AccountId: 011433970860
ContactId: 6b8565cb-f6ab-49e8-9953-f6c6c60aa7a2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 443779 ms
Total Talk Time (AGENT): 225803 ms
Total Talk Time (CUSTOMER): 161403 ms
Interruptions: 2
Overall Sentiment: AGENT=1.6, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/29/6b8565cb-f6ab-49e8-9953-f6c6c60aa7a2_20250129T17:58_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Hi, thank you so much for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII], and I'm trying to inquire um about my insurance since um I had an accident um and I ended up seeing a specialist. And now I have a bill from the specialist because they said that uh my secondary insurance, which is APL, didn't cover anything. So I wanted to know why and cause I, I don't know much about the coverage of the APL insurance.
[AGENT][NEUTRAL] OK, Ms. [PII], I'd love to take a look at that claim with you and figure out what went on. Um, do you have your policy number handy?
[CUSTOMER][NEUTRAL] Yeah, I have my card here. It's um uh outpatient 02337120 um M as in Mario L as in Larry, then the number 8.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK perfect thank you and while I'm getting that pulled up, Miss [PII], do you mind if I also go ahead and snag a good call back number for you in case we get disconnected?
[CUSTOMER][NEUTRAL] It will be [PII].
[AGENT][POSITIVE] Perfect, thank you so much and.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Ms. [PII], I'm just gonna have you verify some information for me real quick and then I'll be able to dig into that claim with you. Um, what is the date of birth we have for you, my friend?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][POSITIVE] Perfect and then the mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Wonderful and then that is all we need right and what was the date of service on that um for that bill uh that you they're billing you for?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Uh let me see if I find it in here.
[CUSTOMER][NEUTRAL] It says my name date of service was back in and.
[CUSTOMER][NEUTRAL] In [PII], that's because I saw up a ladder.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And would it have been with Baptist Health, does that sound right?
[CUSTOMER][NEUTRAL] Mhm. [PII].
[CUSTOMER][POSITIVE] Yeah, bath is right.
[AGENT][POSITIVE] OK, perfect.
[AGENT][POSITIVE] So I was able to find that.
[CUSTOMER][NEUTRAL] I'm not
[CUSTOMER][NEUTRAL] I'm not sure if this insurance covers like as a secondary insurance or is it just for specific stuff? I don't remember.
[AGENT][NEUTRAL] No, absolutely.
[CUSTOMER][NEUTRAL] I hardly go to the doctor, so.
[AGENT][NEUTRAL] So, um, and I can help you go over your benefits too if you'd like today um I do wanna let you know I was able to find that it looks like one of the procedure codes that was charged um was denied. It's the and it states that office visits are not covered by the above number policy and so what that is is saying that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, in this particular case that the consultation charge is not a covered policy or not a covered procedure on your policy, and then that next one, just says that that service and I, I'm so sorry because I actually don't know those what the procedure codes and what the service is off the top of my head, um, but it does say that it that service is not covered when it's performed in a doctor's office setting.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So then I'm over here looking at your benefits and I do see you have like those outpatient calendar year benefits but it looks like the only benefit you have with us that falls um.
[AGENT][NEUTRAL] I'm not showing anything that falls in a doctor's office. So your benefits would be for like an outpatient hospital um or a surgery center or an urgent care, but not anything listed for a doctor's office.
[CUSTOMER][NEUTRAL] So nothing with doctor's office is OK.
[CUSTOMER][NEUTRAL] So, oh, like outpatient, this is what happened. I fell off a ladder and then I ended up in the urgent care. They did X-rays and a whole bunch of things in there, but then they sent me to get uh an MRI and then they sent me to an orthopedic doctor. The orthopedic doctor said, oh, I need to do more tests on you, so they did more X-rays. So I'm guessing those X-rays are the ones that are not covered.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] And I'm so sorry, let me see if I can look up what the procedure code is on here, um, because I just, I'm unfortunately just don't know it like that.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEGATIVE] Or maybe I should contact like my primary insurance? I don't know, I'm so lost.
[AGENT][NEUTRAL] OK, it does look like that procedure code that was denied was for an X-ray.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So as far as your outpatient benefits with this policy, we do try to pick up and pay on things that were applied to your copay, your co-insurance and your deductible, um, when they fall under the parameters of your of your policy in your case, your outpatient benefits um are for a hospital emergency room and urgent care surgery in a hospital outpatient facility, um, diagnostic testing in a hospital outpatient facility or an MRI facility.
[AGENT][NEUTRAL] Outpatient treatment of a mental or emotional disorder in a hospital, outpatient facility, uh, physical therapy facility, or an ambulance.
[CUSTOMER][NEUTRAL] OK, but not anything in the doctor's office, like a spe[PII]'s office. I get it. OK.
[AGENT][NEUTRAL] Yep.
[CUSTOMER][NEUTRAL] Alright, so I guess I'm just gonna have to pay this, uh.
[AGENT][NEUTRAL] Um,
[AGENT][POSITIVE] I'm so sorry. I definitely understand feeling that way when I see a medical bill too.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] It's $104 that they're charging me, and I don't understand because I should have had a co-pay and I'm, I'm gonna contact my primary insurance too to see because the thing is that I didn't see your name on this bill. It looks like my primary insurance pays something, but then now I know that this is just for like emergencies and stuff like that. This is not an actual.
[CUSTOMER][NEUTRAL] Or doctor's offices.
[AGENT][NEUTRAL] No, unfortunately this policy definitely doesn't cover that but if you do find yourself in a situation or I know you went to an urgent care um during this event as well um we do help in those situations so always submit a claim if you're in one of those other areas, OK?
[CUSTOMER][POSITIVE] All right, I appreciate it.
[CUSTOMER][POSITIVE] OK, I appreciate you. Thank you so much for your help.
[AGENT][POSITIVE] Oh, it's my pleasure. I would wish you the best of luck, Miss [PII], and thank you so much for calling and talking to us.
[CUSTOMER][NEUTRAL] All right, OK, bye bye.