AccountId: 011433970860
ContactId: 0ce5a704-dee1-4047-97cf-3090bc5b9931
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 722640 ms
Total Talk Time (AGENT): 273041 ms
Total Talk Time (CUSTOMER): 285183 ms
Interruptions: 11
Overall Sentiment: AGENT=1, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/0ce5a704-dee1-4047-97cf-3090bc5b9931_20250117T22:07_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ACL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, your name's [PII]?
[AGENT][NEUTRAL] Yeah, [PII]
[CUSTOMER][NEUTRAL] Hi [PII].
[CUSTOMER][NEUTRAL] [PII] OK, um, hi, my name is [PII]. I, um, wanted to find out we, we have a patient that has regular, um, uh, you know, a commercial insurance, but she's got the APL as a gap, and I wanna find out what's covered if the if the other one doesn't, if her primary doesn't cover it because of a deductible or a co-pay and then I send it to you guys. I wanna see what coverage she has.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] Of course, yeah, we could take a look at those benefits um [PII] first, if you don't mind, can I get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] Alright thank you and then do you have the policy number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, it's 025743.
[CUSTOMER][NEUTRAL] 21 M as in Mary, L as in Larry 8.
[AGENT][NEUTRAL] Thank you and what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, it's [PII] [PII].
[AGENT][NEUTRAL] Alright, thank you so much for verifying that [PII]. Alright, so the policy is active. Effective date was [PII], and yes, so this is a secondary medical policy, it is designed to help with co-pay, deductible and co-insurance as long as major medical does pay.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, we, as long as they're notified you said?
[AGENT][NEUTRAL] We would just all we need really for claims is the EOB from um primary so yeah.
[CUSTOMER][NEUTRAL] Yeah, that's OK. I, yeah, OK, and then, um, it's for chiropractic care. Can you tell me, um, is it a certain dollar amount per year or yeah.
[AGENT][NEUTRAL] Chiropractic. Let's take a look.
[AGENT][NEUTRAL] Um, let's take a look. Give me just a moment. Um, of course I will let you know verification of coverage is not a guarantee of payment for claims. Um, now is this going to be in a physician's office environment or is this going to be in a spe OK, it is OK, physician's office.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, yeah, position.
[CUSTOMER][NEUTRAL] Yeah, just in, yeah, just in, it's just in the chiropractor's office, uh huh.
[AGENT][NEUTRAL] OK, got you. Let's see, so the outpatient benefit is on a per calendar day basis, so it is $750 max per calendar day that we would pay. Let me verify and make sure that that is going to be covered.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And some of these policies, the visits could be covered, they could not be or treatment could be in office, so give me just a moment.
[CUSTOMER][NEUTRAL] Mhm, yeah.
[CUSTOMER][NEUTRAL] Are you sure it's not 750 max per year?
[AGENT][NEUTRAL] I'm sure, uh, yeah, it's 750 per day.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] That, that's insane. We, we don't charge that all week long.
[AGENT][NEUTRAL] We have some that are oh no we have some that they'll pay like a couple 1000 per calendar day it's crazy.
[CUSTOMER][NEUTRAL] Oh, that's gotta include like physical therapy and all that kind of stuff like I mean we do, we do therapies but not, not that much.
[AGENT][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] Well, this
[AGENT][NEUTRAL] See this does have physical therapy coverage um on this policy. Let's take a look here.
[CUSTOMER][NEUTRAL] Mhm, yeah, that might be some of it, yeah, because we do spinal man manipulation and and therapies, you know, the heat, the cold, the, you know, that type of thing, hot, cold and electrotherapy.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, bear with me just a moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so for this policy office visits themselves are not covered, however, treatment in office could be.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] So the visit itself just would not be covered.
[CUSTOMER][NEUTRAL] Mhm OK.
[CUSTOMER][NEUTRAL] Yeah, we only charge uh an office visit once a year anyway.
[AGENT][NEUTRAL] OK, oh that works.
[CUSTOMER][NEUTRAL] Mhm, yeah, it's just we that most of the insurance companies with chiropractic, they, it's like, you know, when you start at the beginning of the year you have the office visits, so you talk with the patients, see what's going on they only allow it once a year and some of them once every 3 years, some of them once every 3 years.
[AGENT][NEUTRAL] Right, a consultation, yeah.
[AGENT][POSITIVE] OK, well that's awesome.
[CUSTOMER][POSITIVE] I'm like wonderful just come on in.
[AGENT][POSITIVE] Yeah, exactly.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, so any, uh, so the spider manipulation therapies and all that is covered, um, uh, from what you're reading for me, I understand 750 max per day.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's correct. Um, now it does specify it does specify, um, as far as physical therapy. I know you said chiropractic, I would think that's physical therapy, but, um, physical therapy in a physical therapy facility. So I don't know if I guess if it's like a dedicated facility to it, then it would cover it outside of.
[CUSTOMER][POSITIVE] It still is blown me away.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] in
[CUSTOMER][NEUTRAL] Yeah, no, no, we don't, we don't do physical therapy though, we do chiropractic, so that's why I was asking about the chiropractic. Yeah, physical therapist, you could have them in chiropractor's offices, but sometimes you'll, you know, you can have them in a medical doctor's office. It just depends.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, OK, let's see. So, OK, so chiropractor for this policy is considered a specialist office, in which case that is not going to be covered.
[CUSTOMER][NEUTRAL] But this is yeah.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][POSITIVE] Oh, OK, so no coverage at all for chiropractic. Oh, that's really weird because I just last year I had two different patients which I, I've never even heard of APL before and I said, OK, we'll send it I'll send it in and they paid, they paid all of their all they had I think it was up to $1000 for chiropractic care and they covered it all because their insurance.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Well, that's where the verbiage is really well and we have multiple different kinds of these plans they're all very different as to what they will and won't cover um but this does specify treatment received in a physician's office, but it does.
[CUSTOMER][NEUTRAL] Yeah, right, uh huh.
[CUSTOMER][NEUTRAL] My treatment.
[AGENT][NEUTRAL] Act like, you know, specialists and physician's office are different.
[CUSTOMER][NEUTRAL] Mhm I mean they'll they'll call us a specialist we're really not considered a specialist, but I mean we're really not, but sometimes they, it's because it throws it under the specialist.
[AGENT][NEUTRAL] I know that it's, it is listed under the policy as that if you don't mind though, just for clarification's sake, [PII], I, I will put you on a brief hold and reach out to our claim specialist just so that they can kind of confirm what I'm thinking.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, OK, yeah, and that's fine, and she was here one time and what I'm gonna, yeah have you checked, I'm gonna go ahead and wait for to see what um AMed does and still send it to you guys and let somebody review it but she's only been here the one time she said she didn't wanna keep coming because she doesn't know if she's covered, so that's why I thought, well, let me see, let me check with you.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Right, makes sense yeah absolutely OK give me just a moment I'm just gonna put you on hold and I'll be right back with you.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] OK sounds good.
[AGENT][POSITIVE] Alright thank you one moment.
[CUSTOMER][NEUTRAL] OK thanks uh huh.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK, [PII], I'm so sorry about that wait are you still with me?
[CUSTOMER][NEUTRAL] Yes I am.
[AGENT][NEUTRAL] OK, so I did get clarification and apparently this is something that I kind of left up to, you know, it's does that broad wording because for this it simply says physician's office, um, but I did talk to the claims specialist and they did say that specialist which per this policy it lists chiropractic, um, that would be covered so I'm sorry about the confusion. Yes, I'm so sorry for the confusion. I didn't wanna give incorrect information.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] It would be
[CUSTOMER][NEUTRAL] No, no, no, that's OK.
[CUSTOMER][NEUTRAL] No, no, no, so.
[CUSTOMER][NEUTRAL] No, so, oh, so it should be covered once we get the whatever AMed does. I get that then I, and I usually will send the EOB and then I print out another claim with uh APL as the payer, and then I send both of these to you guys.
[AGENT][NEUTRAL] Excuse me.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] Correct, yes, ma'am.
[CUSTOMER][NEUTRAL] OK, OK, so, so it is covered and except the office visit is not covered?
[AGENT][NEUTRAL] That's right, um, treatment in office is but not the visit. I'm so sorry for the confusion, not everything is so clear cut and dry, I guess.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] I know, believe me, I, I, I, I have to work with the insurance companies and everybody's different, so I get it. OK, so on the first one you're probably, you know, they're probably gonna see the office visit because I am gonna bill AdMed. They just won't pay it and that's OK. So it's, it's still a 750 max per day or is that yeah, OK, well, we'll, it won't get anywhere near that. OK, so we, we don't pay. Alright, [PII], can I get a reference number so I have something on file.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Max per calendar day. Yes, ma'am, that is per calendar day.
[AGENT][POSITIVE] Well, that's good.
[AGENT][NEUTRAL] Yes ma'am, of course, that would just be my first name, last initial, and today's date. Uh, so my name is spelled [PII]
[AGENT][NEUTRAL] And was there anything else I can help you with [PII]?
[CUSTOMER][NEUTRAL] OK, and I did get
[CUSTOMER][POSITIVE] No, that's it. I appreciate your help thank you so much and have a wonderful weekend.
[AGENT][POSITIVE] OK, yeah, again sorry about the confusion you too thank you.
[CUSTOMER][NEUTRAL] No, OK, OK thanks bye bye uh huh bye.
[AGENT][POSITIVE] Appreciate you. Bye bye.