AccountId: 011433970860
ContactId: 96426817-d19e-407e-b6e0-00407a89b89f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 719849 ms
Total Talk Time (AGENT): 393328 ms
Total Talk Time (CUSTOMER): 250975 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/29/96426817-d19e-407e-b6e0-00407a89b89f_20250129T17:28_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. Um, how are you today?
[CUSTOMER][NEUTRAL] Um, so I have
[AGENT][POSITIVE] I'm doing well. How are you?
[CUSTOMER][NEUTRAL] I have a gap insurance with you guys, um.
[CUSTOMER][NEUTRAL] But um I was trying to do um endoscopy and then uh the doctor's office told me that they tried calling you guys but uh, that you said that I only have $500.
[CUSTOMER][NEUTRAL] I thought that was a little bit, uh, I didn't understand because my gap insurance is for 20, which is my deductible.
[AGENT][POSITIVE] OK, um, well, I can definitely look into the benefits with you and go over them um with you. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And [PII], may I have your policy number?
[CUSTOMER][NEUTRAL] The group number?
[AGENT][NEUTRAL] Your policy number?
[CUSTOMER][NEUTRAL] I have group number and payer ID.
[CUSTOMER][NEUTRAL] On the card.
[AGENT][NEUTRAL] Oh, OK. Does it say member ID or in-hospital policy cert number?
[CUSTOMER][NEUTRAL] Yeah, in hospital benefits and outpatient benefits.
[AGENT][NEUTRAL] Yeah, the numbers are the same. The ML 7 and 8 at the end is different. I just need the numbers. That's your policy number.
[CUSTOMER][NEUTRAL] OK, it's 02340799 M as in Mary, L as in Larry.
[AGENT][NEUTRAL] Thank you for that, and I have your policy here, and I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] [PII] and what else?
[AGENT][NEUTRAL] Your mailing address and email address?
[CUSTOMER][NEUTRAL] Um, my mail address is [PII], and email is [PII].
[AGENT][NEUTRAL] OK, this one is [PII].
[CUSTOMER][NEUTRAL] OK. It's [PII].
[AGENT][NEUTRAL] Thank you and thank you so much for verifying your information. All the information provided is a verification of benefits, not a guarantee of payment. Um, so the outpatient benefit for your, um, oh, I see where you see the 2000. OK. So your policy is broken up into two groups, inpatient and outpatient. Inpatient is when you're admitted to the hospital and things are done in the hospital. Outpatient is everything else, uh.
[AGENT][NEUTRAL] Emergency room, urgent care, outpatient surgeries, labs. So for inpatient, your calendar year max to use is $2000.
[AGENT][NEUTRAL] For your outpatient, the calendar day, so it resets every day.
[AGENT][NEUTRAL] It is $500. So for your in-office visits, your policy doesn't have like
[AGENT][NEUTRAL] in-office coverage in terms of the coding that they use for the place of service, but it does cover any treatment that's done in the office as long as it's not cosmetic, up to that $500 each day.
[CUSTOMER][NEUTRAL] OK. Uh, but like, for example, if I'm gonna do an endoscopy, because like the whole purpose of having the gap insurance is for the gap insurance to cover my, my deductible, right? So, um, so if I do the endoscopy in the hospital, that means that they cover it? Is that what you're saying? Just because the endoscopy is done in the office, they don't, you guys don't cover it?
[CUSTOMER][NEGATIVE] I don't understand.
[AGENT][NEUTRAL] So when you receive a bill, sometimes the bill has a facility charge.
[AGENT][NEUTRAL] And then it has a treatment charge.
[AGENT][NEGATIVE] If, if your facility charges for like a facility charge, that would not be covered. You don't have like a place of service coverage.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] If they're just billing for the treatment, you have up to $500 a day as long as it's not cosmetic.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Whether it's done in the hospital or the outpatient facility, there's coverage, but the 2000 that you mentioned is the out of I'm sorry, the inpatient max for the calendar year for the inpatient benefits.
[AGENT][NEUTRAL] Which is different than outpatient.
[CUSTOMER][NEUTRAL] OK, so in the, if I do in the hospital, it's covered and if I do in the office it's not, is that what you're saying?
[AGENT][NEUTRAL] No. So if you do it, if whether you do it in the hospital or the office, there's still coverage. The difference is the amount.
[AGENT][NEUTRAL] The in hospitals is 2000.
[CUSTOMER][NEUTRAL] So, in the hospital.
[AGENT][NEUTRAL] Per year
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] An outpatient is $500 each day, so you have $500 to use every day.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] For outpatient.
[CUSTOMER][NEUTRAL] But what's the max?
[AGENT][NEUTRAL] 500.
[CUSTOMER][NEUTRAL] Per day, you said, right? But how, how much, like I can I do it every day, 365 days? No, right? What's the max?
[AGENT][NEUTRAL] Per
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] No, that's not how that works. A calendar day is each day, so you have 5 every day it resets to $500 for you to use for this whole year. Every day it's going to reset and you have $500 that you can use towards outpatient expenses. That's different than calendar year. It's $2000 for the entire year.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] But that's a different benefit, that's inpatient, we're talking of outpatient, which is $500 a day.
[CUSTOMER][NEUTRAL] OK, no, that part I understand. Sorry.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Sorry about that.
[AGENT][NEUTRAL] You're fine.
[CUSTOMER][NEUTRAL] Uh, I, I just don't understand, like, you said that it's 500 per day, right?
[AGENT][NEUTRAL] Right, so today you'll have 500 and then tomorrow you'll have 500.
[CUSTOMER][NEUTRAL] So this is what I
[CUSTOMER][NEUTRAL] OK, but what's the max that I can use? It's 2000 as well?
[AGENT][NEUTRAL] 500.
[CUSTOMER][NEUTRAL] No, I understand that it's, but like the whole year, like.
[AGENT][NEUTRAL] There are two different
[CUSTOMER][NEUTRAL] Don't you have a Mac?
[AGENT][NEUTRAL] Well, then it would be 500 times 12, but that's not how this benefit works. You have a calendar year, you have a calendar day, you have a plan year. A calendar year is a max for the whole year because it's calendar year, but your outpatient benefit isn't a calendar year, it's per day. So you can't, there is no real max because it resets every day versus you have $2000 to use for a whole year. Do you see the difference?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so that's the difference between the two.
[CUSTOMER][NEUTRAL] So, for example,
[CUSTOMER][NEUTRAL] So if, if they charge me 500 today and $500 tomorrow, then I'm fine?
[AGENT][NEUTRAL] Yes, your, your, I don't want you to confuse calendar year, just we can just disregard that. You have a full balance to use for the whole year. After you use that up, you can't use it anymore for the year. That's not how calendar day works. Calendar days you have $500 to use today. Tomorrow you'll have $500 to use. Friday you'll have $500 to use each day, the max is $500.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] No, that part I got it. It's just like I'm trying to understand how to apply that to what I'm trying to get it done, right? Like, I have an endoscopy scheduled and uh they're telling me that my deductible is 1100 and some change, right? So then they called me back and said that I only have 500 to, to cover it. So.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] What I, which I, which I understand as well, but then like for example, if they, if they charge me $500 today and $500 tomorrow instead of charging the $1000 is that OK? How, how does it work?
[AGENT][NEUTRAL] So if
[AGENT][NEUTRAL] No, it doesn't work like that. So it's data service. So if you go in today and it's a $1000 deductible, they're probably going to say you have to pay that before the scan is done or the endoscopy is done. So you'll have to pay that $1000 you'll get the endoscopy, they're going to bill your primary insurance and then if they have our information, they'll automatically bill us. Primary is going to apply.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] You know, based on your coverage with them, and then they'll send it to us. We'll be able to see that you paid such and such for the deductible, but you still only have $500 for that whole day. So there's still, you can, if, if they examine the claim and apply everything.
[AGENT][NEUTRAL] To the reimbursement for the deductible, it would only be up to the $500. That's the max for the day.
[AGENT][NEGATIVE] So it wouldn't be a full reimbursement.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And then, and, uh, regardless, uh, so, and then for the, for the $22,000 for the year.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] How does that work?
[AGENT][NEUTRAL] Same thing. Um, if you're in, if you're in the hospital and um you're admitted and they, they have the endoscopy, then um they'll, same thing, they'll bill your primary, primary will pay and then they'll bill us and you have $2000 for this entire year to use, so.
[AGENT][NEUTRAL] It could pay out. It depends on how it's processed and the paperwork. If, if they examine it and that full $2000 is, is applied, you'll get $1000 from the deductible and $1000 towards.
[AGENT][NEUTRAL] Any leftover expenses, but that can only be determined after it's examined.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So, OK. So then for the office, it's only 500, right? And then for the hospital, it's 2000.
[AGENT][NEUTRAL] And it doesn't even have to be office, it's just outpatient. So even if it's done in an outpatient outpatient hospital or outpatient facility, that's all still under outpatient, which is at 500 per day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So what's the difference between the outpatient and the hospital?
[AGENT][NEUTRAL] What's the difference between outpatient hospital and inpatient?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Inpatient, you're admitted, outpatient, you're going home the same day.
[CUSTOMER][NEUTRAL] Oh, I see.
[CUSTOMER][NEUTRAL] So the 2000 is just for, for in, in the hospital like inpatient, right? Like.
[AGENT][NEUTRAL] Mhm. Yes.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] But that would be, OK.
[CUSTOMER][NEUTRAL] But that is for the hospital, OK.
[CUSTOMER][POSITIVE] Got it. OK. I think I understood. Maybe I gave the wrong insurance. Let me check on that as well. Thank you so much.
[AGENT][POSITIVE] You're welcome, [PII]. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, that'll be all. Thank you.
[AGENT][POSITIVE] All right, you're welcome. Thanks for calling APL. I hope you have a great day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye bye.