AccountId: 011433970860
ContactId: 9db24cb5-1eea-4ec5-b5f5-2430a0bec3df
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 642299 ms
Total Talk Time (AGENT): 247816 ms
Total Talk Time (CUSTOMER): 382228 ms
Interruptions: 7
Overall Sentiment: AGENT=0.8, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/12/9db24cb5-1eea-4ec5-b5f5-2430a0bec3df_20250612T21:57_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, I have APL as a supplemental insurance to my Florida Blue Blue options. Um, I'm, I'm going to see a specialist, uh, next week at Cleveland Clinic, Florida, and the fee to see the doctor is $85 co-pay. There's a facility charge of $350 from the hospital.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I was wondering if the secondary, the supplemental insurance picks up any of the facility fee.
[AGENT][NEUTRAL] OK, uh, your name is?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and Mr. [PII], I can verify benefits for you. Um, what's your policy number, please?
[CUSTOMER][NEUTRAL] Do you want me to spell it?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Outpatient benefit certificate number, is that what you would like?
[AGENT][NEUTRAL] Yes sir.
[CUSTOMER][NEUTRAL] 02634310 Mary Larry 8
[AGENT][POSITIVE] Thank you so much. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] 39. OK, thank you. And Mr. [PII], verify your date of birth and mailing address for me, please.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] OK, thank you. Give me a moment. You said for a facility. Is this gonna be in an outpatient facility like a or surgery center or imaging center or hospital, or is it outpatient like in a doctor's office?
[CUSTOMER][NEUTRAL] It's in the hospital. It's in the hospital, but I'm just, I'm having a 10 minute talk with the doctor. That's it.
[AGENT][NEUTRAL] Oh OK.
[CUSTOMER][NEUTRAL] Just to
[CUSTOMER][NEUTRAL] I thought, yeah.
[AGENT][NEUTRAL] Well, under the policy, it doesn't cover for office visits, but for outpatient, it is covered, um, not a guarantee of payment, it's just a verification of your coverage. The max payable of what primary insurance applies towards your deductible co-pay or co-insurance is up to $750 per calendar day.
[CUSTOMER][NEUTRAL] OK, so if it was, it was an outpatient visit, I'm covered for $750 but just as an office visit, none of the facility charges are picked up by these.
[CUSTOMER][NEUTRAL] Supplemental insurance.
[AGENT][POSITIVE] Uh, correct.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] It depends on the place of service with this plan, but go ahead, I'm sorry.
[CUSTOMER][POSITIVE] OK all right thank you very much.
[CUSTOMER][NEUTRAL] Uh, Cleveland Clinic, Cleveland Clinic in [PII]. That's just, that's the place. That's where I'm going.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK. Is there anything else I can assist you with? Oh, you're welcome, Mr. [PII]. Thanks for calling APL.
[CUSTOMER][POSITIVE] All right, well thank you very much for your assistance.
[CUSTOMER][NEUTRAL] That's gonna do it. Wait, hold on, wait one second, yeah, yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Here's the, she's the here's my wife, she's the policy holder, [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Hi, um, I was, hi, hi, nice to meet you. Um, I was told by the, the, the company that this ADL supplemental coverage comes in handy because it can kick in.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] You know, when things are um not being applied to deductibles. So can you give me an example of how this ADL coverage could benefit me?
[AGENT][NEUTRAL] APL.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh, well,
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, to explain to your husband, it doesn't cover office visits. I understand it may be a co-pay with an office visit, but office visit services are not covered. It covers procedures in office, outpatient or in hospital. So for instance, if you were.
[AGENT][NEUTRAL] Like going to the ER or let's say for your husband, for example, he goes to an outpatient hospital, that is a covered place of service under the plan, and after primary insurance is processed the claim, we pick up deductible, co-pay or co-insurance for that outpatient facility up to that $750 per day for outpatient.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] So let's say they charge $1000 but the primary applies that $1000 towards deductible, the max we're gonna pay is just the 750 for that day.
[CUSTOMER][NEUTRAL] OK, but what if.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, but what if he has a colonoscopy, which is a procedure at a hospital?
[CUSTOMER][NEUTRAL] And that, and they're charging 1500 for the hospital fee because he is having it done inside of a hospital.
[AGENT][NEUTRAL] OK. Well, it also depends on if it's a colonoscopy, if it's for screening, it's not covered since it's not a sickness or an injury. But they're doing, most colonoscopies are outpatient.
[CUSTOMER][NEUTRAL] It's a screening. It would, yeah.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Well, Cleveland Clinic, they just started this. It's been on the news and in the paper. Uh, they are like a lot of hospitals in [PII], they are starting to build for the facility, even if it's a routine colonoscopy, cause you're having it done inside of a hospital, not a, a free-standing um outpatient clinic. So, in that regard,
[CUSTOMER][NEUTRAL] Um, what you're saying is, because it's a colonoscopy and it's routine, the, the APL wouldn't apply. That's what you're saying. So we kinda, we're in between a rock and a hard place. You, you cover things in a hospital, but you don't cover routine screenings in a hospital. It would have to be diagnostic or surgical.
[AGENT][NEUTRAL] It has to be for sickness, correct, because the policy only covers procedures for sickness or injury. So if he has a colonoscopy screening, the screening is not covered, but if he has a diagnostic colonoscopy because of an issue, then that could be covered under the policy as outpatient.
[CUSTOMER][NEUTRAL] That's not a screening.
[CUSTOMER][NEGATIVE] A sickness.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK. So what, no. So basically, it covers, um, it covers uh uh sickness. And if, if it were diagnostic and he had to have it because of something, it would cover that, but will not cover the fact that it's a routine and he's just having it done inside of a clinic that considers itself a hospital. And so,
[CUSTOMER][NEUTRAL] You know, they're billing as they go. I understand fully so operations sickness, health, you guys kick in or diagnostic, you kick in.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] But it's routine screening wellness not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] routine screening, wellness, not covered. It no matter where it is, in a hospital or in a, or in a free standing, no matter where it is. OK.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] No matter whether it's inpatient, office, it doesn't matter. It has to be procedures to be covered, it has to be a sickness or injury. It's not uh covered for wellness.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right. Got it. So if they discover something in a colonoscopy and say, hey, you need to have a procedure on your colon,
[CUSTOMER][NEUTRAL] Then you guys would, what if, what if during the colonoscopy, because this happens a lot, they remove 5 to 10 polyps.
[CUSTOMER][NEUTRAL] Or what, well, honey, it could be a hyperplastic.
[AGENT][NEUTRAL] It would depend on how they have it diagnosed.
[CUSTOMER][NEUTRAL] Correct. She just, she just said it depends on how they diagnose the polyp. So, from my understanding, um, like mine were hyperplastic, so, so they put me on the 10-year plan cause they said that's not here or there, whatever hyperplastic means. My husband came back with more than the standard 4 or 5, and so they told him he has to go every 5 years.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] They told me every 10 years, so.
[AGENT][NEUTRAL] Well, if they
[AGENT][NEUTRAL] It just depends on the diagnosis cause I understand with colonoscopy is uh is different as far as diagnosis. You might have it. They might find some polyps or something. So, like I said, it depends on it's how it's diagnosed. Um,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah. OK. So it depends on how it's diagnosed. Uh, even if it's a screening going in and they diagnose it a certain way, could that impact the outcome as well? Could you think it's, it's a screening and it, and it's free, and then they find something and um could they
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, he's got the code, so he understands.
[AGENT][NEUTRAL] It just, it just depends on the diagnosis. Yes, ma'am. So, they could initially have it as a screening, but sometimes if it is, if a provider finds something or even like they discover it's diverticulitis or something, they could actually have several different diagnoses. So, it would just be what that primary diagnosis is, if it's showing a screening or if it's showing there's a sickness. That's the reason why he had the colonoscopy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, I got it, but they can't go back and change the billing if they find something if they tell you it's a screening going in.
[AGENT][NEUTRAL] Uh, it depends. Like, uh, some providers would do that. They may go in for a screening, but then they may change the diagnosis because they found something. So it, it all depends on how they diagnose it.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, so they, they can, I see. So if they find something legally, they can change the code because they found something and they fixed it.
[AGENT][NEUTRAL] Yes, ma'am. It's whatever how their um hospital or provider how they coded.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, but they code it before you even get it. They don't code it after, correct? Or they code it after the fact?
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Most places do code it after the fact.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Interesting. OK, because they're, I get it now. So they code it after the fact because it's only after that they'll know if they found something or not.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, thanks so much. Do you have any other questions, [PII]?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] OK appreciate your time. All right, bye.
[AGENT][POSITIVE] Yes, ma'am. Thanks for calling APL.