AccountId: 011433970860
ContactId: 012e64a6-0f0c-4f29-993e-6eee723e0d99
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 414299 ms
Total Talk Time (AGENT): 156017 ms
Total Talk Time (CUSTOMER): 210048 ms
Interruptions: 0
Overall Sentiment: AGENT=1.3, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/21/012e64a6-0f0c-4f29-993e-6eee723e0d99_20250521T18:52_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], good afternoon. My name is [PII] with a provider. How are you today?
[AGENT][POSITIVE] Good how are you?
[CUSTOMER][POSITIVE] I'm OK, thank you. I'm calling for the patient uh eligibility and benefits, please.
[AGENT][POSITIVE] OK, I can help you with eligibility and benefits. Do you have a good callback number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And policy number for the patient?
[CUSTOMER][NEUTRAL] Policy number is gonna be OK, policy number is gonna be let's see here.
[CUSTOMER][NEUTRAL] OK, 02141808.
[AGENT][NEUTRAL] And patient name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name and date of birth is [PII] [PII].
[AGENT][NEUTRAL] Uh, it looks like the policy is active and effective, [PII].
[CUSTOMER][NEUTRAL] OK, perfect. Does he have like express care coverage? Meaning let me see.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] Like a walk-in clinic like for like a minor condition like like for a cold, pink eye, earache, rash.
[CUSTOMER][NEUTRAL] Does he have coverage for something like like that?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Are you at an urgent care facility?
[CUSTOMER][NEUTRAL] No, well, he, we are a, um, he came, we have different facilities. We have urgent care, we have express care, we have diagnostic, so we just have, we have different things. So this is just something like he came in, not, not the urgent care, he came in for like a, a walk in the walk-in center for like a, a quick for like a minor condition, like a cold, pink eye, earache, he wasn't feeling well.
[AGENT][NEUTRAL] OK. Um, yeah, so, uh, for this policy, and this is not a guarantee of payment, it's a basic outline of the plan. Um, he does have urgent care facility benefits that pay up to $7900 but he also has, um, office visits, uh, so if he came in for an office visit for a regular physician.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, he didn't come in for an office.
[CUSTOMER][NEGATIVE] Nothing, nothing, nothing for him like being like for like a like a cough, a cold, body ache.
[AGENT][NEUTRAL] Well, it's, it's not necessarily the diagnosis, it's where did he go? What was the place of service? Is the place of service 11?
[CUSTOMER][NEUTRAL] Right, so.
[CUSTOMER][NEUTRAL] I'm sorry, say again, the place of service is what?
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Is it an office or is it an outpatient hospital? Is it an urgent care?
[CUSTOMER][NEUTRAL] Yes, so we're an outpatient facility, so this was for like an outpatient walk outpatient uh express care.
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Which is not not urgent care, so it's so different.
[AGENT][NEUTRAL] So outpatient facility under this plan, it pays up to $7900 per calendar year after primary processes the claim.
[CUSTOMER][NEUTRAL] OK, so he does have outpatient facility coverage?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK perfect sorry if I confused you.
[AGENT][NEUTRAL] Oh, that's OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So let me
[CUSTOMER][NEUTRAL] Let me, let me, let me read you the plan because somebody didn't let me fix it.
[CUSTOMER][NEUTRAL] I always, I always like to ask because sometimes people don't have it.
[CUSTOMER][NEUTRAL] They don't have the the benefit and everything and you know it's important to know, OK, do they have it, do they not have it, you know?
[AGENT][NEUTRAL] Yeah, I mean, it's, it's just based also like when we received the claim like the the CMS 1500 form, the HIFA 1500, it's based on what is the place of service code.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What is the CPT code that's being billed? So, I mean, it depends. He's got, he's got different benefits on here. Um, he, it pays for outpatient facility benefits, which would be hospital, urgent care, um, but it also pays for office visits. So if it's a physician office visit, specialist office visit, treatments and procedures rendered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] You know
[CUSTOMER][NEUTRAL] Right, so he has like urgent care stuff, but he doesn't have anything for like for like a body ache for him being like sick.
[AGENT][NEUTRAL] Well, it's not, it's, it's not necessarily the diagnosis that drives if this is covered. It's, it's where is this rendered? What is the place of service?
[AGENT][NEUTRAL] Yeah, you understand what I'm.
[CUSTOMER][POSITIVE] Right, so we're the right, yeah, I see. OK, I understand. Yeah, so we build the facility.
[AGENT][NEUTRAL] OK, so if it's a feasibility.
[CUSTOMER][NEUTRAL] So I guess it'd be right outpatient go yeah we're the facility that's how we bill that's how we bill us.
[AGENT][NEUTRAL] Yeah, so
[AGENT][NEUTRAL] OK, so if it's billed like place of service 22, which is outpatient hospital, then it pays up to $7900 after his primary insurance processes the claim. So if there's any deductible left over, this picks up a balance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got you. OK, so he does have outpatient uh urgent care coverage.
[AGENT][NEUTRAL] Yes, yes.
[CUSTOMER][NEUTRAL] I'm sorry, I, I'm sorry, outpatient, I, I said urgent care, outpatient facility coverage for the right because we, because that's how we bill, OK.
[AGENT][NEUTRAL] Uh
[AGENT][POSITIVE] Yes, that's good.
[CUSTOMER][POSITIVE] OK, perfect. Just wanted to double check. Um, OK, so he has the outpatient facility coverage because it's because he builds the facility, OK, which is perfect. And then what, what's his group name, [PII]?
[AGENT][NEUTRAL] Uh, group name is Medlink, S as in Sam, F as in Frank, X as in X-ray.
[CUSTOMER][NEUTRAL] No, is there no like a.
[AGENT][NEUTRAL] Oh, the group, I'm sorry, hold on a second, the employer.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, the group, the group name. I was sorry, yes, please.
[AGENT][NEUTRAL] A city of [PII].
[CUSTOMER][NEUTRAL] City
[CUSTOMER][NEUTRAL] OK, and his group number?
[AGENT][NEUTRAL] 15493.
[CUSTOMER][NEUTRAL] 15493 OK perfect and he's the subscriber?
[AGENT][NEUTRAL] Um, hold on just a second. I think he is.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Yes, he is.
[CUSTOMER][POSITIVE] OK, perfect. And his medical gap plan. OK.
[CUSTOMER][NEUTRAL] Right, medical gap. OK, perfect. OK. And do you have a right and is your name [PII] [PII].
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] All right, thank you.
[AGENT][POSITIVE] OK, thanks for calling APL Catherine. I hope you have a great day.
[CUSTOMER][POSITIVE] Have a nice day thanks [PII] bye bye.
[AGENT][POSITIVE] Thank you.