AccountId: 011433970860
ContactId: 9d0e0095-106e-442e-8e31-2a906a229d8b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 642900 ms
Total Talk Time (AGENT): 244565 ms
Total Talk Time (CUSTOMER): 274638 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/9d0e0095-106e-442e-8e31-2a906a229d8b_20250219T17:07_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII].
[AGENT][NEUTRAL] Hi, [PII].
[CUSTOMER][NEUTRAL] I'm calling because I have, I'm supposed to have um a procedure outpatient procedure, and I have the understanding, um, that I have to pay up front uh my deductible and some of the coinsurance with my regular book of from Blue Shield card. Now my question to you is, um, will, um, if I pay upfront, with APL, um, cover, uh, that for me?
[AGENT][NEUTRAL] OK, um, I can check on your benefits, Miss [PII]. I can look that up. Can I please get your date of birth and your policy number?
[CUSTOMER][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] And I have here 2 numbers. I don't know. One is in hospital benefits, the other one outpatient, so it should be the outpatient, right?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] It's 141.
[CUSTOMER][NEUTRAL] 82
[CUSTOMER][NEUTRAL] 09
[CUSTOMER][NEUTRAL] M as in Mary, L as in Louis, number 8.
[AGENT][NEUTRAL] OK, let me look that up.
[AGENT][NEUTRAL] OK, um, Miss [PII], for security reasons, can you please provide for me your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And then I'm also gonna need your address, phone number, and email address that we have on the policy for you.
[CUSTOMER][NEUTRAL] Phone number is [PII]. My address is [PII].
[CUSTOMER][NEUTRAL] And you need something else?
[AGENT][NEUTRAL] OK. And if, mhm.
[AGENT][NEUTRAL] Your email address?
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][NEUTRAL] Thank you Miss [PII] and then if we get disconnected, is this a good number to call you back on?
[CUSTOMER][NEUTRAL] Yeah, the [PII] mhm.
[AGENT][NEUTRAL] OK, alright, thank you so much. OK, so looking at your policy, this is just for your benefits. It's not a guarantee of payment. I'm looking to see if you have um physician office and outpatient.
[AGENT][NEUTRAL] So it's gonna be just a second while I look over the benefits for you real quick.
[CUSTOMER][NEUTRAL] Mhm, that's fine.
[AGENT][NEUTRAL] OK, I'm gonna go ahead and pull your policy in.
[AGENT][NEUTRAL] And review it.
[AGENT][NEUTRAL] To see if it will help with the deductible copay or co-insurance for you.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] A
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] She was already.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] Difficult
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEGATIVE] Yeah, I don't understand why she came here. Uh, my husband said it was for a second opinion without any medical work.
[CUSTOMER][NEUTRAL] And um and he he didn't know.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] I'll let the doctor know was very great.
[CUSTOMER][NEUTRAL] So they find different ways.
[CUSTOMER][NEGATIVE] too much.
[AGENT][NEUTRAL] OK, so, um, looking at the policy, you do have physician office visits.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] coming back
[CUSTOMER][POSITIVE] Yeah I told her I can
[AGENT][NEUTRAL] You have a benefit amount per calendar year of $2500 to go towards your deductible co-pay or co-insurance.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] I got you.
[CUSTOMER][NEUTRAL] OK, so it's only uh 2500. So what's the deductible on right?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, and the policy does not actually cover the visit itself but it does help with the physician's um office visit fee for the physician's fee.
[CUSTOMER][NEUTRAL] He didn't have.
[CUSTOMER][NEUTRAL] I think because.
[CUSTOMER][NEUTRAL] Usually
[CUSTOMER][NEUTRAL] OK, um, go ahead, go ahead.
[AGENT][NEUTRAL] So what happens
[AGENT][NEUTRAL] What happens is, is, is your primary insurance is billed first and depending on what they pay and the diagnosis procedure codes that they pay is based on what we pay secondary.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Like.
[CUSTOMER][POSITIVE] I got you.
[CUSTOMER][POSITIVE] Great.
[AGENT][NEUTRAL] OK, and um let me tell you about our online services.
[AGENT][NEUTRAL] Sign up for the online service center it's a direct portal to your policy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you can get copies of your car, you can file claims, you can uh download your policy.
[AGENT][NEUTRAL] And see it, um.
[AGENT][NEUTRAL] There also, let me give you that website.
[CUSTOMER][NEUTRAL] I think I'm registered if I'm not mistaken.
[AGENT][NEUTRAL] Oh good good well if you're registered for that um it also has all the information that you need uh if you go inpatient or outpatient.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] It it's a good place to go and see your policy.
[CUSTOMER][NEUTRAL] But when you mentioned physician office visit.
[CUSTOMER][NEGATIVE] Um, does this apply to the doctors doing the surgery because they are the ones that are charging me, you know, a big chunk of money, uh, for the procedure.
[CUSTOMER][NEUTRAL] Because they want my deductible upfront and the 30% coinsurance on my insurance.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So it's almost a total of 60s.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, ma'am. So,
[CUSTOMER][NEUTRAL] So this this 2500 will apply to that it's applicable.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] If it's a diagnosis code that it will qualify.
[AGENT][POSITIVE] Yes, that's correct. Yes, you, you have a good.
[CUSTOMER][NEUTRAL] And we will know that until the claim is submitted.
[AGENT][POSITIVE] Right, correct.
[CUSTOMER][NEGATIVE] OK. So that doesn't help a lot.
[AGENT][POSITIVE] Also, if the facility that you're going to, if they want to call and verify your coverage with us, we will give them benefits over the phone too.
[CUSTOMER][NEUTRAL] OK, well, the one that is asking for the money upfront is the the doctor that is performing the, the procedure, the surgery.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah, they're asking for 59.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Right and if um if they need to give them the same number that you called and we will let them know that you have that benefit for outpatient procedures.
[CUSTOMER][NEGATIVE] Yeah, but I told them that I had this insurance and they said that they won't be or do anything with you guys.
[AGENT][NEUTRAL] OK, well make sure that you give them the card.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So that they can file.
[AGENT][NEUTRAL] The claim for you along with your primary insurance. Both cards need to be filed together.
[CUSTOMER][NEUTRAL] You mean, you mean at the hospital you mean at the hospital?
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, give them
[CUSTOMER][NEUTRAL] Yeah, yeah, the hospital, yes.
[CUSTOMER][NEUTRAL] But in this case, who is charging me the money upfront my deductible and everything is the, the office, you know, the doctor, the one that is doing the procedure.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Because normally the hospital will take care of the deductible, but in this case they want everything upfront before they do anything.
[AGENT][NEUTRAL] Oh no, right, I understand. Now, um, if it comes down to it, you can also file your own claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, and you can also do that through the online service center.
[CUSTOMER][NEUTRAL] You mean with you guys?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, now is it up to 2500 that I get towards my deductible and coinsurance only because I had the understanding that it was 5000.
[AGENT][NEUTRAL] No, ma'am. Um, let me look back again.
[AGENT][NEUTRAL] You have 5000.
[CUSTOMER][NEUTRAL] When I spoke to the when I enroll, yeah, when I enrolled, um, the human resources lady said that it was up to 5000 a year.
[AGENT][NEUTRAL] Right, and that's if you go inpatient. If you stay in the hospital for 18 hours or more, your hospital stay will pay up to $5000 for deductible, co-pay or co-insurance. Your outpatient benefit is $2500.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so the in hospitals is the 5000, but if, uh, if it's outpatient is.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's just the 2500. OK. Got you.
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] All righty.
[CUSTOMER][NEUTRAL] OK, so I guess I'll think about it.
[CUSTOMER][NEUTRAL] What I'm gonna do.
[AGENT][NEUTRAL] OK, Ms. [PII].
[CUSTOMER][POSITIVE] Thank you so much for your help.
[AGENT][POSITIVE] You're very welcome. You have a blessed day and I hope your procedure goes well, and thank you for calling APL.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][POSITIVE] OK. Same to you. Have a good day.
[AGENT][NEUTRAL] You too. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.