AccountId: 011433970860
ContactId: d92cb3a0-19b9-432e-87c2-1b79e55183a7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 497839 ms
Total Talk Time (AGENT): 215592 ms
Total Talk Time (CUSTOMER): 268840 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/26/d92cb3a0-19b9-432e-87c2-1b79e55183a7_20250226T13:15_UTC.wav
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[AGENT][NEUTRAL] APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, yes, um, my name is [PII], and my company, I have your, um, supplemental insurance through my company, and I have a, um, question about coverage because I have an appointment tomorrow with a cardiologist here in [PII] and they say I have a very fairly high deductible.
[CUSTOMER][NEUTRAL] Um, something like $150 instead of like I thought I was just gonna pay the $60 specialist copay, but they, their pre-billing, um, says told me it's like $150 or something and then I, I've never used, I've, I've used APL for over a year, but I've actually never used it like I've paid for it but I've never used it. I don't know how it works so I was wondering, can you tell me if that'll cover.
[CUSTOMER][NEUTRAL] The difference between the $60 co-pay, like, do you cover deductibles? How does it work?
[AGENT][NEUTRAL] OK, I'll need to get some information from you, ma'am, to proceed. Can I get your first name? Can you spell it for me?
[CUSTOMER][NEUTRAL] I know I'm not explaining myself.
[CUSTOMER][NEUTRAL] OK, yeah, [PII]
[AGENT][NEUTRAL] And do you have your policy number?
[CUSTOMER][NEUTRAL] I do it is um.
[CUSTOMER][NEUTRAL] Oh, I have a group number, is that what you want?
[AGENT][NEUTRAL] The policy cert number that begins with a 0.
[CUSTOMER][NEUTRAL] Well, I'm holding my card.
[CUSTOMER][NEUTRAL] And I don't, oh, I see it. oh in hospital benefit or outpatient benefiter number. There's 2 numbers on here.
[AGENT][NEUTRAL] The number before the LM should be the same, so just give me the number before the letter L.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] I have 02262355 ML 7.
[AGENT][NEUTRAL] And a good phone number in case we're disconnected [PII]?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you, let me pull up your information.
[CUSTOMER][NEUTRAL] But, but again, there's two numbers. One is ML 7 and one is ML 8.
[AGENT][NEUTRAL] I just need the number before the M.
[CUSTOMER][NEUTRAL] Oh, before the M, I got you. OK, sorry.
[AGENT][NEUTRAL] No worries if you can verify your date of birth, your current mailing address, and your email for me please?
[CUSTOMER][NEUTRAL] Uh, my birthday is [PII].
[CUSTOMER][NEUTRAL] My email is well so it would be my work email or my personal I don't know which is associated with this account.
[AGENT][NEUTRAL] Looks like it could be your work email address.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] And your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thanks for that information [PII] and you said that this is for an office visit?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] It is for a first patient appointment offices for a cardiologist, but she works out of, they claim it's a hospital outpatient.
[CUSTOMER][NEGATIVE] Situation, which I don't understand why.
[CUSTOMER][NEUTRAL] Um, but that's what they say.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so I'll give you the outpatient benefit if it's if it's going to be, uh, once we receive the the claim the itemized bill if it's coded as an office visit or that the service was performed in a specialist office, uh, the office visit fee is not covered by the policy, um, if they're saying that it's being done at an outpatient location, uh, that benefit is up to $1000 and that is per calendar year.
[AGENT][NEUTRAL] And any information provided is verification, not a guarantee of payment and what you may want to do is have that office contact our office and then we can verify the place of service.
[CUSTOMER][NEUTRAL] So when I go to, well, cause I spoke to them yesterday and they said,
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Um, that I should contact you to find out if.
[CUSTOMER][NEUTRAL] You will pay the deductible is what she told me to ask you.
[AGENT][NEUTRAL] So we, it, it can be considered if it's done on an outpatient basis, meaning in a hospital setting or a, you said it's cardiology, what type of test is it?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's first patient appointment. It's just I'm going to a new cardiologist.
[AGENT][NEUTRAL] Oh, this is the initial consultation?
[CUSTOMER][POSITIVE] Yeah, first appointment, yes.
[AGENT][NEUTRAL] OK, so this may be done in an office setting. If it is, it's not gonna be covered by this policy.
[CUSTOMER][NEUTRAL] Right, but what I'm saying is it is an office setting, but they're billing it as a hospital outpatient because that's the, the, the medical group that I'm going to, it's called You Health Medical whatever, and it's um a hospital, even though it's in an office, it's they, they bill it as a hospital setting.
[AGENT][NEUTRAL] Correct. And so if I.
[CUSTOMER][NEUTRAL] So really just depends on how they bill it to you.
[AGENT][NEUTRAL] Correct, correct, so I've indicated that if it's done in an office, should it be happen to be done in an office visit setting, it's not covered if it's coded as outpatient facility, then I provided that benefit, um, and so yeah, we cannot make a determination until we get the uh claim documentation.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so when I go, so, just correct me if I'm wrong, because I've actually never used my card before. When I go to the office and I go to pay whatever I pay, I present not only my insurance card, but also the APL card.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm, your major medical ID card and your APL ID card, correct.
[CUSTOMER][NEUTRAL] And then they know what to do at that point.
[AGENT][NEUTRAL] Yeah, and you may wanna just sit by ask them if they could call to verify that way we can get a little bit more information as far as the coding like the place of service but ultimately, you know, of course we can't guarantee anything until we get the claim documentation, you know, to review.
[CUSTOMER][NEUTRAL] Understood so.
[AGENT][NEUTRAL] But it's, but I know a lot of, I know a lot of specialists have like um buildings inside of a hospital. It's still considered office.
[AGENT][NEUTRAL] And not outpatient.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Yeah, even on the portal, even on the portal, it says this is being billed as hospital outpatient. Like they're telling me ahead of time that's how it's being billed. Like that's the only reason why I know this. So I that that's what like at first the, the, the prepay was like over $300 and when I called yesterday, I'm like why isn't it just a $60 specialist fee? And they, and then they, they had run my wrong insurance. I have new insurance in [PII]. So then when they re-ran the new insurance.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] It dropped a little bit, but it was still over like $150. So then that's why I was like, oh wait, I have APL. Let me see if that will cover the difference. I understand I have the copay, but I was wondering if that would cover the difference. So.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And again, I understand this is not set in stone. It's just until you get the the coding and everything, but from what you're saying that you should be able to cover the difference between the $60 copay for the specialist and the balance of the of the deductible because it sounds like they are going to build in a hospital outpatient code kind of thing.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, can't, yeah, it's like again, I'm not verifying anything, um, you were just providing you the benefit based on what you're asking, so it the the copay is not gonna be covered if it's coded as office and then if it's coded as outpatient facility, um, that benefit is up to $1000 per calendar year, which means.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, if it is coded as being done in an outpatient facility, any amount applied towards your major medical deductible, co-insurance, or co-pay amounts, we could review for benefit of up to 1000 per calendar year.
[AGENT][NEUTRAL] That makes sense?
[CUSTOMER][NEUTRAL] So do I pay? Yeah, absolutely. Do I pay up front tomorrow or do I not pay and then get billed once everything's sorted out?
[AGENT][NEUTRAL] Um, we can advise, and it's gonna depend on the, the doctor's office as to whether they require that you pay something up front. We have no control over that. But most providers will contact both insurances to verify your benefits. So you may want to suggest that as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK perfect I appreciate your help thank you so much.
[AGENT][POSITIVE] Oh, you're welcome [PII]. Did you have any other questions I can help out with today?
[CUSTOMER][POSITIVE] No, I'm good thank you you have a great day.
[AGENT][POSITIVE] OK, you too, thanks for calling APL have a good day.
[CUSTOMER][NEUTRAL] Bye bye.