AccountId: 011433970860
ContactId: d4e82f3f-56f0-47ed-b79e-2767bbddd4f7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 779979 ms
Total Talk Time (AGENT): 504607 ms
Total Talk Time (CUSTOMER): 245129 ms
Interruptions: 7
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/d4e82f3f-56f0-47ed-b79e-2767bbddd4f7_20250416T15:01_UTC.wav
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[AGENT][NEUTRAL] For calling APL, this is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling regarding my husband [PII].
[AGENT][NEUTRAL] Sure, [PII], I can assist you with that. Can I have a callback number for you and a policy number?
[CUSTOMER][NEUTRAL] It's uh [PII].
[CUSTOMER][NEUTRAL] [PII] his policy number is 01662.
[CUSTOMER][NEUTRAL] 963.
[AGENT][NEGATIVE] [PII], you sound like me with the um sinus. I could barely talk the other day.
[AGENT][NEUTRAL] [PII], could you verify um the mailing address and his date of birth, and let me verify we have permission to speak with you.
[CUSTOMER][NEUTRAL] I know both of us spoke to somebody before.
[AGENT][NEUTRAL] And did he give us permission to speak with you?
[CUSTOMER][NEUTRAL] Yes, he did.
[CUSTOMER][NEUTRAL] We're both sitting on a couch talking to I don't have that paperwork who I spoke to.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] No, I, I put it away.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, in [PII].
[AGENT][NEUTRAL] He has to get that updated. It has, it expires after a certain amount of certain period of time.
[AGENT][POSITIVE] I think it lasts for 2 years.
[CUSTOMER][NEUTRAL] OK I see
[AGENT][NEUTRAL] And you did it on?
[CUSTOMER][NEUTRAL] We just did it. It's the first time we've ever.
[CUSTOMER][NEUTRAL] I know he's been in since [PII]. It's the first time.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] That we've ever requested gap. I, I didn't even know what this was and he was explaining it to me and I'm still kind of confused about it.
[AGENT][NEUTRAL] Well, it's a good part. Well, it's good to have. Um, could you verify his date of birth and his mailing address and his full name?
[CUSTOMER][NEUTRAL] [PII], it's [PII] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you, and how can I assist you today [PII]?
[CUSTOMER][NEUTRAL] He's been going to see a physical therapist is rotator cuff and I've been getting stuff back.
[CUSTOMER][NEUTRAL] He paid out of pocket and I got the receipts for that.
[CUSTOMER][NEUTRAL] But I'm getting explanation of benefits back for certain dates and the same paid to provider.
[AGENT][NEUTRAL] Right, so that means that they be paying the provider. Like for data service, [PII], you pay the provider for orthopedic care, total orthopedic care.
[CUSTOMER][NEUTRAL] And I'm just
[CUSTOMER][NEUTRAL] Uh huh yep.
[AGENT][NEUTRAL] Mhm, yeah, we've been paying them.
[CUSTOMER][NEUTRAL] See my receipt um.
[CUSTOMER][NEUTRAL] See, I, I got a receipt from them.
[AGENT][NEUTRAL] Pay for [PII].
[CUSTOMER][NEUTRAL] [PII] I got a receipt that he paid 1661. [PII] I got a receipt he paid $60. Now [PII], here's the one paid provider 5401. I got the receipt that he paid $60.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see what they're submitting. So it looks like they're charging him up front versus them submitting his claims to the primary insurance company and then seeing what is remaining to be sent to his secondary.
[CUSTOMER][NEUTRAL] I'm, I'm wondering
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Well, we didn't.
[CUSTOMER][NEUTRAL] We didn't jump on this until like 2 weeks into.
[AGENT][NEUTRAL] Well y'all have, she had this policy for a while.
[CUSTOMER][NEUTRAL] But then when he went after
[CUSTOMER][NEUTRAL] Yes, he has the first time we ever used it, but.
[AGENT][NEUTRAL] You've had it since [PII].
[CUSTOMER][NEUTRAL] Yeah, we never used it never now that I know they.
[AGENT][NEUTRAL] You guys are sleeping on.
[AGENT][NEUTRAL] Money like this policy is designed to assist with
[CUSTOMER][POSITIVE] Thank the good [PII], he's healthy.
[AGENT][NEGATIVE] You know, the co-pay deductible and coinsurance, and I wish I had a policy like they offered us a me a policy like this to meet my deductible and out of pocket expenses cause I have to pay for that. Each time we go to the doctors and my daughter is clumsy.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Exactly, but he was paying out of pocket.
[AGENT][POSITIVE] So she got me on the way that she can.
[CUSTOMER][NEUTRAL] Thank [PII], thank [PII] he's been healthy. We didn't really need it, but um we were told that only he doesn't do deductibles. It was only certain things they told us when we were sitting on the couch.
[AGENT][NEGATIVE] No, who told you that? Because that wasn't accurate information. It could have been no one here at American Public Life because here at American Public Life, he has $3000 say if he were in had this gonna knock on wood for he never has to go and do an inpatient stay. That's $3000 per calendar day, I mean, I'm sorry, per calendar year, and then he has $1500 for outpatient benefits.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] Per calendar year and that's
[CUSTOMER][NEUTRAL] OK, all right, but that's not like a normal going to see the doctor co-payment, they don't cover that.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] No, so the physical therapy will be considered as this outpatient benefits?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Will fall on his outpatient benefits, physical therapy would, but like office visits, treatment received in the office. If it's not because of a cancer diagnosis, then it won't be covered. And the benefits that I just provided is not a guaranteed benefits, just a disclaimer of the policy's coverage, but all of his physical therapy benefits, um, his visits for physical therapy, they'll be considered as outpatient and fall under his $1500 per calendar year.
[CUSTOMER][NEUTRAL] OK, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I'm curious because it looks like.
[CUSTOMER][NEUTRAL] APL is paying a provider but we got receipts that they charged us and I know that it was probably like 2, maybe 4 visits in that's when it's like he went back in there he's like, listen, I got the secondary.
[AGENT][NEUTRAL] So it looks like.
[CUSTOMER][NEUTRAL] But he even after that we still, we still have bills that I mean receipts that he would still pay after he gave them the card he still has receipts that he was paying out of pocket to them so I was under the impression that I'm gonna submit these receipts and APL will reimburse us.
[AGENT][NEUTRAL] So it looks like.
[AGENT][NEUTRAL] So it looks like.
[AGENT][NEUTRAL] This, um, so for data service of [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And I know because I work for an insurance company now I understand like when something is billed like the provider will be their amount which was 310.
[AGENT][NEUTRAL] However, but the allowed amount because you're in network with my insurance is $59.28. So that was, that's what went towards.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] My allowed amount is $59.28 but $54.01 went towards my deductible. So then it has the the primary, you know, adjusted the amount because of the provider being in network. So it's like they have him paying for the things that the provider, the insurance provider didn't pay like it says benefits for.
[AGENT][NEUTRAL] PR 119, it says benefits maximum for the time period of occurrence has been reached. So that means that
[AGENT][NEGATIVE] They're not supposed to be charging him something that the, the primary insurance wrote off.
[CUSTOMER][NEUTRAL] Because I got receipt for every visit he had been, so that's why I thought, well, the gap insurance is gonna just reimburse us so that's that's not what you're telling me because I got the provider, the, the, the main insurance Blue Cross.
[AGENT][NEUTRAL] Who
[AGENT][NEUTRAL] On this be.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Yeah, they, they be doing these, these, I'm not gonna say this on bad put bad things on in your head about providers, but you definitely have to check behind your, make sure that you check your ELBs from your primary insurance company to verify what went towards your deductible co-pay and co-insurance.
[AGENT][NEUTRAL] That is the only thing that you are responsible for your deductible, co-pay and co-insurance. So when they leave you an amount towards your deductible copay and co-insurance, this is when your secondary kicks in. If it's for services that's covered under the policy, then it'll go towards your deduct whatever amount is towards your deductible co-pay and co-insurance.
[CUSTOMER][NEUTRAL] Oh, maybe that's what it's going because I see where the deductible amount is there. I'm looking at his um it's got Florida Blue.
[AGENT][NEUTRAL] Right, but for that date of service.
[CUSTOMER][NEUTRAL] And then it shows you went you owe.
[AGENT][NEUTRAL] But for that date of service under the deductible, it was $54.01.
[CUSTOMER][NEUTRAL] So that money he put out
[CUSTOMER][NEUTRAL] Oh OK, I see.
[AGENT][NEUTRAL] The loud amount, so do you see the, the bill amount was totaled up to 310 if you're looking at the same date of service of [PII], so the total bill amount was 310, but after they submitted it to the insurance company and they I guess they're in network with the policy.
[CUSTOMER][NEUTRAL] Uh huh
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] With the insurance company, so they have a discounted rate. So now the allowed amount is only 5928. So if the allowed amount is $59.28 then it went towards the deductive column of $5401 that means that the patient responsibility is only $5.27.
[AGENT][NEUTRAL] But it has on here that the patient responsibility is $94.01 but how is that possible if the allowed amount is $59.28?
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] So that means that the provider is not just charging you.
[AGENT][NEUTRAL] With the insurance company.
[AGENT][NEUTRAL] Suggest that they charge because you're in network, but they're charging you the full amount of the 310.
[AGENT][NEUTRAL] That's what they're doing.
[CUSTOMER][NEUTRAL] OK, I'm OK, I'm gonna look into this more, but I don't have to submit anything to you, right?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] No, you don't, you don't need anything. You just and I can give you the check numbers so you can call the providers and you get your ELBs from the primary and you just call them that says a loud amount, but first ask them if they're in network with your insurance company with Blue Cross. Ask them if if they're in network. So if they're in network.
[CUSTOMER][NEUTRAL] At
[AGENT][NEGATIVE] Call your primary insurance company for them to explain it to you. And once they give you the knowledge that you need for this to show like, hey, I see nothing went towards my deductible, but 5401, but the loud amount was 5928. Why do I have a patient responsibility of 9408? Could you explain 9401, could you explain that to me? And when they explain that to you and if they tell you that that's not your responsibility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] The 50, the only responsibility is the 5401, then they, they're adding the 5928 that they're adding money to the this that they're really adding money and they really can get in trouble for that because that's considered as insurance fraud.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I have
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, I got that information. I got the estimated.
[AGENT][NEUTRAL] But call your primary insurance company and make sure that they give it to you, the, the actual amount that you needed.
[CUSTOMER][NEUTRAL] OK, will do.
[CUSTOMER][POSITIVE] OK all right well thank you so much.
[AGENT][NEUTRAL] And I hate that you're experiencing that, but we're here if you need us. So let me give you the check numbers.
[CUSTOMER][POSITIVE] Uh, it's all right. He's getting better. That's what's most important.
[AGENT][NEUTRAL] Let me give you the check numbers to those two claims, so when you do contact the actual facility after you're done talking to the primary insurance company, so the first check number for [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's 203-8235. That's 2038235 and that amount is $54.01.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And then the second claim that we for?
[AGENT][NEUTRAL] Was for date of service [PII].
[AGENT][NEUTRAL] It was for $54.00 and the check number is 2037874.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh huh
[CUSTOMER][POSITIVE] 7874. OK, well thank you so much. I will follow through on this.
[AGENT][NEUTRAL] You're welcome, [PII]. Is there anything else that I can assist you with today?
[CUSTOMER][POSITIVE] Alright, nope, that's it. Thank you so much.
[AGENT][NEUTRAL] And [PII], if it's possible, when you get the outcome, could you call me back to let me know if they were really just.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Doing something that they weren't supposed to be doing. Thank you.
[CUSTOMER][NEUTRAL] OK, will do.
[CUSTOMER][NEUTRAL] If I dial this number, would it go straight to you? Alrighty.
[AGENT][NEUTRAL] Uh, uh, you can ask for [PII]. I'm the only [PII] here.
[CUSTOMER][NEUTRAL] And spell your name please?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] OK, thank you [PII].
[AGENT][POSITIVE] You're welcome, [PII] thanks for calling APL and uh have a great day. Goodbye.
[CUSTOMER][POSITIVE] All right have a good.
[CUSTOMER][POSITIVE] You too thank you bye bye.
[AGENT][POSITIVE] Thanks