494679 ms
Total Talk Time (AGENT): 186636 ms
Total Talk Time (CUSTOMER): 253666 ms
Interruptions: 3
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/4ddc32c1-6a5e-4f18-8ad0-5da10cacef1e_20250408T18:36_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Hey, [PII]. I, uh, I'm just, uh, I got a, I'm just trying to inquire about uh.
[CUSTOMER][NEUTRAL] Uh, a, a procedure I had done and see if, you know, um, my, the supplemental insurance my, my wife has in the family it may cover.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Because I, because I paid out of pocket and uh.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You know, I don't know, they're giving me the run around, so I figured I'd call you guys first or second, you know, kind to clear the.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, what is the policy number?
[CUSTOMER][NEUTRAL] Uh, the policy number, you need the payer ID or you need the uh.
[AGENT][NEUTRAL] Policy start number?
[CUSTOMER][NEUTRAL] The group
[CUSTOMER][NEUTRAL] I mean, all I have is a payer ID or a group number.
[AGENT][NEUTRAL] There's a policy certification number that begins with a 0.
[CUSTOMER][NEUTRAL] Or I have a in house uh outpatient benefit.
[AGENT][NEUTRAL] Does it say policy search number?
[CUSTOMER][NEUTRAL] Uh, that
[CUSTOMER][NEUTRAL] 00, you mean the benefit certification number, OK, so this would be outpatient, so 01299855.
[CUSTOMER][NEUTRAL] M as in Mike, L as in Lima, 8.
[AGENT][NEUTRAL] Mhm. And what's your first name?
[CUSTOMER][NEUTRAL] My first name is uh [PII] Last name [PII], but it's under my wife's name.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and what's a good phone number in?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] What's a good call back number in case we're just.
[CUSTOMER][NEUTRAL] Oh, my number is [PII].
[AGENT][NEUTRAL] Give me one moment to pull up your policy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And Mr. [PII], what's your date of birth?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and so are you calling to verify what the outpatient benefit is?
[CUSTOMER][NEUTRAL] Uh, no, I just wanted to see if it covers a certain procedure that I had done because I paid out of pocket and at first they told me that my primary insurance wouldn't cover it.
[CUSTOMER][NEUTRAL] But I called my primary insurance that I would be covered, but the only thing is that their co-pay was less than what the actual procedure was. So, since it is covered by them.
[AGENT][NEUTRAL] OK, and what
[CUSTOMER][NEUTRAL] By then, I have a CPT code. Does that help?
[AGENT][NEUTRAL] Mhm, do you have the description of the er this this procedure you're having?
[CUSTOMER][NEUTRAL] Oh, I already had the procedure I, and I pay out of pocket. It will say uh.
[AGENT][NEUTRAL] OK. What type of procedure did you have?
[CUSTOMER][NEUTRAL] It was, it was a CAT scan, calcium score test, a CAT scan of the heart, the calcium score test.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK. And that was for a medical concern?
[CUSTOMER][NEUTRAL] Yeah, because my primary uh asked me to get a, a, a stress test.
[CUSTOMER][NEUTRAL] So he referred me to a cardiologist, but then my cardiologist said that the insurance wouldn't pay for a stress test. I had to go other test first, like a, like a, so he made me do an echo.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] graph of my, uh, I guess my, uh, the, the veins on my neck, I don't know, and then also the, the CAT scan of the heart calcium, uh score test. So since I paid out of pocket, I was wondering if, you know, the supplemental insurance would kick in, cause I, I forgot I had it and then.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I got a new card after the procedure and I, I, you know, it reminded me, so I figured I'd call.
[AGENT][NEUTRAL] Mhm. And so under your policy, um, was it done like in a diagnostic facility or in a hospital setting?
[CUSTOMER][NEUTRAL] It was at uh it was at a imaging place called Reyes.
[AGENT][NEUTRAL] OK, OK, so I'll provide you with the outpatient benefits and of course any information provided is verification only, it does not guarantee payment, uh, until we receive the actual documentation for review. So under your policy, the maximum outpatient benefit is up to $4000. Uh, this is a per calendar year benefit per covered person.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so this policy is secondary to your major medical plan, so, uh, whatever amount your primary insurance applies towards either your deductible, co-insurance, or co-pay amount, uh, this policy will cover that amount uh of covered charges up to the policy maximum which is the $4000 per calendar year.
[CUSTOMER][NEUTRAL] OK, so Reyes didn't bill my insurance company.
[CUSTOMER][NEUTRAL] Because, well, at first they said it wasn't covered, but I called Florida Blue and they said it was covered, but then they told me that their co-pay would be $250 but the procedure was only $95. So,
[AGENT][NEUTRAL] OK, so,
[CUSTOMER][NEUTRAL] In this case, with, you know, American public life covered the $95.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We would, we, we will need to have the primary explanation of benefits in order to consider a benefit so um the location would need to send it to your primary to be processed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Because that the information on their explanation of benefits determines what we owe if anything.
[AGENT][NEUTRAL] So we'll need the primary EOB.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, but, so if, if, if the procedure is $95 and they send it to my primary, my primary says, well, your copay is $250 they're not gonna bill me $250 right? Because the procedure is only $95.
[AGENT][NEUTRAL] But, but they're saying that you owe a $250 copay, is that what you're saying?
[CUSTOMER][NEUTRAL] They would just bill me the $95.
[CUSTOMER][NEUTRAL] Well, I just called them and they said yes, for a CT scan of the heart for calcium test, they said the copay would be 250.
[CUSTOMER][NEGATIVE] But when I went to Reyes, they told me it wouldn't be covered, so it made me pay out of pocket, which was only $95.
[CUSTOMER][NEUTRAL] So, they have to bill them and then get a a letter back saying
[CUSTOMER][NEUTRAL] That you know,
[CUSTOMER][NEUTRAL] Uh, the co-pays up to $250 right? So then I would still, they would still take my payment of $95 which they did, and then that's when APL would kick in.
[AGENT][NEUTRAL] Right, the claim would need to be submitted to the primary insurance carrier. Once they've processed the claim, we will need a copy of their explanation of benefits and then an itemized bill.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] And that will come
[CUSTOMER][NEUTRAL] And they, they do that automatically with you, do you?
[AGENT][NEUTRAL] No, so generally the provider will submit the claim wherever you have the, the CT scan that location.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] We'll submit a claim to your primary insurance.
[AGENT][NEUTRAL] Your primary insurance will process the claim, send an explanation of benefits back to the location where you had the service.
[AGENT][NEUTRAL] And then at that time the primary ELB and the itemized bill which comes from the location where you had the test, they will submit those two documents to APL for review.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, all right, let me call them back and get this all going. I appreciate your time.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You're welcome. And so whatever amount is reflected on your primary ELB and the deductible co-insurance and or co-pay column, those are the amounts that APL could, could perhaps, you know, pay.
[CUSTOMER][NEUTRAL] Potentially cover, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK excellent well thank you so much I appreciate that.
[AGENT][POSITIVE] Oh, not a problem. Did you have any other questions, Mr. [PII], I can help with today?
[CUSTOMER][POSITIVE] No, that's it that's it for now. Thank you.
[AGENT][POSITIVE] All righty. Thank you for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] Alright bye bye.