AccountId: 011433970860
ContactId: 04a7e717-a3a4-4847-9188-e0d5778f56ab
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 326959 ms
Total Talk Time (AGENT): 181412 ms
Total Talk Time (CUSTOMER): 90532 ms
Interruptions: 1
Overall Sentiment: AGENT=1.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/10/04a7e717-a3a4-4847-9188-e0d5778f56ab_20250610T19:15_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][POSITIVE] Yes, I need to get benefits for this patient's policy.
[AGENT][NEUTRAL] Hello?
[AGENT][NEUTRAL] OK, did you say you were needing to get benefit information for a member? Is that correct? Yes, ma'am, I can help you with that, but you do not need eligibility. You're only needing benefits, is that correct?
[CUSTOMER][NEUTRAL] Yes, mhm.
[CUSTOMER][NEUTRAL] Well, kind of both they have this as their secondary insurance, um, so I'm trying to see if you know the benefits have been coordinated. Do y'all know that you are secondary, um, and you know what portion y'all pick up of their primary.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, I can help you with eligibility and benefits. So who am I speaking with, please?
[CUSTOMER][NEUTRAL] My name is [PII]
[AGENT][NEUTRAL] [PII]. Is that correct? [PII] OK, fair, thank you. And your callback number?
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And what is the member's policy number?
[CUSTOMER][NEUTRAL] It is 02541662.
[AGENT][NEUTRAL] OK, thank you [PII]. One moment while I get that information pulled up.
[AGENT][NEUTRAL] And any information that I do provide for you today, [PII] would be a verification of benefits and not a guarantee of payment. What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] Um, this is for [PII] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so again, any information provided will be a verification of benefits and not a guarantee of payment. So I do show that she is a dependent on this supplemental policy, and the supplemental policy is active with an effective date of [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And we are not a major medical insurance. Again, this is a supplement that is designed to help with co-pays, deductibles and co-insurance amounts of covered services.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So what type of benefit information would you need for her inpatient, outpatient or office?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, she's coming to a special. She's here now. She's at a specialist's office and she's having a wart removed.
[AGENT][NEUTRAL] OK. So, off the, the office visit, if there's an office visit charge, that is not covered.
[CUSTOMER][NEUTRAL] OK, office visits are not covered, OK, and there would be OK.
[AGENT][NEUTRAL] Is not. That is correct. OK. Now, the treatment could be reviewed under her outpatient benefit.
[CUSTOMER][NEUTRAL] Office
[AGENT][NEUTRAL] And the outpatient benefit maximum per calendar year for covered outpatient services is $5000 I think. Oh, give me just one second my screen, yes, I'm sorry, $5000 per covered person per calendar year for covered services with no deductible.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, but we don't know if that'll process as outpatient because it's done in a specialist office or.
[AGENT][NEUTRAL] The treatment is something that we can review under her outpatient benefit, but the office visit would not be covered under this supplemental policy. And because this is a supplement to their primary insurance plan, when the claim is submitted to APO for review, we must also receive a copy of her primary insurance company's explanation of benefits.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] As well for review and then once.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, it looks like the other one, yeah, her other one's not gonna pay much so it looks like it's gonna mostly it's a high deductible plan, um, so it looks like it's mostly falling back on y'all.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Again, so we would just have to receive the claim along with the primary EOB for review.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, but definitely office visit will not be covered, so they will have to pay a co. OK, I need to look up their benefits. OK, can I get a call reference number?
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] Yes, you're gonna use my name along with today's date and then one additional piece of information there and if you all end up filing a claim with us for this number once the claim has been processed here at APL, we do have a portal in which you should be able to check claim status and the portal website is located at [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, alright, perfect, and what's your your first name?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Again, my name is [PII].
[CUSTOMER][POSITIVE] [PII], OK, thank you so much.
[AGENT][POSITIVE] OK, well, you're very welcome. So again, if that's all I can help you with, thank you for calling APL Fair and have a wonderful afternoon.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you, bye bye