AccountId: 011433970860
ContactId: 915caae8-88c5-41f8-92e3-6da7cf2620a3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 429480 ms
Total Talk Time (AGENT): 185331 ms
Total Talk Time (CUSTOMER): 156640 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/23/915caae8-88c5-41f8-92e3-6da7cf2620a3_20250123T16:59_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. I'm a member of APL, and I'm receiving some medical bills from, uh, some procedures that I had done, and I'm wondering if you guys have received the charges and, and if has anything been paid on them.
[AGENT][NEUTRAL] Uh, we can definitely take a look. [PII], do you have your policy number?
[CUSTOMER][NEUTRAL] Yes, do I give you, OK, the group number?
[CUSTOMER][NEUTRAL] Or the payer ID number.
[AGENT][NEUTRAL] Um, if you have the card, it should be, do you see like an in-hospital certificate number or outpatient, anything like that? OK.
[CUSTOMER][NEUTRAL] Yes, yes, yes, which one do you want in hospital or outpatient?
[AGENT][NEUTRAL] Either will work, ma'am.
[CUSTOMER][NEUTRAL] OK, 02505772 M as in Mary, L as in Larry 8.
[AGENT][POSITIVE] All right, thank you for that.
[AGENT][NEUTRAL] And then for security, I will need to verify your date of birth and address, please.
[CUSTOMER][NEUTRAL] 10167 address is [PII].
[AGENT][NEUTRAL] Alright and the email address on file is [PII]. Is that still a good email for you?
[CUSTOMER][NEUTRAL] Yes, it is.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, let's see. Um,
[AGENT][NEUTRAL] Do you have a specific like date of service that the procedures were done on?
[CUSTOMER][NEUTRAL] Yes, yes, I have a few. One of them is [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] They were done at UM.
[CUSTOMER][NEUTRAL] And I'm getting charges for two separate doctors.
[AGENT][NEUTRAL] Let me do a search for that date.
[AGENT][NEUTRAL] OK, so there was, it looks like a claim for that date of service and then there was a benefit payment sent to the provider, um, it looks like the benefit payment maxed out the benefits for [PII], so.
[AGENT][NEUTRAL] What are they showing for [PII]? Are they showing an amount as far as responsibility?
[CUSTOMER][NEUTRAL] Yes, they're telling me that for 724, for Doctor [PII], I'm gonna owe $39.29.
[CUSTOMER][NEUTRAL] And for Doctor [PII], I'm gonna owe $77.70.
[AGENT][NEUTRAL] OK, this claim that I see here that the payment was sent on just shows the provider as UMHC. There's no breakdown as far as like a yeah, a doctor's name.
[CUSTOMER][NEUTRAL] Yes, that's the same one.
[CUSTOMER][NEUTRAL] Yeah, it's the same thing.
[AGENT][NEUTRAL] So the claim the claim was paid, it didn't pay the full amount just because of the benefit amount for the year was maxed out so it paid the most it was able to pay.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] I thought that APL is supposed to pay my deductible that Aetna doesn't pay.
[AGENT][NEUTRAL] There is a limit as far as the amount it's going to pay for the calendar year, so under your outpatient benefits the max is 2500.
[AGENT][NEUTRAL] And so it had been exhausted for the calendar year.
[CUSTOMER][NEGATIVE] So, OK, I don't understand this. So anything over $2500 I have to pay it?
[AGENT][NEUTRAL] Correct, the plan would not pay over that amount.
[CUSTOMER][NEUTRAL] So let's say that tomorrow I have an accident, it's $200,000 and you guys only cover $2500.
[CUSTOMER][NEUTRAL] I, I thought there was, the 6000 was for outpatient and for hospital.
[AGENT][NEUTRAL] So there's two, there's two different set amounts. There's outpatient benefit which is 2500 on your plan and then inpatient which is 7900.
[AGENT][NEUTRAL] Inpatient is defined as being confined in the hospital for 18 hours or longer, so the $7900 would only apply towards claims where you were actually in a hospital and confined for, yeah, over 18 hours. The outpatient would be for everything else, any time maybe you're getting treatment in an office from a physician.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] In the hospital.
[CUSTOMER][NEUTRAL] OK, OK, I got it.
[AGENT][NEUTRAL] Um, if the plan covers an office visit fee, um, all of those other things would fall under outpatient where that amount is 2500.
[CUSTOMER][NEUTRAL] OK, and that's OK, so let me see if I understand this correctly because the reason I have APL is to cover the deductible that Aetna has.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] If Edna has a $2500 deductible for inpatient.
[CUSTOMER][NEGATIVE] Then and you guys are covering it because that's the limit, shouldn't they be paying the difference?
[CUSTOMER][NEUTRAL] Because I've already met my deductible with them?
[AGENT][NEUTRAL] So yeah, so yeah, so this will cover the deductible or co-pay that your primary does not up to that amount, correct?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEGATIVE] OK, so why do they tell me that they paid the max that they're gonna pay and they're not gonna pay anymore?
[AGENT][NEUTRAL] There were other claims throughout the year that had already been paid.
[CUSTOMER][NEGATIVE] I don't understand
[CUSTOMER][POSITIVE] OK, alrighty, OK.
[CUSTOMER][POSITIVE] But then having to, to call different companies, it's better than, it's better than to just pay it, it's not a big deal, you know.
[CUSTOMER][NEUTRAL] Whatever.
[CUSTOMER][POSITIVE] OK. Thank you very much, ma'am. Have a good day.
[AGENT][POSITIVE] You're, you're welcome, [PII]. You too. Bye-bye.
[CUSTOMER][NEUTRAL] Bye-bye