AccountId: 011433970860
ContactId: f6bc536a-4c4f-4347-bca9-932e5fe9ff6b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 376750 ms
Total Talk Time (AGENT): 223761 ms
Total Talk Time (CUSTOMER): 138054 ms
Interruptions: 3
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/05/f6bc536a-4c4f-4347-bca9-932e5fe9ff6b_20250505T14:25_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], it's [PII].
[AGENT][NEUTRAL] Hey, [PII].
[CUSTOMER][NEUTRAL] I've got um hey I've got this [PII] on the phone or but anyway I'm gonna destroy that last name and her her policy her policy number is 257-8794. She's been verified. She's calling about claim number 3586.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 206. I read of the remarks about um the part of the claim was uh paid towards the deductible and she has further questions about it. She's um wanting a better understanding.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I mean, what, what more is there?
[CUSTOMER][NEUTRAL] She said that she knows that she gets 4 visits per year and she thought that the that the visits were paid $25 each. She's not understanding that the deductible for outpatient accident or sickness needs to be paid first and then the claim pays, but she wants further understanding.
[AGENT][NEUTRAL] Let me double check something. I mean, I don't, I don't know what else you could possibly explain.
[CUSTOMER][NEUTRAL] You're just gonna
[CUSTOMER][NEUTRAL] You're gonna just reiterate what I said and maybe be hearing it from a second person will.
[AGENT][NEUTRAL] Yeah, exactly, like, and it's just like major medical, you know, you have a deductible and until you make that deductible you have out of pocket cost.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And for this policy, um,
[AGENT][NEUTRAL] Let me double check something.
[AGENT][NEUTRAL] This is the office treatment router.
[AGENT][NEGATIVE] And the office treatment router doesn't even pay for.
[AGENT][NEUTRAL] The physician's fee.
[AGENT][NEUTRAL] So, that tells me that somebody didn't do something right anyways.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Can I, is it OK to let her go?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Like, are you ready for the call yet?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] If the certificate deductible is only per occurrence, receives more than one covered outpatient service and only one certificate deductible will be required to be met, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I was just trying to make sure there wasn't any like.
[AGENT][NEGATIVE] Extra something out here that I needed to be aware of. I don't see anything. They applied the deductible to the office visit fee though and we don't pay that under this router, so that wasn't even done correctly in the first place.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] But I'm not gonna tell her that.
[CUSTOMER][NEUTRAL] Yikes.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] I'm just gonna have to send an error to the, yeah, yeah, it'll be even worse.
[CUSTOMER][NEUTRAL] That'll make her flipper wig.
[AGENT][POSITIVE] OK, yep I got you.
[CUSTOMER][NEUTRAL] OK. All righty. Bye-bye, [PII].
[AGENT][NEUTRAL] All right. Bye.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Ms. [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hey this is [PII] um with the claims department. How are you?
[CUSTOMER][POSITIVE] Hi [PII], doing well. How are you?
[AGENT][NEUTRAL] I'm doing well, um, so [PII] was stating that on your most recent claim, uh, you had a question in regards to um the remark code stating that.
[AGENT][NEUTRAL] The $25 going towards your deductible?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's correct. I understood that I guess that the insurance covered like up to 4 deductibles a year up to $25 per year.
[AGENT][NEUTRAL] OK, so this policy, it will it does cover any co-pay, co-insurance or deductibles. However, it also has its own deductible per calendar year for outpatient services. You don't have them for emergency room services or for inpatient or in hospital services, but you do have a per calendar year outpatient deductible of $100. So once that $100 has been met for all outpatient services.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, then we will start picking up anything else. So, God forbid, but let's say you go to the emergency room.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And your patient responsibility from your major medical deductible co-insurance and copay is a combined of like $500 or whatever is remaining of your $100 deductible with us for outpatient because you were just seen in the ER you weren't admitted as an inpatient afterwards, um, any remaining balances or any remaining benefit amount um would be payable up to your, um, $4000 per year that will pay out and cover.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And and for the remainder of the year you no longer have an outpatient deductible because it's only $100 per year for us it's not per occurrence it's not per day or anything like that for the whole year so once that $100 is, is um covered and paid, then for the rest of the year up to the $4000 we will start covering everything at 100%.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so outpatient, OK, that must have changed, but you know I'm knock on wood, you know, I mostly go to either Wellcare or urgent care for flu or something like that, so I'm not complaining, but, um, and that's why I didn't fully understand and I know now our employer pays 100%, so it may have changed when that changed. OK, that's all I needed.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] No, that's fine.
[AGENT][POSITIVE] Got you. It might have, yeah. OK, well, if you have any more questions, let us know, OK? Yes, ma'am. You have a great day.
[CUSTOMER][POSITIVE] Yes, well thank you so much.
[CUSTOMER][POSITIVE] Thank you bye bye.
[AGENT][NEUTRAL] Bye bye.