AccountId: 011433970860
ContactId: fb3bc2b2-d6bf-4622-9414-76ea9c15b769
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 725599 ms
Total Talk Time (AGENT): 305461 ms
Total Talk Time (CUSTOMER): 265053 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/23/fb3bc2b2-d6bf-4622-9414-76ea9c15b769_20250623T16:21_UTC.wav
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[AGENT][NEUTRAL] For calling APL, my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. Um, I'm kind of new to having a gap coverage, and I wanted to ask a few questions, um, because I'm getting some medical bills in the mail and I wanted to understand um the payments that APL has made and a little bit about my coverage so that I can call them understanding how it's supposed to work because I have a feeling that I'm getting charged for stuff I wasn't supposed to be charged for.
[AGENT][POSITIVE] OK, I'd be happy to assist with your claims today, [PII], if I can get a good call back number for you.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And what is your policy number?
[CUSTOMER][NEUTRAL] Uh, is that on my card?
[AGENT][NEUTRAL] Um, we can just use your social.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] I'm logged in. I could probably get, oh, I have the policy number if that helps.
[CUSTOMER][NEUTRAL] It's on the, it's online.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, well I have you pulled up if you could just verify your date of birth and your email address for me.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, my date of birth is [PII] and my email address is [PII].
[AGENT][POSITIVE] Thank you for that.
[AGENT][NEUTRAL] Um, now what is the data service that you're.
[AGENT][NEUTRAL] Calling in reference to.
[CUSTOMER][NEUTRAL] Well, I'm getting bills from two different providers. Um, the first one is the date of service of [PII].
[CUSTOMER][NEUTRAL] And it was for Doctor [PII] at Yavaal Eurogynecology.
[AGENT][NEUTRAL] OK, I see we only have one claim for that data service. Let me see who that's from.
[AGENT][NEUTRAL] Um, is he with Vital MD Group Holdings?
[CUSTOMER][NEUTRAL] Yeah, that's her, yeah.
[AGENT][NEUTRAL] OK, well, they submitted a claim, uh, your patient responsibility was $45 and we paid that. Let me see what day we paid that.
[CUSTOMER][NEUTRAL] Yeah, I paid that too.
[AGENT][NEUTRAL] We paid that on [PII].
[CUSTOMER][NEUTRAL] OK, I paid, um, and, and the $45 you paid it because it's my co-pay?
[AGENT][NEUTRAL] Well they submitted the claim, so we processed it.
[CUSTOMER][NEUTRAL] Right, but what I'm saying is, do you pay the $45 because you cover my co-pay?
[AGENT][NEUTRAL] Well this wasn't for the um did you pay 45 I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Or was that for medicine?
[CUSTOMER][NEUTRAL] I'm just I'm just asking if the $45 is to cover my co-pay, because I also paid the co-pay when I went.
[AGENT][NEUTRAL] Now, they built this
[CUSTOMER][NEUTRAL] So that's what I wanna ask.
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] It's OK, go ahead.
[AGENT][NEUTRAL] They billed as an office visit and this was for a procedure at an office visit so the patient responsibility was $45. Now they may have charged you $45 for the co-pay associated with any physician's charges because we don't cover, um, let me make sure.
[AGENT][NEUTRAL] You don't have, yeah, we don't cover the copay associated with the physician's charges for an office visit, but we do cover treatment and procedures, and they bill for a procedure at that office visit which was $45. So just make sure the $45 that you paid was associated with the physician's charges and not associated with any treatment or procedures at that visit.
[CUSTOMER][NEUTRAL] OK, so the $45 you paid it because it was a procedure charge.
[AGENT][NEUTRAL] Correct, that's what you owed for the procedure that was performed on that day and we cover procedures and treatment. We don't cover the copay that's associated with the general physician's charges. What he charges just to talk to you, treat you.
[CUSTOMER][NEUTRAL] Right, right, right. OK, yeah, it just happened to be the same amount, so I wanted to make sure, um.
[AGENT][NEUTRAL] You know,
[CUSTOMER][NEUTRAL] OK, and you said that that was paid on what day?
[AGENT][NEUTRAL] Um, that check went out on the [PII] and it cashed. It was cashed on [PII], so they got the payment.
[CUSTOMER][NEUTRAL] All right, and for that day, that's the only payment that you all made, is that correct?
[AGENT][NEUTRAL] For [PII].
[AGENT][NEUTRAL] Uh alright, hold on.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] That is the only claim that we received that one claim for [PII].
[CUSTOMER][NEUTRAL] OK. Um, there is
[CUSTOMER][NEUTRAL] Another date of service for the same provider of [PII].
[CUSTOMER][NEUTRAL] And you all send $200 for that one.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] And that is your per day maximum.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So anything over 200 a day is gonna be your responsibility so we paid the maximum for that data service.
[CUSTOMER][NEUTRAL] OK. Um, so,
[CUSTOMER][NEUTRAL] And that's fine, so that explains my West Kendal um.
[CUSTOMER][NEUTRAL] Visit for my kidney stone, also the 200 mg per day.
[CUSTOMER][NEUTRAL] Per day max. OK, so you, you kind of already answered another question. All right, so I guess the only thing that's left is for me to understand better what the gap insurance pays for.
[CUSTOMER][NEUTRAL] Is there um do you have that information because I tried to look online and it isn't really, I looked at the, the benefits schedule of benefits and um.
[CUSTOMER][NEUTRAL] It really it it isn't really clear to me what you cover above and beyond what my United Healthcare coverage covers. I mean, obviously you're covering stuff because the payments are going out, but I just wanna be able to understand my, my, my explanations of benefits better. So can you tell me what it is that the APL pays for?
[AGENT][NEUTRAL] If you're hospitalized, I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] I, I, I know it's not copay.
[CUSTOMER][NEUTRAL] Yeah, I know it's not copays now.
[AGENT][NEUTRAL] So if you're hospitalized um per year, you're covered at, um, we will cover your patient responsibility up to $1000. So if you're hospitalized and your co-pay is $500 we're gonna pay the full $500. If you're hospitalized again that year,
[AGENT][NEUTRAL] And the copay is um $700 we're gonna pay $5 and then you're maxed out for the rest of the year. So it's $1000 per calendar year for inpatient. That means anything if you're admitted in the hospital or if you're under observation for more than 18 hours. Now for outpatient.
[AGENT][NEUTRAL] We cover $200 per day. And outpatient includes your treatment and procedures and your office visits, um, any ER, urgent care, um, diagnostic facilities, surgical facilities, um, that even includes your lab and durable medical equipment. So all of that that falls under outpatient is covered at $200 per day.
[CUSTOMER][NEUTRAL] OK, and but that is aside from any co-pays that I have, is that correct?
[AGENT][NEUTRAL] Um, the only thing that we would not cover is your copay associated with the physician's charges at an office visit. If the bill is coded as an office visit and it has a physician's charge on it, we're not gonna pay it. If you have a copay associated with the ER, the urgent care, the diagnostic facility, the lat, anything else that would be payable.
[CUSTOMER][NEUTRAL] OK, cause I'm getting a bill for um
[CUSTOMER][NEUTRAL] A date of service of [PII].
[CUSTOMER][NEUTRAL] From West Kendall Baptist Hospital for $150.
[CUSTOMER][NEGATIVE] They did not
[CUSTOMER][NEUTRAL] Charge me anything when I went in.
[CUSTOMER][NEUTRAL] And I see that you all paid them $200 so I'm trying to understand why they're billing me $150.
[AGENT][NEUTRAL] Because they billed as an ER.
[AGENT][NEUTRAL] And so your patient responsibility was $350. We paid 2, so you owe them $150 because you remember at for outpatient you're only covered at $200 per day.
[CUSTOMER][POSITIVE] Right, but UnitedHealthcare also paid them, like my primary insurance also paid them.
[CUSTOMER][NEUTRAL] So when you say my, my
[AGENT][NEUTRAL] OK, let me pull up the EOB so that I can, one moment, let me pull up the EOB that we received so I can see how the claim was processed. One moment please.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so the total cost of that visit was $12,921. OK, so.
[CUSTOMER][NEUTRAL] Well
[AGENT][NEUTRAL] Your insurance.
[AGENT][NEUTRAL] So that was a covered charge.
[AGENT][NEUTRAL] Your insurance paid $7,402.60.
[AGENT][NEUTRAL] Because you got a discount, you got a discount because obviously the hospital you went to is in network. So your discount, your discounted rate was $7,752.60. Your insurance paid $7,402.60. That left a co-payment of $350 for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We received the bill.
[CUSTOMER][NEUTRAL] Of which you paid 200, OK.
[AGENT][NEUTRAL] We pay 200 and now you owe 150.
[CUSTOMER][POSITIVE] OK, I understand it better now.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. All right. Thank you so much for your help. I, I understand things better now and I understand why I'm getting these bills.
[AGENT][NEUTRAL] OK, well, was there anything else I can assist with?
[CUSTOMER][POSITIVE] So, um I appreciate your help.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] There seems to be a delay in the, in the
[CUSTOMER][NEGATIVE] There seems to be a delay in the um in the communication like through the phone.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][POSITIVE] Yeah, so anyway, thank you for your help, um, and have a good day. Thank you.
[AGENT][POSITIVE] Thank you for calling APL. Have a good day.