AccountId: 011433970860
ContactId: 013174a4-6733-41ce-a764-2d98f45f473d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 425600 ms
Total Talk Time (AGENT): 151009 ms
Total Talk Time (CUSTOMER): 219337 ms
Interruptions: 0
Overall Sentiment: AGENT=1.4, CUSTOMER=1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/08/013174a4-6733-41ce-a764-2d98f45f473d_20250508T20:47_UTC.wav
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[CUSTOMER][NEUTRAL] um, you're gonna do have a minimum.
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII], last initial [PII]. Uh, my best call back number is [PII], uh, no extensions, and I'm calling from, uh, Sequoia Iroup in regards to, uh, actually not Sequoia Iroup calling from [PII] I group in regards to, uh, one of our patients.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, well, I'll be more than happy to assist you with your patient. And [PII], may I have a good, um, well, you have to give me the contact number. May I have the policy number and the reason for the call?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes. So, uh, the policy number is 025.
[CUSTOMER][NEUTRAL] 194.
[CUSTOMER][NEUTRAL] 19.
[CUSTOMER][NEUTRAL] And the reason I'm calling is because I would like to know, uh, first of all, the coordination of benefits for this patient, so whether or not this insurance is, uh, the patient's secondary. And then I would like to know uh the.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The benefits uh that this insurance uh gives the member and especially their benefits for a specialist office visit.
[CUSTOMER][NEUTRAL] And then in office diagnostic testing.
[AGENT][NEUTRAL] Diagnostic. OK.
[AGENT][NEUTRAL] Alright, so I have the policy here. Can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, it's uh [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So the policy, um, this is their secondary insurance, we're second to Health Easy.
[AGENT][NEUTRAL] We applied to the co-pay, deductible and co-insurance of covered charges after primary.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, this policy has been effective since [PII].
[CUSTOMER][NEUTRAL] OK, yeah, OK.
[AGENT][NEUTRAL] And for the office visit, specialist office and diagnostic testing that would both be under outpatient. The benefit is um $2,025 per calendar year.
[CUSTOMER][NEUTRAL] We
[AGENT][NEUTRAL] Did you want me to see if any of that balance has been used?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Alright, and none of the benefits have been used for [PII], um, so she still has that full um balance for the outpatient benefit.
[CUSTOMER][NEUTRAL] I got it on my phone.
[CUSTOMER][POSITIVE] Got it and uh these benefits, um.
[CUSTOMER][NEUTRAL] Let's see, so you, this insurance applies to the co-pay, co-insurance and deductible, correct? That's what you said?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And so then I'm assuming that any charges uh from the primary are then sent to the secondary and they're essentially picked up. So the, so the uh patient is not responsible for those.
[AGENT][NEUTRAL] Not necessarily. The secondary policy has its own benefits, so it's, we apply to the co-pay, deductible and co-insurance of covered charges. So it as long as it's a benefit that's listed, you know, that's either outpatient or inpatient, then we would pay towards it, but I don't want to say that we'll just pick up anything because that that wouldn't be true.
[CUSTOMER][NEUTRAL] I understand. And so then, uh, sorry, you mentioned there is um that 2025 number that you mentioned so far. Could you explain again what that that is?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's the maximum amount that they have to use towards outpatient benefits for the whole year.
[CUSTOMER][NEUTRAL] Oh, I understand. So when the, uh, when the claim is sent from the primary to the secondary, which is you guys, the maximum, uh, that can be used of the benefits is uh $2,025.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, for the whole year. So, um, if we can apply, we definitely will, um, if not, you know, if, if the max has been met or something, then of course the the policy or the claim will be denied, but
[AGENT][NEUTRAL] Yes, that's the total max for the year for outpatient services.
[CUSTOMER][NEUTRAL] OK, I understand so um.
[CUSTOMER][NEUTRAL] Until that $2,025 is met, you guys will pay for whatever applies.
[AGENT][POSITIVE] Exactly.
[CUSTOMER][POSITIVE] Perfect. OK, thank you, thanks for your patience on that.
[AGENT][POSITIVE] You're welcome. Oh, you're welcome.
[CUSTOMER][NEUTRAL] OK, um, so yeah, just to kind of review everything that we talked about, uh, before we go ahead and get that reference number, um, for [PII], uh, this plan is the secondary for her, um, the benefits of this plan are that, um, it applies to the co-pay, the co-insurance and deductible.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And she has a maximum benefit of $2,025 for this year.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] In the case that that $2,025 is met, well, what happens then when the claim is sent to you guys?
[AGENT][NEUTRAL] It will be denied um stating that the calendar year max has been met.
[CUSTOMER][NEUTRAL] OK, and then, uh, will the patient then be responsible uh for any other charges?
[AGENT][NEUTRAL] So we don't determine patient responsibility because we're not the major medical. So that would be um whatever your procedures are um on outstanding or remaining balances.
[CUSTOMER][NEUTRAL] Is
[CUSTOMER][NEUTRAL] I understand, OK.
[CUSTOMER][POSITIVE] Sounds good.
[CUSTOMER][POSITIVE] Uh, thank you for, yeah yeah.
[AGENT][NEUTRAL] Alright, it was
[CUSTOMER][POSITIVE] Yeah, I'm ready for the reference number.
[AGENT][NEUTRAL] OK, well, there's no call reference number, but you can use my name and today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And uh what was the first name again? Sorry about that.
[AGENT][NEUTRAL] It's OK. My name is [PII]
[CUSTOMER][NEUTRAL] and then
[CUSTOMER][NEUTRAL] And then [PII]. And today's date you said?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][POSITIVE] Got it. uh, alright, and uh thank you so much for your help then.
[AGENT][POSITIVE] You're welcome and thanks for calling APL and I do hope you have a great day.
[CUSTOMER][POSITIVE] Bye bye you have a great day as well.
[AGENT][NEUTRAL] Bye bye.
[AGENT][POSITIVE] Thank you. Bye bye.