AccountId: 011433970860
ContactId: d8f959a4-7e6f-4c01-8666-a2bfc660c22c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1040900 ms
Total Talk Time (AGENT): 362991 ms
Total Talk Time (CUSTOMER): 398987 ms
Interruptions: 4
Overall Sentiment: AGENT=0.4, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/18/d8f959a4-7e6f-4c01-8666-a2bfc660c22c_20250218T21:35_UTC.wav
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[AGENT][POSITIVE] Thank you for calling.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hello, this is [PII] with APL. How may I help you?
[CUSTOMER][POSITIVE] Hey, [PII], thanks for answering my call, dear. Um, I really need your assistance. I'm a member of APL through my employer.
[CUSTOMER][NEUTRAL] And I need to learn a little bit better about the benefits because I'm having a hard time to understand when I get coverage, when I do not.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, all right, I can help you with your benefits. Can I get your name and um your policy number, please?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] My name is last name is [PII] and my policy number is 023.
[CUSTOMER][NEUTRAL] 639-08.
[AGENT][NEUTRAL] OK, let me look that policy up.
[AGENT][NEUTRAL] OK, and what is your first name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And um can you just verify your date of birth for me, please?
[CUSTOMER][NEUTRAL] Sure. [PII].
[AGENT][NEUTRAL] Thank you. And then also for security reasons, we're gonna need to verify your address, phone number and email address that's on the policy.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And email address [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and then what is your phone number, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK thank you and if we get disconnected, would this be a good number to call you back on?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you so much. All right, and this is just to verify your coverage. It's not a guarantee of payment. This is a supplemental insurance policy that is billed secondary to your major medical primary insurance.
[AGENT][POSITIVE] It helps, helps you with deductible, co-pay, and co-insurance.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] So if you go.
[CUSTOMER][POSITIVE] Correct. So that, yes sir.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, ma'am. Go ahead.
[CUSTOMER][NEUTRAL] Because I'm having bills back to me for co-payments.
[AGENT][NEUTRAL] OK. Um, what type of facility did you use?
[CUSTOMER][NEUTRAL] Urgent Care.
[AGENT][NEUTRAL] OK, let me look and see if you have benefits for urgent care. I'm gonna pull up your policy real quick.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] It's gonna be a moment so the computer can load your policy so that I can read it.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Excuse me.
[AGENT][NEUTRAL] OK, so you do have an urgent care facility benefit.
[AGENT][NEUTRAL] Um, a medical facility or clinic where ambulatory patients can be treated on a walk-in basis without an appointment and receive immediate urgent care, um, for sickness or injury.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And when I presented myself to the facility, I did provide them, and I saw actually I went there yesterday again, unfortunately, and they always make a copy of the APL card and put into the file.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] And I also have 3 children, and they've been to doctor appointment, and if they have to do labs, I'm also getting billed back for the co-payments of all of that.
[CUSTOMER][NEUTRAL] What should they do?
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] So, on, you do not have office visits on your policy?
[AGENT][NEUTRAL] You only can go to an ER urgent care center MRI imaging center or an ambulatory center.
[AGENT][NEUTRAL] Uh, the way that this policy works is this your primary pays and then we pay secondary and if your primary doesn't cover it, then we don't cover it.
[AGENT][NEUTRAL] Because it's only for deductible, co-pay, or co-insurance.
[CUSTOMER][NEUTRAL] OK, so for instance, if, uh, um, I don't know, maybe I can give you the date of a specific bill you can see if they try to reach out to APL and didn't go through at least I can get to understand better.
[AGENT][NEUTRAL] Yes, of course, yes, ma'am, I can look at your, um, and it.
[CUSTOMER][NEUTRAL] Let me give, let me, let me give an example.
[AGENT][NEUTRAL] OK, and who is it for? Is it gonna be for yourself?
[CUSTOMER][NEUTRAL] Uh, date of service.
[CUSTOMER][NEUTRAL] For me, yeah, this was for me. So [PII].
[AGENT][NEUTRAL] For, for
[AGENT][NEUTRAL] OK, let me look and see if have a claim for that day.
[AGENT][NEUTRAL] OK, I do not show the.
[AGENT][NEUTRAL] File the claim for that date of service [PII] for yourself.
[AGENT][NEUTRAL] So they'll need to file the claim.
[CUSTOMER][NEUTRAL] You do not
[AGENT][NEUTRAL] Yeah, it's not showing.
[CUSTOMER][NEUTRAL] You don't.
[AGENT][NEUTRAL] So in order for the policy to pay, they have to file the claim. I do show the last claim for yourself.
[AGENT][NEUTRAL] Was September data service was [PII] for South Miami Hospital and that that claim was paid.
[CUSTOMER][NEUTRAL] Oh, so the one before they didn't present.
[AGENT][NEUTRAL] Right, so they need to send that in.
[CUSTOMER][NEUTRAL] OK. I'm gonna.
[CUSTOMER][POSITIVE] OK perfect so I'll make a note on that one because they are sending me like a last notice. OK, so let me give you another one. I'm sorry.
[AGENT][NEUTRAL] Is this for yourself or for one of your children?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] And now it's for my children and uh just to go again, when they go to labs, request diagnostic, uh, the co-payment of the lab would be covered by APL as a second.
[AGENT][NEUTRAL] If it's done in an ER urgent care center, MRI imaging center or an ambulatory center.
[CUSTOMER][NEUTRAL] In a lab facility note, in their own lab facility note.
[AGENT][NEUTRAL] Not if it's considered an office visit.
[CUSTOMER][NEUTRAL] How I would know. OK, let's try another service date so you can look it up for me. This is under one of my children. It's my daughter. Her name is [PII]
[AGENT][NEUTRAL] OK. Yes.
[AGENT][NEUTRAL] OK, let me get.
[CUSTOMER][NEUTRAL] Last name [PII]
[AGENT][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] All right. I do not show that any claims have been filed on her at all.
[CUSTOMER][NEUTRAL] OK, so you have the one as a service date [PII]. So I need to call each provider and make sure they, they put the claim towards APL for payment.
[AGENT][NEGATIVE] Yeah, no, no.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] They're missing to do that. But let me tell you, most of them, they are not familiar. When I insist that I have APL, there's a lot of
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Workers that they are not familiar with the policy.
[AGENT][NEUTRAL] Well if you ever if you ever get push back from anybody at a facility you have them call the same number that you called and we will verify your benefits over the telephone with them.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that they know.
[CUSTOMER][NEUTRAL] Now, I do have some correspondences I received, uh, which is the one that I use the most is for my son because he was, um, being seen by uh some orthopedic services.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And the last time the office called me to tell me that they put the claim of the claim was declined and I ended up paying them uh the balance for the for payment of the office visits and.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I, I just felt bad because the lady said that she insists and she got declined and I, I didn't continue to leave her unpaid, but if you can take a second look for me, please.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, and what, what is your son's name?
[CUSTOMER][NEUTRAL] It's 4 months ago.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me look at him.
[AGENT][POSITIVE] Real quick.
[AGENT][NEUTRAL] OK, and what is the data service?
[CUSTOMER][NEUTRAL] Uh, I have different dates. So, let's see.
[CUSTOMER][NEUTRAL] It's my friend.
[AGENT][POSITIVE] Or if you even have the claim number I can even look it up by the claim number if they give that to you.
[CUSTOMER][NEUTRAL] OK, I have one of them because it's a few, so.
[CUSTOMER][POSITIVE] Hold on, OK number my glasses, thank you.
[CUSTOMER][POSITIVE] Sorry about that.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] 353-3733
[AGENT][NEUTRAL] OK, let me look it up.
[AGENT][NEUTRAL] OK and this is for sports medicine associates?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] And
[AGENT][NEGATIVE] This one wasn't paid because office visits are not covered by your policy.
[CUSTOMER][NEUTRAL] Oh, I got here in one of the explanation of the benefits. Even if he's going for not a regular office visit, but it's a recurrent um therapy.
[CUSTOMER][NEUTRAL] Maybe it's the way that they are.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, if it's done in an office visit setting, the way that they send in the claim, the way that they do the EOB, we've got to use the procedure codes that they give us and the procedure code that they gave us was 99213, which is an office visit setting, so it was not covered.
[CUSTOMER][NEUTRAL] Treatment.
[CUSTOMER][NEUTRAL] OK, alright, just to make sure, uh, under there, do you see or you can only look claim by claim, or, or are you able to look under their so the name of my son to find at least if someone was covered correctly.
[AGENT][NEUTRAL] Uh, I can look at all of his claims. I can see, I can pull up the ones from January that were sent in, um, for.
[AGENT][NEUTRAL] Rehab clinics PTA.
[AGENT][NEUTRAL] Where we pay $25 to the facility.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, let me look and see if there's any remarks on that.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so on that date of service, let me tell you the date of service.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] was
[AGENT][NEUTRAL] [PII] and it was rehab clinics PTA and
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We paid $25 to them and let me see.
[AGENT][POSITIVE] Oh no, there's a, there, I'm so sorry, there's an ambulance going by my house and my dog is howling.
[CUSTOMER][POSITIVE] No worries, no worries at all.
[AGENT][NEUTRAL] Crazy dog.
[CUSTOMER][POSITIVE] I have, I have, I don't have an ambulance. I have my son doing some bicycle work, doing a lot of noise and I'm sorry for that as well.
[AGENT][NEUTRAL] Oh, that's OK. That's OK. OK, so we paid the $25 and then it has a remark on it that the insured's major medical coverage provided full benefits. So no benefits were payable because the in your primary insurance provided the full benefits.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] I mean, OK, it was just to clarify because it seems was being recurring visits it got to a point that I just ended up paying them, but.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But for the quest, just to clarify before I contact them to see a little bit complicated.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] The brand quest labs, like when the doctors ask labs, we have the option to go to the actual quest facility.
[CUSTOMER][NEUTRAL] With the, the, the doctor's orders to do some lab work.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And that has co-payment or there's a copayment over the labs that were performed those that would have.
[CUSTOMER][NEUTRAL] The support of APL with those charts.
[AGENT][NEUTRAL] If it's an office visit.
[AGENT][NEUTRAL] No, because it does not cover office visits. Um, like I said, it's all depends on how the primary insurance pays their part and the procedure codes that they use.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] OK. I'll call them and I'll verify, but thank you so much. Uh, you're very kind. I appreciate.
[AGENT][POSITIVE] It is no problem at all. I really, I enjoyed talking with you. I'm glad I was able to help you.
[CUSTOMER][POSITIVE] Your time and funny.
[CUSTOMER][POSITIVE] Yeah, likewise, dear God bless you for the rest of your day.
[AGENT][POSITIVE] God bless you too. You too. Mm.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.
[AGENT][NEUTRAL] Bye-bye, Ms. [PII].