AccountId: 011433970860
ContactId: a8913abc-accb-4b6b-bbfe-52f51333d32b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 244259 ms
Total Talk Time (AGENT): 95800 ms
Total Talk Time (CUSTOMER): 114146 ms
Interruptions: 0
Overall Sentiment: AGENT=1.3, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/30/a8913abc-accb-4b6b-bbfe-52f51333d32b_20250430T19:16_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] and customer service. How are you?
[AGENT][POSITIVE] Good, how are you?
[CUSTOMER][NEUTRAL] I'm good. I have an insured on the line wanting to uh verify her benefits.
[AGENT][NEUTRAL] OK. Do you have the policy number?
[CUSTOMER][NEUTRAL] Yes, it is 245.
[CUSTOMER][NEUTRAL] 1509
[AGENT][NEUTRAL] And has she been verified?
[CUSTOMER][NEUTRAL] Yes ma'am and her callback number is the number in the system.
[AGENT][POSITIVE] OK, perfect. Thank you so much. You can release her on over.
[CUSTOMER][POSITIVE] Alright, here she comes thank you.
[AGENT][NEUTRAL] You
[AGENT][NEUTRAL] Hi, this is [PII] on the care team. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, yes, I was calling to see um what all my policy covered. Um, I'm expecting to have a surgery here soon. I wanted to know if it would cover anything and as it relates to that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and is it gonna be outpatient or is that gonna be inpatient?
[CUSTOMER][NEUTRAL] Um, that it would be outpatient. Yeah, I should, uh, be able to go home soon, yeah.
[AGENT][NEUTRAL] OK, let's see. OK, anything I quote is not a guarantee of payment. It's a basic outline of your policy. So this policy will pay after your primary insurance has processed the claim. So it could potentially pick up deductible, co-pay and co-insurance um after primary processes.
[AGENT][NEUTRAL] Um, let me see what your benefit is.
[AGENT][NEUTRAL] So for your outpatient benefit, it pays a maximum of 500 per occurrence.
[AGENT][NEUTRAL] And so per occurrence would be like per treatment for the same problem, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Um,
[AGENT][NEUTRAL] In a 90 day period.
[CUSTOMER][NEUTRAL] Um, question, OK, so, um, I was told by my primary, um, that I haven't paid enough of a deductible or haven't met the deductible, um, so I would have to pay out of pocket for this. Um, I, what happens in that instance?
[AGENT][NEUTRAL] You know how much your primary deductible is?
[CUSTOMER][NEUTRAL] Um, so,
[CUSTOMER][NEUTRAL] Uh, what I would pay to the doctor's office, is that what you're saying, or?
[AGENT][NEUTRAL] Uh, your, your primary insurance, do you have like a $1000 deductible or $1500 or $500?
[CUSTOMER][NEUTRAL] Oh, I'm sorry, um, so the deductible is, I believe it's 2000.
[AGENT][NEUTRAL] OK. So after your primary insurance, they get the claim from your hospital, they process it like this is just an example. So say your primary insurance, who's your primary through?
[AGENT][NEUTRAL] United Healthcare Aetna. OK, so Aetna processes the claim and they apply $2000 towards your deductible. Then the claim is submitted to us along with Aetna's explanation of benefits showing how they processed. We would pay 500, so that's the most that we would pay.
[CUSTOMER][NEUTRAL] Um, Edna.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] OK, um, OK, well then that's good to know, um.
[CUSTOMER][NEUTRAL] I'll include you all's information um for a secondary.
[AGENT][POSITIVE] Yes, definitely.
[CUSTOMER][NEUTRAL] Um, but uh, yeah, I wanted to get with you all before, um.
[CUSTOMER][NEUTRAL] Before anything happens. I know I have to pay to the doctor before the actual surgery and the rest of the fees are with the hospital. And I'm, I'm guessing that's what you guys would help out with.
[CUSTOMER][NEUTRAL] Um, but, OK.
[AGENT][POSITIVE] Yes, correct. Yeah.
[CUSTOMER][POSITIVE] Um, OK. Um, I just wanted to get with you all, um, to confirm that, but I appreciate your help.
[AGENT][NEUTRAL] OK. Anything else I can help with today, [PII]?
[CUSTOMER][NEUTRAL] No, that's all.
[AGENT][POSITIVE] OK. Well, thank you for calling APL. I hope you have a good day.
[CUSTOMER][POSITIVE] Thank you as well.