AccountId: 011433970860
ContactId: 1afbf929-694d-4215-bef8-d09e309bb1ca
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 532270 ms
Total Talk Time (AGENT): 268519 ms
Total Talk Time (CUSTOMER): 169730 ms
Interruptions: 0
Overall Sentiment: AGENT=1.3, CUSTOMER=1.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/1afbf929-694d-4215-bef8-d09e309bb1ca_20250408T13:32_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello, Ms. [PII], this is [PII] in customer service. How are you, dear?
[AGENT][POSITIVE] Hey [PII], I'm good. How are you?
[CUSTOMER][NEUTRAL] I'm good, honey. I'm good. And uh I have a provider on the phone. Her name is [PII] and then she said the letter [PII], so I guess that's her last name. Anyway, she is calling, uh, I forgot to verify her phone number. She is calling on policy number 233.
[CUSTOMER][NEUTRAL] 2588.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, participant #2.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can we verify the date of birth and address?
[CUSTOMER][NEUTRAL] And what she is needing is physical therapy benefits for a specialist.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one second, let me pull that up.
[CUSTOMER][NEUTRAL] So, certainly, certainly.
[AGENT][NEUTRAL] Where's the difference there.
[AGENT][NEUTRAL] There you go.
[AGENT][NEUTRAL] My gosh, these allergies have me sounding crazy.
[CUSTOMER][NEGATIVE] This one, it's horrible.
[AGENT][NEGATIVE] I'm holding my throat. I like, oh, it's terrible. OK, let me see, physical therapy specialist office. Hm OK.
[CUSTOMER][POSITIVE] Oh my goodness.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] You ready for?
[AGENT][POSITIVE] Mhm I'm ready.
[CUSTOMER][POSITIVE] I did verify the benefits. OK, honey. Thank you.
[AGENT][POSITIVE] All right, you're welcome.
[CUSTOMER][POSITIVE] Oh dear, I hope you feel better.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Hello, Ms. [PII].
[CUSTOMER][POSITIVE] Hey, hi, uh, good morning.
[AGENT][NEUTRAL] Hello, [PII].
[AGENT][NEUTRAL] Hi, is this [PII]?
[CUSTOMER][POSITIVE] Hi, yeah, good morning.
[CUSTOMER][NEUTRAL] Yes, this is [PII] speaking.
[AGENT][NEUTRAL] Hi, my name is [PII]. I'm on the care team and [PII] was letting me know that you're needing assistance with physical therapy benefits in a specialist office.
[CUSTOMER][POSITIVE] Yeah, that is correct. I'm actually a provider from South Florida physical therapy and sports rehab.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and all the information provided is a verification of benefits, not a guarantee of payment. So the member
[AGENT][NEUTRAL] So for the outpatient benefits, the max is $2000 per calendar year. Now the policy itself does not have any coverage for, um, well, the physical therapy facility, if it's an actual like the outpatient facility, there's coverage for it, um, up to that $2000 per calendar year.
[AGENT][NEUTRAL] If it is in an office setting.
[AGENT][NEGATIVE] This secondary policy doesn't have any coverage for the office setting.
[AGENT][NEUTRAL] But it does have coverage for treatment in the office because they've added the office treatment rider. So it could still be covered up to that $2000 per year if it is in the office because of that rider as well.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] I see. So what if, um, because, uh, the, the benefit I need is physical therapy, right? But, uh, it, this is, uh, the place of service is office and performed by a specialist, so is that covered?
[AGENT][NEUTRAL] So then, so then only the office treatment rider could be used and again it's because of the secondary policy, there is no coverage on the place of service, only the treatment up to $2000 per calendar year. So yes, you can still file.
[CUSTOMER][NEUTRAL] OK, so the patient is still have the coverage for, because this is for initial evaluation.
[AGENT][NEUTRAL] So for the initial evaluation, the secondary policy may not come into effect, only the primary because they only have treatment, they don't have facility coverage. So this will come into play once the treatment begins.
[CUSTOMER][NEUTRAL] Oh, I see. So just to make sure if I got you correctly, so for now, the patient don't have a coverage only after, only if the treatment begins.
[AGENT][NEUTRAL] If you build the easiest way to remember to to handle this, if you're billing us for a facility charge, it most likely will not be covered. If you're billing us for treatment, she does have the treatment writer, so we could um process and see how the decision is.
[CUSTOMER][NEUTRAL] Mm, I see. So you said $22,000 per calendar year. That's uh that's the deductible or the out of pocket?
[AGENT][NEUTRAL] Neither. So this is their secondary policy. So the deductible and the out of pocket that applies to primary. Secondary, we pay towards the copay, that primary applies, the deductible or the co-insurance after primary. So $2000 is the max that we will pay on any outpatient expenses for the year.
[CUSTOMER][NEUTRAL] OK, so basically, no co-pay, co-insurance, deductible, and out of pocket.
[AGENT][NEUTRAL] We don't charge that, we help pay that from primary.
[CUSTOMER][NEUTRAL] OK, and do you have a visit limitation?
[AGENT][NEUTRAL] Um, let me see. If it's not in an actual physical therapy facility, then no, there's no limitation.
[CUSTOMER][NEUTRAL] Yeah, it's, it's actually in an actual physical therapy facility.
[AGENT][NEUTRAL] So, are you considered a specialist office or are you considered a physical therapy facility because that's two different things.
[CUSTOMER][NEUTRAL] Because we, we are, um, uh, South Florida Physical therapy is actually a facility, but all of the patients there is billed by a specialist.
[AGENT][NEUTRAL] So it's an outpatient facility, but the
[AGENT][NEUTRAL] So that then goes into the billing. So, OK.
[AGENT][NEUTRAL] So then if it's an outpatient facility, then it would be considered the physical therapy facility, which then we don't have to worry about facility or provider.
[AGENT][NEUTRAL] But if you're then saying that it is in a physical therapy facility, but it's billed as a specialist because of the different therapists, then the then the only way to guarantee that would be to process the claim because I don't know if you're going to bill just for the facility or if you're billing for the specialist as to provide the
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The therapist that provided the service, so it depends on how it's sent in.
[AGENT][NEUTRAL] But either way, the max is $2000. It'll just be whether we use the facility therapy or the physical therapy facility or the outpatient treatment rider, the benefit is the same.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it. And are you requiring authorization or referral?
[AGENT][NEUTRAL] Um, no, there's no prior authorization or pre-cert required for the secondary policy.
[CUSTOMER][NEUTRAL] OK, and this plan runs in a calendar year, right?
[AGENT][POSITIVE] Correct. Mhm.
[CUSTOMER][NEUTRAL] And lastly, what's your timely filing for claims and the claims mailing address?
[AGENT][NEUTRAL] So there's no um timely filing as long as the policy is active, you can file the claim at any time. And our um address is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it thank you and yeah I'm all all set now um can I have the reference number for this call?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. And again, that's [PII], first initial to my last name is [PII].
[CUSTOMER][POSITIVE] OK, thank you and uh take care bye bye.
[AGENT][POSITIVE] You're very welcome.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Was there anything else I could assist with?
[CUSTOMER][POSITIVE] And this will be it for now, thank you.
[AGENT][POSITIVE] Alright have a great day bye bye.
[CUSTOMER][NEUTRAL] Bye bye.