AccountId: 011433970860
ContactId: b4553204-eb97-46e2-a164-b978a39cfff8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 311350 ms
Total Talk Time (AGENT): 141282 ms
Total Talk Time (CUSTOMER): 146357 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/b4553204-eb97-46e2-a164-b978a39cfff8_20250121T15:16_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. I'm hoping that you can. I wanted to know what my benefits covered. I recently was taken in an ambulance and I didn't know if APL covers any of that.
[AGENT][NEUTRAL] OK. What's your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Your, your name, uh, first name is [PII]
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, what's your policy number?
[CUSTOMER][NEUTRAL] So there's 2, there's an in hospital benefits certificate number and then a group number. Which one did you want?
[AGENT][NEUTRAL] The policy er number.
[CUSTOMER][NEUTRAL] OK, it's 1479643 ML 7.
[AGENT][NEUTRAL] OK, and what's a good phone number, [PII], in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And verify your date of birth and your mailing address for me.
[CUSTOMER][NEUTRAL] Sure, it's [PII]. I'm not sure which mailing address you have now I'm at [PII]. I don't know which one do you have a [PII] address maybe?
[AGENT][NEUTRAL] What's the zip code?
[CUSTOMER][NEUTRAL] It's [PII] I think hold on I have to look it up. I don't remember. Is that what you have? OK, good. Oh good.
[AGENT][NEUTRAL] OK, that's
[AGENT][NEUTRAL] Yeah, this is the one that we have, uh huh, the [PII] and what's your your email address?
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, thank you for verifying. And you wanted to know if the ambulance charge is covered?
[AGENT][NEUTRAL] Under your policy? OK.
[CUSTOMER][NEGATIVE] Yeah, I just didn't know what the, yeah, first of all, I didn't know how much of it I could use, had used for 2024 because that's when this happened in [PII], so I didn't even know if I used any, um, and then if any of the ambulatory because my first insurance does not cover it because they said that my the ambulance was not covered in their network, which is ridiculous, that now I have to ask when I call [PII] to find out if they're in the network.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] So that the ambulance transport you to the hospital?
[CUSTOMER][POSITIVE] Yes, correct.
[AGENT][NEUTRAL] OK. OK.
[CUSTOMER][POSITIVE] The hospital part was covered. They, you know, I just have my $200 co-pay. That was fully covered with the Sparta Blue.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] I'm looking through your policy here.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK, so I do show that ambulance is covered under the outpatient benefit under your policy. So now, do you not have an out of network benefit under your major medical policy?
[CUSTOMER][NEUTRAL] Mm, I don't think so, although I think it was a PPO, so that would mean I do, right?
[CUSTOMER][NEGATIVE] And it was, I, I'm not sure, believe it or not, I don't remember if it was an HMO or PPO. I think it was the higher coverage, so I don't know, honestly. But she, I just called them and they told me that none of it's covered.
[AGENT][NEUTRAL] Do you know
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, but do you know whether it was applied towards like an out of network deductible or was it just denied as not covered period?
[CUSTOMER][NEGATIVE] It was denied as just not covered, period.
[AGENT][NEUTRAL] OK, so this is, of course, you know, secondary to your major medical and when it's denied by your major medical, it's not covered under this policy either. So that's why I was asking. Some insureds think that because it wasn't paid, it means it's denied. And I was asking, are you sure uh whether or not you have out of network benefits under your primary policy?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So that's what I have to ask them, do I have out of network benefits? OK.
[AGENT][NEUTRAL] Yeah, because they could have applied it towards your out of network deductible.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And if that be the case, then we could, you know, you could send that to us, you know, the itemized bill and then your primary EOB and we can review it, um, because this, this policy will reimburse amounts applied towards your major medical deductibles, co-insurance and or co-pay amounts. So you may wanna always ask that if it's denied, does it mean, was it applied towards your out of network? If you have an out of network benefit, you may not. I don't know.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right. OK.
[CUSTOMER][NEUTRAL] Do I have an out of?
[AGENT][NEUTRAL] And if you do, was that applied towards your out of network deductible?
[CUSTOMER][NEUTRAL] OK, alright, OK, alright, let me call them but yes makes total sense. Alright, so let me call them back and see and then I'll call your company back.
[AGENT][NEUTRAL] The ambulance fee.
[AGENT][NEUTRAL] That makes sense?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And if, if, what if, if you do not have an out of network benefit under your major medical, then it would not be covered under this plan.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] OK, OK, alright, perfect, so let me call them and I'll find out and then I'll give you guys a call. Thank you.
[AGENT][NEUTRAL] OK. OK. OK. All right, [PII]. Anything else?
[CUSTOMER][POSITIVE] No, that's it. Thank you.
[AGENT][POSITIVE] You're welcome thanks for calling APL have a good day.
[CUSTOMER][NEUTRAL] Mm, sure, you too.