AccountId: 011433970860
ContactId: 52f95d93-a202-49f7-a70a-f60b16dc710e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 729590 ms
Total Talk Time (AGENT): 215289 ms
Total Talk Time (CUSTOMER): 264542 ms
Interruptions: 3
Overall Sentiment: AGENT=-0.1, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/09/52f95d93-a202-49f7-a70a-f60b16dc710e_20250509T18:35_UTC.wav
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[AGENT][NEUTRAL] Calling APL, my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] And now I'm calling in regards to uh my benefits.
[AGENT][POSITIVE] OK, I'll be happy to assist with your benefits. I have your policy number, please?
[CUSTOMER][NEUTRAL] 01423751
[AGENT][NEUTRAL] And your name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And Mr. [PII], if I can get a good call back number for you?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and if you could verify your date of birth and email address for me.
[CUSTOMER][NEUTRAL] [PII] and it's [PII].
[AGENT][NEUTRAL] Thank you for that information. Please be advised the verification of coverage is not a guarantee of payment. And what questions did you have in regards to your um benefits today?
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEGATIVE] I got two questions. One, an emergency room was denied.
[CUSTOMER][NEUTRAL] And wondering where that one was.
[AGENT][NEUTRAL] What is the date of service?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I have up here.
[CUSTOMER][POSITIVE] I believe it was smart.
[AGENT][NEUTRAL] I think I see it. Is this the [PII] 1?
[CUSTOMER][NEUTRAL] Yeah, March.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][POSITIVE] This is the same as the other one. Yeah, it was the March best.
[AGENT][NEUTRAL] OK, so it looks as though that the.
[AGENT][NEUTRAL] Charge amount was 2.
[AGENT][NEUTRAL] Alright.
[AGENT][NEUTRAL] Yeah, $200 you have an ER deductible of $300 so that $200 was applied to your deductible.
[CUSTOMER][NEUTRAL] Um, these, these had been paid before.
[CUSTOMER][NEUTRAL] Without deducted.
[AGENT][NEUTRAL] And which date service was paid without the deductible being applied?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] January
[CUSTOMER][NEUTRAL] And it's probably
[CUSTOMER][NEUTRAL] If I believe
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEGATIVE] Off the top of my head, I don't have the explanation of benefits in front of me. I think the code was that I had reached my max already or something.
[AGENT][NEUTRAL] I'm showing that there is an ER visit [PII] $200 was applied to your deductible.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Right, so that was paid.
[CUSTOMER][NEUTRAL] By you guys and what I'm just going and what changed.
[AGENT][NEUTRAL] We didn't, what did we pay?
[AGENT][NEGATIVE] I don't see where we paid.
[CUSTOMER][NEUTRAL] Mm, that one was paid.
[CUSTOMER][NEUTRAL] So, explain to me my deductibles for emergency.
[AGENT][NEUTRAL] It's a $300 deductible, so.
[CUSTOMER][NEUTRAL] How's that supposed to work.
[AGENT][NEUTRAL] The 1st $300 you would be responsible for and then we pick up so say they billed us $500.
[AGENT][NEUTRAL] Then
[AGENT][NEUTRAL] We would have paid too because your deductible is $300.
[AGENT][NEUTRAL] But they only bill 200 and your deductible is 300.
[CUSTOMER][POSITIVE] OK, repeat that again, I'm sorry.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's my
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] I believe that one was paid.
[AGENT][NEGATIVE] I don't see where we paid it sir.
[CUSTOMER][NEUTRAL] And then I was ER again.
[CUSTOMER][NEUTRAL] Let me log into my computer.
[CUSTOMER][NEUTRAL] So basically,
[CUSTOMER][NEUTRAL] If my deductible at the hospital is 300.
[CUSTOMER][NEUTRAL] You guys don't
[CUSTOMER][NEUTRAL] But like what you said, 500.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] That means that you guys only pay 200?
[AGENT][NEUTRAL] Right. Your, your deductible is only 200. So it looks as though every time you go to the hospital,
[AGENT][NEUTRAL] Your deductible for it or your copay or whatever it is, is only $200 so but you you are deduct well with us is 3.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] So unless you're billed more than $300 when you go to the ER.
[AGENT][NEUTRAL] It's gonna be, it's always gonna apply to your deductible.
[CUSTOMER][NEUTRAL] No, I'm billed more than 300, but my insurance is being covered on the other.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But my deductible for, from my own insurance is $200.
[CUSTOMER][NEUTRAL] And but obviously the ER is more, but they're billing the other side to the insurance.
[AGENT][NEUTRAL] Right. So,
[CUSTOMER][NEUTRAL] But my insurance deductible is 200.
[AGENT][NEUTRAL] So, yeah.
[CUSTOMER][NEGATIVE] The Airbus just ran out of battery.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] I mean, obviously no ER visit's going to cost under 200 bucks.
[CUSTOMER][NEUTRAL] Um, but that is my insurances deductible that I pay.
[CUSTOMER][NEUTRAL] And this is what we were told APL was supposed to cover.
[CUSTOMER][NEUTRAL] That deductible.
[CUSTOMER][NEUTRAL] That's why they sold that to us. Not that my, uh, because I, I,
[CUSTOMER][NEGATIVE] I'm correct. I mean, the only one on, when I look at my chart in my hospital, this is the first one that's gotten denied.
[CUSTOMER][NEUTRAL] But let me log in to make sure we're talking about the same date that was denied.
[CUSTOMER][NEUTRAL] Uh, ouch.
[CUSTOMER][POSITIVE] OK cool.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Where is this at?
[CUSTOMER][NEUTRAL] Alright switch this over to.
[CUSTOMER][NEUTRAL] I log into my chart here.
[CUSTOMER][NEUTRAL] linked accounts memorial jump to account, OK.
[CUSTOMER][NEUTRAL] Alright, so my view details and my.
[CUSTOMER][NEUTRAL] Uh 28
[CUSTOMER][NEUTRAL] Insurance claims when in response.
[CUSTOMER][NEUTRAL] OK, so emergency visit.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So [PII], that was a different insurance I paid that [PII].
[CUSTOMER][NEUTRAL] That shows the pending insurance also, OK, the $200.
[CUSTOMER][NEUTRAL] And then on [PII] they're automatically telling me $200. The one for [PII] is still pending, which was submitted to you guys.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEGATIVE] But the way this plan was sold to us was that no, it's supposed to cover the $200. I mean, why would I
[CUSTOMER][NEGATIVE] Get like a plan, and I gotta wait to spend $300 that's not gonna cover my regular copay.
[CUSTOMER][NEGATIVE] That's not the way it was explained to us.
[AGENT][NEUTRAL] Um, probably because this is, the deductible is only in regards to the ER. Say you went to the hospital because you had surgery. There is no deductible. If they bill 5, we're gonna pay 5.
[CUSTOMER][NEUTRAL] Well
[AGENT][NEUTRAL] The it's just that it looks like in your case, you're just always going to the ER. So, the plan is not benefiting you because you always use the ER.
[AGENT][NEUTRAL] Had you just been going for outpatient surgery or?
[AGENT][NEUTRAL] Any other, you know, reason for going to the hospital outside of the ER we're gonna immediately pay um.
[AGENT][NEUTRAL] Whatever your patient responsibility, up to $1000. And then if you're hospitalized or admitted, we pay up to $3000 per year. So I think the problem you're running into is that.
[CUSTOMER][NEUTRAL] OK, but
[AGENT][NEGATIVE] You mostly use the ER and so because your major medical only charges you $200 to go to the ER this plan is not benefiting you for going to the ER because we don't pay until it's more than $300.
[AGENT][NEUTRAL] Now, it's some major medicals, they charge you $500 to go to the ER. That would be if you had that, it would benefit because then at least we would be paying 2 of that $500.
[AGENT][NEUTRAL] You wouldn't have to pay the whole 500 because we would pay 2, but because of how you're, oh, I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] But part but partly, but also partially in this. I mean that.
[CUSTOMER][NEUTRAL] Um, like, for example,
[CUSTOMER][NEUTRAL] Yeah, this bill for [PII] was over $1800.
[CUSTOMER][POSITIVE] Um, but my insurance covered for the majority of it.
[CUSTOMER][NEUTRAL] I mean, so what you're saying is they should have billed you first.
[CUSTOMER][NEUTRAL] And then my other insurance for that to reply.
[AGENT][NEUTRAL] No, because we're, we're secondary. We're always gonna process the claim after your major medical has processed the claim and assigned your patient responsibility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and then you say the cover is outpatient, but then I also had an outpatient on uh.
[CUSTOMER][NEUTRAL] Or no 226.
[CUSTOMER][NEUTRAL] And then I get an explanation saying, appears to be, well, that's a duplicate. This is the other one, but they were saying that this is not covered when performed in doctor's office or clinic, but that was an outpatient.
[CUSTOMER][NEUTRAL] I mean, they did a little surgery and now that's.
[AGENT][NEUTRAL] She was at the that.
[AGENT][NEUTRAL] The doctor's office and the outpatient hospital are two different things. You don't have coverage for
[AGENT][NEUTRAL] In an office or clinic setting.
[CUSTOMER][NEGATIVE] That's ridiculous.
[CUSTOMER][NEGATIVE] It is, it's, it's, it's a scam. It's.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] and unfortunately, it's not, you know, you guys. This is, this is a damn thing that the city scam with this BS because
[CUSTOMER][NEGATIVE] I'm not gonna get into it.
[CUSTOMER][NEUTRAL] OK, um, so I know you have nothing to do with this, so.
[CUSTOMER][NEUTRAL] Alright, let me, uh.
[CUSTOMER][NEGATIVE] Give my bitch and grind to the city, not to you.
[AGENT][NEUTRAL] Oh, that's fine. Was there anything else I could assist with today?
[CUSTOMER][NEUTRAL] No, that was it.
[AGENT][POSITIVE] OK, well thank you for calling APL. You have a good day.
[CUSTOMER][POSITIVE] Thank you too.