AccountId: 011433970860
ContactId: 0cf7c6ae-9013-4318-859c-961c48c52d1f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 287040 ms
Total Talk Time (AGENT): 149622 ms
Total Talk Time (CUSTOMER): 130726 ms
Interruptions: 6
Overall Sentiment: AGENT=1.8, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/10/0cf7c6ae-9013-4318-859c-961c48c52d1f_20250410T17:08_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII], um, and I'm calling from Ortho, Illinois, and I just had a coworker call and get benefits, and I just wanna make sure that she, she's telling me that there was $35 3500 dollars that would go toward her surgery.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, [PII].
[CUSTOMER][NEUTRAL] I wanna make sure if it's for professional and facility or if it's only for facility.
[AGENT][NEUTRAL] OK, [PII], so you're wanting to verify some benefit information for a member, is that correct? Yes, ma'am. I can help you with that. And [PII], what is your callback number?
[CUSTOMER][POSITIVE] Correct, correct.
[CUSTOMER][NEUTRAL] It's [PII] and that is a direct line it's.
[AGENT][POSITIVE] Thank you and the member's policy number, please.
[CUSTOMER][NEUTRAL] It is 02350220.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] She did, she did put um.
[CUSTOMER][NEUTRAL] So now
[CUSTOMER][NEUTRAL] I yeah I just.
[AGENT][NEUTRAL] OK, and send me any information that is provided would be a verification of benefits and not a guarantee of payment. What is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] He brought it to your test and she said.
[CUSTOMER][NEUTRAL] Is Medicare, but I would think.
[CUSTOMER][NEUTRAL] Unless he he just send invoice.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, and again, any information provided is a verification of benefits and not a guarantee of payment. So I do show that [PII] is a subscriber on the supplemental policy and the supplemental policy is active, effective [PII].
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] One.
[CUSTOMER][NEUTRAL] Once you hit a state you have to let them know.
[AGENT][NEUTRAL] And are you needing inpatient, outpatient or office benefits?
[AGENT][NEUTRAL] Again.
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] I want to make sure we were given benefits that she had $3500 and 181647 is remaining. I want to know is that for the whole surgery or is that just for the facility?
[AGENT][NEUTRAL] No, that is the total. The 3500 is the maximum.
[CUSTOMER][NEUTRAL] Or does it include the.
[CUSTOMER][NEUTRAL] For a surgery that's professional and.
[AGENT][NEUTRAL] That is the maximum, uh-huh, outpatient benefit.
[AGENT][NEUTRAL] For covered services with no deductible.
[CUSTOMER][NEUTRAL] OK, so as long as they do it at an out outpatient they would get that to go toward.
[AGENT][NEUTRAL] Well, again, as of now, you know.
[CUSTOMER][NEUTRAL] That 1816.
[AGENT][NEUTRAL] We would have to receive the claim obviously along with the primary insurance company's explanation of benefits for review, but that is the maximum.
[CUSTOMER][NEUTRAL] OK, go ahead.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Benefit that is available or for per calendar year for covered outpatient services and yes as of now she has used $1,683.53.
[AGENT][NEUTRAL] Of her calendar your benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you would pay up to that 1816 47 toward the professional and the facility.
[AGENT][NEUTRAL] Again, if those, if correct, if that amount is still available, there would be no way if we were to receive it, you know, so, so in theory, as of this moment.
[CUSTOMER][NEUTRAL] If you know everything once you get the claim.
[CUSTOMER][NEUTRAL] Right, right, no, I understand that.
[CUSTOMER][NEUTRAL] OK, I just wanna make sure if it was for just the surgical center or if it was for the professional fees as well.
[AGENT][POSITIVE] Correct. Yes, ma'am. I understand.
[CUSTOMER][POSITIVE] OK, alright, great, alright, thank you so much.
[AGENT][NEUTRAL] OK, and then I do, you're very welcome. And one last thing, [PII], I don't know if um the other, your co-worker who called in was given this information, but make sure that when the claim is submitted to APL for review, we do have to have a copy of the primary insurance company's explanation of benefits as well. And then once the claim has been processed, we have a portal that you should be able to check the claim status in for us by going to secured.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] OK, I think we've got all of that, so, alright, great, thank you so much mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] Well, you're welcome. So is there anything else, [PII], I can help you with?
[CUSTOMER][NEUTRAL] Bye bye.
[CUSTOMER][POSITIVE] Um, no, I think you've taken care of it.
[AGENT][POSITIVE] OK. Well, thank you again for calling APL. Have a wonderful afternoon.
[CUSTOMER][POSITIVE] Thank you bye bye.
[AGENT][POSITIVE] You're welcome