AccountId: 011433970860
ContactId: d9d34416-2303-4dda-9e22-ac77fc34e496
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1134969 ms
Total Talk Time (AGENT): 438864 ms
Total Talk Time (CUSTOMER): 557286 ms
Interruptions: 4
Overall Sentiment: AGENT=0.2, CUSTOMER=-1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/05/d9d34416-2303-4dda-9e22-ac77fc34e496_20250605T13:08_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], good morning. My name is [PII]. Um, I am new to having a plan with you guys through my employer, and there's recently we needed to use our insurance and so there's been a lot of confusion about what this policy is and oh my gosh, sorry, my [PII] just poured my coffee everywhere.
[AGENT][NEGATIVE] Oh no.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It's not hot, so she's fine, but um it's on my carpet. It's just been a morning. Sorry if you hear any yelling in the background. It's my [PII]. Sorry about that. Um, so anyways, I need to kind of just get a better understanding because she has some procedures scheduled and so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It's a whole morning.
[AGENT][NEUTRAL] It's OK
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's OK, [PII]. I needed to see what this plan actually covers like when it kicks in because I you know I have a primary insurance and um from my understanding this policy essentially was supposed to lower our deductible, but that doesn't seem like that's necessarily what the policy is designed for so can you help me with that?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I sure can. Um, I'll be more than happy to go over your policy and the details of it with you. Um, [PII], may I have a good contact number in case we're disconnected and your policy number?
[CUSTOMER][NEUTRAL] Yes, so it's [PII].
[AGENT][NEUTRAL] And the policy number whenever you're ready.
[CUSTOMER][NEGATIVE] And um forgive me, I need to go.
[CUSTOMER][NEUTRAL] Um, I do not have that available. Give me one moment to find that card.
[AGENT][NEUTRAL] Oh, it's OK. I can search it with your social if that'll be easier for you. No, it's fine.
[CUSTOMER][NEUTRAL] To be more prepared.
[CUSTOMER][NEUTRAL] Sure, um, it's [PII] or no that's my phone number, sorry, [PII].
[CUSTOMER][NEUTRAL] 836279
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] I'm just waiting for the um policies to populate here. Hold on one moment.
[CUSTOMER][NEUTRAL] Or
[AGENT][NEUTRAL] All right, and I have you here. I just need you to verify your date of birth, your mailing and email address on file.
[CUSTOMER][NEUTRAL] Um, [PII], um, and my home address is uh [PII]. What do you want [PII]? I'm not sure what you want, darling. [PII].
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] And then just your
[CUSTOMER][NEUTRAL] And what else did you need? I'm sorry.
[AGENT][NEUTRAL] That's OK. Your email address?
[CUSTOMER][NEUTRAL] Oh, I don't, I'm not sure which one they gave you. Um, it's either [PII] or [PII].
[AGENT][NEUTRAL] Thank you, and all the information provided is a verification of benefits, not a guarantee of payment, and I'm waiting for your um full policy to pull up so I can see all the benefits. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do you mind telling me what email my employer put down um because I was trying to create an online account and I wasn't able to and I think that might be why.
[AGENT][NEUTRAL] It is. I was getting ready to let you know there's no email on file, so we can add whichever you prefer and then that's the one you'll use to create it.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, yes, well just let me know when you are ready for that information, um, the [PII].
[AGENT][NEUTRAL] Uh, which one did you prefer?
[AGENT][NEUTRAL] OK, [PII], you said [PII]?
[CUSTOMER][NEUTRAL] Yes, so my first name, my last name [PII].
[AGENT][NEUTRAL] OK, [PII].
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Alright, hold on one moment.
[AGENT][NEUTRAL] Alright, just trying to make sure it's saved. Hold on one moment.
[AGENT][POSITIVE] All right, and it has saved.
[CUSTOMER][NEUTRAL] You book lady?
[AGENT][NEUTRAL] Alright, so this is your secondary policy. So we pay towards the copay, deductible and co-insurance of covered charges after your primary.
[AGENT][NEUTRAL] Um, so it's broken down into inpatient and outpatient benefits. Inpatient is anytime you're admitted into the hospital, outpatient is, uh, for us, everything else really, um, urgent care, emergency room, office visits, uh, specialist, physical therapy, um, so,
[CUSTOMER][NEUTRAL] So the ER is the ER is under outpatient.
[AGENT][NEUTRAL] Like
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What about surgeries? Like at surgery centers.
[AGENT][NEUTRAL] Like you like outpatient surgery, if, if she's not admitted into the hospital, it's outpatient.
[AGENT][NEUTRAL] Or if anyone on the policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So, um, and that does include like outpatient surgeries though in a facility or hospital outpatient um outpatient hospital.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Um, so if you have like
[CUSTOMER][NEUTRAL] So this
[CUSTOMER][NEUTRAL] Go ahead I'm sorry.
[AGENT][NEUTRAL] No, no, you're fine. Go ahead with your question.
[CUSTOMER][NEGATIVE] Basically, what I have been told is what my employer told me was that basically you guys paid up to $5000 towards my deductible.
[CUSTOMER][NEGATIVE] And basically that gave me a lower deductible. Well, it's come to my attention that that's not entirely accurate and that you guys only pay for certain services with the plan they signed up for. So from my understanding, the $5000 that you'll help pay is like literally if we're hospitalized, and that's it.
[CUSTOMER][NEUTRAL] Is that accurate?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I don't know what 5,000 $5000 they're referring to. Hold on one moment.
[AGENT][NEUTRAL] Is it maybe
[CUSTOMER][NEUTRAL] Well, so,
[CUSTOMER][NEGATIVE] Please, why don't I just let you tell me what my policy is because I basically every time this hospital that I'm dealing with my daughter's outpatient procedures.
[AGENT][NEUTRAL] Because you have a
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] They tell me that I can't, I can't bill primary and secondary insurance, which I don't understand that the Blue Cross Blue Shield is my primary and then y'all are my secondary basically they say it has to go through one or the other so I'm like, OK, well I guess bill Blue Cross Blue Shield and then I'll deal with APL but I need to know like when does APL pay like because I have like an $8000 deductible per.
[AGENT][POSITIVE] Wow.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Person in my family, so that's what I'm trying to understand, trying to understand when APL pays.
[CUSTOMER][NEGATIVE] How they pay like do I have to submit claims? Like I just, I don't, I don't understand how this works. I've never had a secondary um policy like this. I've always just had a primary.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, so I kind of want to speak to the hospital, but I mean that's up to you. That is incorrect. That's the whole purpose of a secondary policy because it goes after the first, the primary. Um, you do have outpatient benefits. So there's a, you have a max that you
[AGENT][NEUTRAL] You have a calendar year max that you can use towards inpatient after she after anyone's admitted or outpatient. It's $4200 each, one for inpatient, one for outpatient. Your outpatient benefits, they're supposed.
[AGENT][NEUTRAL] Now, every facility is.
[CUSTOMER][NEUTRAL] So y'all will pay up to $4000?
[AGENT][NEUTRAL] Yes, 4200.
[CUSTOMER][NEUTRAL] For each one of those is that my understanding?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] $4200.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So we
[CUSTOMER][NEGATIVE] So when do you guys start paying though like after I meet my deductible or do you like that's what I don't understand.
[AGENT][NEUTRAL] Well, I'm trying
[AGENT][NEUTRAL] Yes, that's what I'm trying to let you know. So,
[CUSTOMER][NEUTRAL] You're trying to explain that. I'll be quiet, OK.
[AGENT][NEUTRAL] So how it's supposed to work, you give them your Blue anytime you give the Blue Cross Blue Shield card, you give your APL card. They're supposed to build Blue Cross Blue Shield. Blue Cross Blue Shield has their own set of benefits for their policy. We have our own set of benefits. If Blue Cross Blue Shield does not apply to a claim, doesn't pay anything to a claim, we cannot pay anything to a claim because we're second to them.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] The provider is supposed to build Blue Cross, they pay, you know, based on their policy and then whatever is left over, they send it directly to us. So with the explanation of benefits, so that we see everything that was charged, everything primary paid, everything you paid. If there's a co-pay or deductible that's required for the service, you would have to pay that upfront.
[AGENT][NEUTRAL] And once the claim is filed, that is how and we and we process it, that's how you're reimbursed or if the provider is still owed something, that's how we pay to them, um.
[AGENT][POSITIVE] I would encourage the hospital to give us a call. Every every provider.
[CUSTOMER][NEUTRAL] Well, apparently they did.
[AGENT][NEUTRAL] Hold on.
[CUSTOMER][NEUTRAL] And they were told that in when they filed it under APL.
[CUSTOMER][NEUTRAL] Exclusively, I think I was responsible for.
[CUSTOMER][NEUTRAL] Close to $1500.
[CUSTOMER][NEUTRAL] And then you guys would start paying for it with a maximum of that 4200.
[AGENT][NEUTRAL] Let me see if there's a deductible on here.
[CUSTOMER][NEGATIVE] So basically my Blue Cross, this is, I guess what I don't understand is, I've never had a high deductible plan or as crappy of insurance as this ever, so forgive me, I'm just
[CUSTOMER][NEGATIVE] I'm frustrated
[CUSTOMER][NEUTRAL] And I'm trying to understand it because I've never had to deal with this before, so basically my current Blue Cross Blue Shield plan like doesn't cover anything. I mean there's a network providers they don't, I have like a copay for.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Specialty visits like ER like um urgent care visits, etc. But many of the services are, we don't pay until after you meet your deductible, which is a high deductible. It's like $8000 per person. I don't even know the family max, it's like probably $20,000. So when I'm getting my daughter has this procedure scheduled.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] There for through our primary, we have to meet our deductible.
[CUSTOMER][NEUTRAL] Which is like $8000 so do I have to.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And so I guess I'm confused as do I have to pay $8000 to Blue Cross Blue Shield before you guys will pay anything?
[CUSTOMER][NEUTRAL] Like for that 4200.
[AGENT][NEUTRAL] OK, so where
[AGENT][NEUTRAL] So we are, we work together, but it's two separate policies. So whatever your deductible is with Blue Cross Blue Shield, if that has to be paid first before the services, yes, you would have to take care of that before the services because APL does not come in until the claim is filed.
[AGENT][NEUTRAL] So anything that has to that the provider is requiring to be paid to have the services, co-pay, deductible, whatever they require, yes, it would have to be paid upfront or, you know, before the services usually and on the back end when the claim is filed, that is when we can come in and reimburse or if there's still something old, paid to them, but
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] This policy
[CUSTOMER][NEGATIVE] But that's not how it was explained to me.
[CUSTOMER][NEUTRAL] My employer basically explained that because you guys pay towards the 40, 4200.
[CUSTOMER][POSITIVE] That that essentially helped us lower our out of pocket costs that we're paying towards our deductible.
[CUSTOMER][NEGATIVE] But that's not how this works. It doesn't sound like it.
[AGENT][NEUTRAL] Right, it sounds, and I do apologize, it sounds like you were given the wrong information, um.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes, we do pay towards the copay and the deductible, but if your primary insurance is not paying anything until the deductible is paid, your secondary cannot apply because primary never paid anything. You see what I'm saying?
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] I guess that makes sense. He's a book now. He's there, baby. What's wrong? I don't know why you're so fussy today. It's OK. I know. All right.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] That's so how can I access all this information? I'm just a visual person so I can like kind of read it and look at it. Is that gonna be through when I can set up the account online?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Um, I mean, you can do it when you sign up to the online service center, but I can email you a copy of your, your like your policy with all the breakdown.
[CUSTOMER][POSITIVE] I would love that if you could do that for me please.
[AGENT][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Cause this is just, it's crazy because NSC was like well we can bill APL directly.
[AGENT][NEUTRAL] Who said they can bill us directly?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] The hospital organization that was, that's dealing with her procedure.
[AGENT][NEUTRAL] Also, the
[CUSTOMER][NEUTRAL] The, they're basically, they were like, we can either build Blue Cross Blue Shield for her procedure or we can build APL.
[AGENT][NEGATIVE] I have never, I don't understand that, that, that, I don't understand that. If you, if you want, it doesn't.
[CUSTOMER][NEGATIVE] It makes no sense to me. This is a secondary plan.
[AGENT][NEUTRAL] And you can have secondary trier, you can have as many, I mean, policies as long as they know the coordination of benefits and which one to bill first, but that's why we have primary and secondary. I, yeah, I don't understand that and I don't know who they called and spoke with.
[CUSTOMER][NEUTRAL] So the secondaries.
[CUSTOMER][NEUTRAL] So like if my, if on my Blue Cross Blue Shield plan, it says you pay up to the deductible max.
[CUSTOMER][NEUTRAL] Then you pay 50% until your out of pocket max is reached, then insurance pays the rest. That's awful, but that's what it is. So basically because if that's what it says under a service, we have to reach that deductible max before APL covers anything.
[CUSTOMER][NEUTRAL] That's what you're saying.
[AGENT][NEUTRAL] Right, I had to think about it, yes, because
[AGENT][NEUTRAL] They're they're not going to see you until the deductible is paid.
[AGENT][NEUTRAL] We're not going to get filed until we're not going, they're not going to file a claim to us to pay until after the services are done. So technically APL won't even know anything about anything until we receive a claim.
[CUSTOMER][NEGATIVE] I guess I thought it was one of those things where if you file the Blue Cross Blue Shield they pay what they're gonna pay and then it gets sent to you and then you pay what you're gonna pay and that's not how it works.
[AGENT][NEUTRAL] Which is
[AGENT][NEUTRAL] If you didn't have a high deductible, yes, that would be how it works because there would be nothing to pay upfront and uh Blue Cross Blue Shield would just pay out on the claim and then it would be sent to us to pay out on. But because the policy has a high deductible, the deductible has to be met before insurance pays anything, that's what's giving the catch-22.
[CUSTOMER][NEGATIVE] What a mess.
[CUSTOMER][NEGATIVE] OK, well I'm basically paying all this money for nothing.
[CUSTOMER][NEUTRAL] Because I can basically ask for a self-pay rate and pay way less money, so.
[CUSTOMER][NEUTRAL] Because we're never gonna reach the high deductible that they have. OK, I'm sorry, I'm just trying to process this all. If you could just send me that information I'd.
[AGENT][NEUTRAL] No, no, it's fine, and I had to do the same thing with me and my baby.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] I'm just, I don't even, I can't I'm sorry, I'm just like so upset right now. I really can't even continue this conversation. I mean, I'm a health care provider too and everyone deserves good insurance, which is not the case in our country, but I can't believe that my employer would change to an insurance like this it's absolutely ridiculous, um.
[AGENT][NEGATIVE] It's frustrating.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, um, yes, if you could just email me that please and then um I will just have to call you back if I have any further questions or concerns.
[AGENT][NEUTRAL] OK. Well, I am emailing this to you now. Excuse me.
[AGENT][POSITIVE] So you should be receiving it shortly. I'm getting ready to press send. Um, I wish I had better news for you, [PII]. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] All right, well, thank you so much for calling APL. I hope you also. Bye-bye.
[CUSTOMER][POSITIVE] Thank you so much. You have a great day.