AccountId: 011433970860
ContactId: 873c7b19-fb26-4053-bcfc-267b2aefbb11
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 646450 ms
Total Talk Time (AGENT): 236031 ms
Total Talk Time (CUSTOMER): 218159 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/873c7b19-fb26-4053-bcfc-267b2aefbb11_20250207T18:11_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APL. This is how can I help you?
[CUSTOMER][NEUTRAL] Hi, good, uh, good morning. I'm calling, uh, my, my call dropped earlier a few minutes ago. I'm calling to see, uh.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I, I don't have my, uh, my my, my, uh, my account number, but I could, but I could provide you with my social security.
[AGENT][NEUTRAL] Policy number?
[AGENT][NEUTRAL] OK. Is this [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and that number?
[CUSTOMER][NEUTRAL] My social?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. Can you give me a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] I'm going through my email trying to find uh a statement from you guys or something. I just can't find.
[AGENT][NEUTRAL] OK, let me see, let me find your policy number.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Uh, I can find the, uh, the emails from you guys, the policy number there.
[AGENT][NEUTRAL] OK, what's your date of birth? OK, uh, verify your your.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And your mailing address?
[CUSTOMER][NEUTRAL] Uh, either [PII] or [PII].
[AGENT][NEUTRAL] OK, I show the [PII]. OK.
[CUSTOMER][NEUTRAL] Yeah, that's where I'm currently living, correct.
[AGENT][NEUTRAL] OK, and then your email address on file please?
[CUSTOMER][NEUTRAL] Uh [PII], which is my last name.
[AGENT][POSITIVE] OK, thanks [PII] for verifying that for me. And how can we help you today?
[CUSTOMER][POSITIVE] I'm, uh, I'm, I'm getting a procedure done for, uh, uh, infertility, uh, to see, uh, on, in two weeks and then they call my insurance, my insurance will cover, uh, will cover the surgery. However, it has a down, it has a deductible.
[CUSTOMER][NEUTRAL] And I was wondering if I could provide you with the code of the uh surgery or whatnot if the uh deductible will be covered under my insurance, under the gap insurance that uh on the benefits that I would that I have.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. What type of surgery is it?
[CUSTOMER][NEUTRAL] Uh, it's, uh, it's, uh, for inf infertility because, uh, to see if they could find any, uh, sperms, uh, and, uh, and extract them. I could give you the code.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The code of it is uh let me look for it.
[CUSTOMER][POSITIVE] Mm, give me one second, I'm so sorry.
[AGENT][NEUTRAL] No rush.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I know that uh the underlying disease that I have is uh isoremia or something, it's something like that.
[CUSTOMER][NEUTRAL] I'm trying to look for him.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Um, it was Thursday.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] The code is 55899.
[AGENT][NEUTRAL] 558.
[CUSTOMER][NEUTRAL] And I was diagnosed with, yeah.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] Is that the only code they gave you?
[CUSTOMER][NEUTRAL] Uh, diagnosed with N46.01.
[AGENT][NEUTRAL] OK, thank you for that information. One moment.
[AGENT][NEUTRAL] And that's not considered an elective surgery, is it, Ernesto?
[CUSTOMER][NEUTRAL] What do you mean by elective surgery?
[AGENT][NEUTRAL] Um, not necessarily medically necessary. It's just something you want to have done.
[CUSTOMER][NEUTRAL] Well, uh, it's uh, it's an underlying disease. It's uh it's called Azothermia. A Z P H E R M I.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And so you do have an outpatient benefit.
[AGENT][NEUTRAL] Under your policy and this policy is secondary to your major medical plans, so to answer your question, cover charges that are applied towards your primary insurance deductible, co-insurance, and or co-pay amounts, um, can be considered under this policy. Um, the maximum outpatient benefit is up to $7900 per covered person per calendar year.
[AGENT][NEUTRAL] And of course this information is verification. It does not guarantee payment of a claim. Uh, there's also a family maximum of up to $15,800 per calendar year for all covered persons, um, combined.
[CUSTOMER][NEUTRAL] OK, so that means that
[CUSTOMER][NEUTRAL] Yes, but it's not guaranteed that I will pay back my deductible.
[AGENT][NEUTRAL] So, uh, when we receive the uh claim for review [PII], um, and we will review it if it's covered by your policy. It sounds like it's a medical concern. Um, this policy will reimburse the amount that your primary insurance.
[AGENT][NEUTRAL] Applies towards you said it's going towards your deductible?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Your primary deductible, is it being applied towards your primary deductible?
[CUSTOMER][NEUTRAL] Uh, I don't know, my, the, uh, the, uh, the doctor's office called me and they explained to me uh the, uh, procedure and the deductible would be a total of $6000.
[AGENT][NEUTRAL] OK, so the, so it's being applied towards deductible based on what you just said and so this policy is a is is a supplement policy to your major medical plan and so any amount of any covered amount applied towards your deductible, this policy with APL, which is your Metlink policy, uh, can consider the benefit up to $7900 per person per calendar year.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] But what so what what my question is it's uh it's when I submit the request it's really up to them to approve it or not, correct?
[AGENT][NEUTRAL] When you say them, who are you referring to?
[CUSTOMER][NEUTRAL] Uh, well, the, the insurance, whoever approves the, uh, request, uh, from APL.
[AGENT][NEUTRAL] Right, we'll review the claim, yes, and so.
[CUSTOMER][NEGATIVE] But it's not guaranteed that I will receive any type of refund.
[AGENT][NEUTRAL] We can't guarantee a benefit payment until after we receive the claim documentation.
[CUSTOMER][POSITIVE] OK, OK, perfect.
[AGENT][NEUTRAL] Mhm. Now, are you sending the claim to us or will the healthcare provider send it to us on your behalf?
[CUSTOMER][NEGATIVE] My provider has been a headache. I've been trying to figure this thing out for the past 3 months. I have the surgery coming up in 2 weeks, and now it's when they're calling me, and now it's when they're calling me. So yeah, they haven't been very helpful.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and so
[AGENT][NEUTRAL] OK, and so usually uh you would present both of your identification cards, your major medical ID card, and then your APL card and let them know that your APPL policy is, is secondary to the major medical and generally, and this is a conversation you can have with them, they'll submit to both of your insurance companies that way it takes you out of it. You don't have to do anything, but you wanna have that discussion, you wanna have that discussion with all of your healthcare providers.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][POSITIVE] OK, perfect, perfect. Uh, oh, that's awesome.
[AGENT][NEUTRAL] Yeah, and you know that you'll have like a hospital charge, is it, and then you probably have a surgeon's charge, maybe an anesthesiologist charge as well. And so the benefit will be paid out to whomever submits their claim first, just so you know that.
[CUSTOMER][NEUTRAL] That's all.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So let's, let's say, let's say we receive the hospital claim first.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And they apply $6000 towards your deductible, then we would issue that payment if it's if it's payable to the facility.
[AGENT][NEUTRAL] So it's kind of first come first serve.
[AGENT][NEUTRAL] As far as your providers are concerned, just so you know.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] All right perfect thank you.
[AGENT][POSITIVE] All [PII], anything else I can assist with today?
[CUSTOMER][POSITIVE] Uh, that'll be all, thank you.
[AGENT][POSITIVE] Alrighty thank you for calling APL have a good day.
[CUSTOMER][NEUTRAL] You too bye.