AccountId: 011433970860
ContactId: c805892b-b89e-43b1-b592-272608a1b995
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 650700 ms
Total Talk Time (AGENT): 313597 ms
Total Talk Time (CUSTOMER): 228890 ms
Interruptions: 2
Overall Sentiment: AGENT=0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/28/c805892b-b89e-43b1-b592-272608a1b995_20250528T17:35_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]. Good afternoon. How are you?
[AGENT][POSITIVE] Good, how are you?
[CUSTOMER][NEUTRAL] I'm doing well, thank you. I'm calling, I have a um scheduled procedure on [PII], that this Monday, um, and they called to tell me that the gap insurance.
[CUSTOMER][NEUTRAL] Uh, isn't covering the 1256 out of pocket that I have to pay? Can you tell me why?
[AGENT][NEUTRAL] OK, I can look that up for you. Um, can I get your name and a good call back number in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure. My name is [PII]. My last name is [PII].
[CUSTOMER][NEUTRAL] And my callback number is [PII].
[AGENT][NEUTRAL] And what's your policy number?
[CUSTOMER][NEUTRAL] It is, uh, you want the one for the outpatient benefit sir? because that's the one that's what it's gonna be the outpatient.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, it's 02465388, the letter M, the letter L and the number 8.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Give me just a moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can I get you to verify your date of birth?
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[AGENT][NEUTRAL] And the address and phone number that we have on file?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] OK, and phone number that we have on file?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you so much.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me pull up your policy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Because I handled that call today when they called to verify and I gave them your benefits, um,
[AGENT][NEUTRAL] I remember that call. I just told them that this is secondary gaps so your primary will need to um pay benefits first. So whenever you submit a claim through this policy, your Medlink policy, we'll need the copy of the primary EOB or explanation of benefits.
[AGENT][NEUTRAL] Um, because that call was
[CUSTOMER][NEGATIVE] So what she told me was that I still had to pay that out of pocket the day of the service, otherwise they won't do it.
[AGENT][NEUTRAL] Uh, no, I, I said we don't do patient responsibility and you just need to pay, uh, or I'm sorry, your primary insurance will need to cover, um, benefits first, not it, it shouldn't have to be the day of the surgery. That depends on the hospital themselves, um, but let me pull up.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So, OK, the lady, the lady that I spoke to, her name was [PII]. She said, if you could call me with the people from APL.
[CUSTOMER][NEUTRAL] Um, you know, to clear it up before the day of, I won't have to cancel it.
[CUSTOMER][NEUTRAL] So is it possible for me to call that lady that I spoke to?
[AGENT][NEUTRAL] Yes, and also, um, and I can also give you, it looks like we do have an email on file um are you signed up for the online service center?
[CUSTOMER][NEUTRAL] She gave me her name and number.
[CUSTOMER][NEUTRAL] I don't think I am.
[AGENT][NEUTRAL] OK, so, um, if you'd like to do that as well, you will be able to access your policy and policy card, ID cards, anything like that, um, and file claims through that through that portal if you would like to, um, and I can read you the benefits that you have on your policy. I am showing outpatient benefits for surgery in hospital.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, and, and the lady that I spoke to yesterday told me that I've only used 900 of it and I still, and it was like up to 5000.
[CUSTOMER][NEUTRAL] So that the 1256 should be covered because I haven't used it or maxed it out or whatever for the year.
[AGENT][NEUTRAL] Right and then on top of whatever your primary um pays because we pick up after primary so as long as your primary doesn't deny the claim, the the initial claim this one should be able to pick up as long as it's a covered um.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] As long as it's covered.
[AGENT][NEUTRAL] And I am showing um let me see so this is a verification of benefits and not necessarily a guarantee payment you do have an outpatient benefit maximum of up to $5000 per calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, with a $0 deductible, a $0 emergency room deductible, and it looks like surgery in hospital outpatient facility or free-standing outpatient surgery center is covered. It is subject to a maximum of 30 days of treatment per covered person per calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Um, yeah, so I don't know why they're, they're telling me, you know, that I have to give that to the day of, and then I would have to put in a claim with you guys to get it back and I'm like, well, that's not how it works like, you know, I don't have it first of all, I give you.
[AGENT][NEUTRAL] They can file the claim on your behalf.
[AGENT][NEUTRAL] Yeah, they can file the claim on your behalf. They have your policy number.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I, I believe I gave her.
[CUSTOMER][NEUTRAL] Do you mind if I call the lady?
[AGENT][NEUTRAL] Oh, go ahead.
[CUSTOMER][NEUTRAL] I just see you, I guess we're all on the same page cause like I said, the, the, the procedures on Monday and I'm like stressing out about this because
[CUSTOMER][NEUTRAL] I don't want it to be an issue when I get there. OK.
[AGENT][NEUTRAL] Yeah, you can go ahead and call.
[AGENT][NEUTRAL] Yeah and we'll do a joint call.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] Thank you for calling Coral Ridge Outpatient Center. If this is a true emergency, please hang up and dial [PII]. Please listen carefully to the following prompts.
[CUSTOMER][NEUTRAL] Press 1 if you are a patient arriving for a procedure today or picking a patient up. Press 2 if this is a doctor's office or hospital. Press 3 for the pre-medical clearance nurse. Press 4 for the insurance verification department.
[CUSTOMER][NEUTRAL] Hm, I just feel I'm gonna get the voicemail and I've left like 3 voicemails in.
[AGENT][NEUTRAL] You can always give them our callback number.
[CUSTOMER][NEUTRAL] Your call has been answered by a.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] But you said that they can follow it.
[CUSTOMER][NEUTRAL] A claim on my behalf.
[AGENT][NEUTRAL] Right, they can file the claim um they have.
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] They have the ability to file the claim as long as you gave them your policy number which I have because when she called me earlier this morning, she gave it to me, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And they should be able to file that on your behalf we don't do networks um as long as it's a covered procedure.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So I would have them uh.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I would have them file the claim through us but they will need to file through primary first um.
[AGENT][NEUTRAL] Because we have to see that the primary paid certain benefits first and then we pay, we pick up the rest as long as it's a covered service, which if it's a surgery like you said in the hospital, it should be covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Pick up the rest. Sorry, I'm just writing notes down that you're saying because I'll forget all the verbiage that you're using.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] You're OK. And then, um, like I said, if you would like, um,
[CUSTOMER][NEUTRAL] OK. All right. Um.
[AGENT][NEUTRAL] If you would like to sign up for the online portal, you will be able to see your policy and if you go to policy certificate and you scroll down to uh your outpatient schedule of benefits which is on page 34, it'll have all of this so if you need to screenshot it, if you need to print it off and show it to them um to show you can do that um if you would like to sign up for an.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You said it's on page 34. What is the um how do I sign up to get all that stuff?
[AGENT][NEUTRAL] 34, yeah.
[AGENT][NEUTRAL] OK, so, uh, you will go to [PII].
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you will click on new user.
[AGENT][NEUTRAL] And it'll ask you for I believe your last name, your social, your zip code and you'll need to have the email that we have on file um a lot of people will get an error message because they'll try to use a different email it has to be the one that we have on file um and if you'd like to verify that with me.
[CUSTOMER][NEUTRAL] OK, that one's my work one. It's [PII].
[AGENT][NEUTRAL] Yes, so you'll use that email um to sign on and you should be able to see your policy certificate. You'll scroll down the schedule of benefits, yours, um, just so you don't get confused, yours is separated out between in hospital or inpatient and outpatient, so you'll want to scroll all the way down to outpatient scheduled benefits, so it'll be page 34 out of 47.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's a lot, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] It's fine. This gives me a better idea of what I'm getting ready to do. I appreciate your help. Thank you so much.
[AGENT][NEUTRAL] OK, any time and like I said um if they won't file the claim on your behalf, you're able to file a claim through our online portal as well um but they should be able to because it should, it looks like it's a covered service.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] OK. You're welcome. And is there anything else I can help you with?
[CUSTOMER][POSITIVE] No this is all enjoy your day.
[AGENT][POSITIVE] OK, have a great day, [PII]. Thank you for calling APL.
[CUSTOMER][POSITIVE] Thanks bye bye.
[AGENT][NEUTRAL] OK.