AccountId: 011433970860
ContactId: ff989290-3fec-4e77-ac28-a48033b9144e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 454380 ms
Total Talk Time (AGENT): 224540 ms
Total Talk Time (CUSTOMER): 195550 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/ff989290-3fec-4e77-ac28-a48033b9144e_20250109T21:14_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Afternoon, thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yes, hi. Uh, my name is [PII], and um, what do I need to give you? I wanna ask if, uh, a certain procedure I'm gonna do would be covered uh by my APL additional uh insurance.
[AGENT][NEUTRAL] OK, do you have um the policy number?
[CUSTOMER][NEUTRAL] I have the group number 18635.
[AGENT][NEUTRAL] Um, do you see some numbers in the bottom where it says inpatient outpatient cert number?
[CUSTOMER][NEUTRAL] And I have the.
[CUSTOMER][NEUTRAL] Yes, yes, yes, so that it's an outpatient.
[AGENT][NEUTRAL] OK, let me have the outpatient. Mhm.
[CUSTOMER][NEUTRAL] OK. 12
[CUSTOMER][NEUTRAL] Sorry, I'm gonna start again. 1256051 ML 8.
[AGENT][NEUTRAL] Mm OK.
[AGENT][NEUTRAL] Let me have a callback number just in case we get disconnected.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And may I have your date of birth for security?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, I don't think I've pulled the correct policy number. Can you repeat that policy number one more time?
[CUSTOMER][NEUTRAL] Yeah. 1256051 M as in mother, L as in Larry, and then the number 8.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, Ms. [PII], um,
[AGENT][NEUTRAL] OK, I need to verify your um mailing address and email address for verification.
[CUSTOMER][NEUTRAL] Mailing address is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] All right. Let's see, here we go. And what type of procedure are you being, is being rendered?
[CUSTOMER][NEUTRAL] Uh, cataract procedure. It's a cataract.
[AGENT][NEUTRAL] So it's a surgery for cataracts?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. And this surgery is gonna take place in an office setting or is it gonna be in an outpatient surgical center?
[CUSTOMER][NEUTRAL] It's in uh [PII]. Uh, it's a hospital in uh [PII].
[AGENT][NEUTRAL] The hospital. OK.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] But it's an outpatient. I don't stay in the hospital.
[AGENT][NEUTRAL] All right. OK. So let me look at your benefits. Um, before I give you benefit information, I need to let you know that this is not a guarantee of payment, just a verification of coverage. And I see, OK, you have an outpatient maximum of 3500 per covered person per calendar year. Um, and this is for outpatient surgery as well, as long as it's in an outpatient facility or a hospital.
[CUSTOMER][NEUTRAL] I understand.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Correct. Now, when I called the Basin Palmer, they told me that APL is not contracted with them.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] And that's because we are, we are the secondary. We, we're not contracted with any of them because we're just a secondary policy. This is not a major medical. So they need to be contracted with the major medical.
[CUSTOMER][NEUTRAL] Is this correct?
[AGENT][NEUTRAL] And we are the secondary ones that help with the deductibles, co-payment, and co-insurance, um, just in case they can, uh-huh, go ahead.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] Yeah, sorry to interrupt you. I was gonna tell you that last year in Novem in [PII], I did a procedure there in my eye and um they sent all the to Blue Cross Blue Shid and then whatever Blue Cross did not uh pay they sent to you and then you covered up to 3500.
[AGENT][NEUTRAL] Yes
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] So now they're telling me I don't know if it's the lady that answered the phone didn't wanna because she was a little bit short with me and didn't have the patience to answer my questions. So I'm not sure it's because of her, but she said that they're not contracted and we don't contact them. They will not cover anything. I said, I know I have the insurance with them and they cover up to 3000 and they covered last year. She said things changed this year.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So I wanted to make sure that the, the hospitalization, 3500 will, uh, and, and like you said, it's no guarantee, but it also could be applied to this procedure in this facility, outpatient hospital, [PII].
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Well, it could be applied to um that procedure in any hospital. Now, I cannot tell you if they do take it or not because the, they, they all have their own limitations and policies and regulations and
[AGENT][NEUTRAL] So I'm not sure if they they're gonna send in the claim for you but um if they will not send in the claim for you and you end up having to pay that out of pocket, you can always submit a claim for reimbursement.
[CUSTOMER][NEUTRAL] With you.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And what will you need in that case for reimbursement?
[AGENT][NEUTRAL] OK. Uh, for reimbursement, uh, you need to submit a claim, which is gonna be a claim form. You can find the claim form through our website at [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And we also need for you to ask them to give you an itemized bill with diagnosis codes and charge amounts.
[CUSTOMER][NEUTRAL] Itemize bill with diagnosis quotes.
[AGENT][NEUTRAL] In charge amount.
[CUSTOMER][NEUTRAL] And what? I'm sorry, and charge amount?
[AGENT][NEUTRAL] And the charge amount. Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And we also need the copy of the explanation of benefits from the primary insurance indicating how much they apply towards the deductible co-payment or co-insurance.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So as long as you have all those documents, you can submit your own claim for reimbursement if you need to.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. All right.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][MIXED] Thank you very much, but it's not that um uh like you know if they don't, it's not like you will not be covering that somehow.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Well, um, like I said before, we cannot guarantee any payments over the phone. Now, it, it sounds like it's a covered service, um, and, um, yeah, if they, if they cannot submit a claim for any reason like if they don't have a way or they decided not to work with the secondaries no more, then um you can go ahead and um submit your own claim, but again, we cannot guarantee until we receive the claim.
[CUSTOMER][NEUTRAL] Until you see a claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Mhm mhm OK, all right, thank you very much.
[AGENT][NEUTRAL] Mhm
[AGENT][POSITIVE] You're welcome. Is there anything else I may help you with today?
[CUSTOMER][POSITIVE] OK. No, this is enough for today. I mean, if you answered my question, you've been very helpful. Thank you.
[AGENT][NEUTRAL] OK
[AGENT][POSITIVE] You're welcome and thank you for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] OK. OK. OK, bye bye.
[AGENT][NEUTRAL] Mm bye.