AccountId: 011433970860
ContactId: 23a1ba4e-1a65-41d4-9609-7a9b6aed69cf
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 288399 ms
Total Talk Time (AGENT): 161794 ms
Total Talk Time (CUSTOMER): 95222 ms
Interruptions: 2
Overall Sentiment: AGENT=0.9, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/22/23a1ba4e-1a65-41d4-9609-7a9b6aed69cf_20250422T18:00_UTC.wav
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[AGENT][POSITIVE] Thank you for contacting APO. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Um, hi, my name is [PII], and I need to verify eligibility and benefits for the number, please.
[AGENT][NEUTRAL] I can help with eligibility and benefits. [PII], what's that policy number, please?
[CUSTOMER][NEUTRAL] 02551634
[AGENT][NEUTRAL] Thank you. And the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] [PII] and her date of birth, how did it get off my spreadsheet? Hold on, let me pull her back up. One second. I'm so sorry.
[CUSTOMER][NEUTRAL] 52669.
[AGENT][POSITIVE] OK, thank you very much. I have a callback number please.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Am
[AGENT][NEUTRAL] you have any events that were disconnected?
[CUSTOMER][NEUTRAL] I'm sorry, did you say something? the phone was breaking up?
[AGENT][NEUTRAL] Yes, I'm sorry, is there a callback number I can have in the event that we're disconnected?
[CUSTOMER][NEUTRAL] Uh yes, [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. The policy went into effect on [PII]. It is active. Uh, this is a secondary or gap insurance and there's in and out of hospital benefits. Is there anything in particular that I can tell you about the secondary or gap insurance?
[CUSTOMER][NEUTRAL] Um, yes, so is it only just for hospital coverage only, not for like if she's going to see like a specialist doctor or something like that?
[AGENT][NEUTRAL] Well, now there is, uh, there is a benefit for treatment or procedures within the physician's office. It does not cover the office visit co-pay, but for treatment or physicians, uh, excuse me, yeah, treatment or procedures, then yes.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] OK, um, I have some CPT codes that I needed to verify to see if they had coverage with, um, and if precert was required or anything like that.
[AGENT][NEUTRAL] Well, now those things would be part of the, of the primary insurance. So what we do is this, um, if you are covered or if you are in network with their primary insurance and there's a deductible, co-payment or co-insurance on the in the, on the uh major medical EOB that you send us, then we're fine.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But if you, um, uh, if you're not in network with them and there's no, you know, and that major medical doesn't pay anything or doesn't put anything towards the deductible, co-payment or co-inter, then there's a problem. So we don't, we don't have pre-certifications, so we don't need to look up the CPT codes. That would be something you'd need to do with their major medical because as long as they're OK, then we're fine.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so you guys just pay whatever the coinsurance is so after.
[AGENT][POSITIVE] Absolutely.
[CUSTOMER][NEUTRAL] We get the um payment from the primary OK um do you guys have a network that you guys?
[AGENT][NEUTRAL] That's exactly what happens.
[AGENT][NEUTRAL] No, we do not. No, you, it's a major medical that you'll be looking at for that.
[CUSTOMER][NEUTRAL] OK, um, do you guys
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right, um.
[CUSTOMER][NEUTRAL] And you guys, do you guys like have an underwriter like um like one of the major medical like groups like United Healthcare or anything like that or you're just your own independent insurance?
[AGENT][NEUTRAL] We are our own insurance. um, now it looks like they have Aetna. Uh, it looks like your, your patient has Aetna, and that's fine. Um, we always make sure that we are, um, that, uh, the major medical, uh, is, you know, that we can work with them, uh, before we, um, get involved with a, with a employer group. So in this case, um, you will send your, your claims to Aetna first. They'll send them on to us and then as long as we, as long as the place of service is covered.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Uh, then we are fine. Um, the only thing that we have here that, that probably would not, uh, be covered or definitely would not be covered would be that office visit co-pay, but that treatment office is.
[AGENT][NEUTRAL] So it's, it's really most of the questions that you have are gonna be for the major medical, not, uh, you know, because we followed them.
[CUSTOMER][NEUTRAL] Got it. OK.
[CUSTOMER][NEUTRAL] OK, that's fine. Uh, yeah, I've, I've called Aetna and we've got that information. I was just asked to call the secondary to see how you guys paid, and I, I normally just call for the primary, so I was just asking a normal question. Sorry, but thank you for clarifying all that for me.
[AGENT][NEUTRAL] Oh, sure, of course. No, yeah. Yeah, if you have any questions, just let us know. It is confusing, but yes, that's what we do is we, we follow the major medical in, in most ways except for that office visit copay.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Got it. OK. All right, Ms. [PII], may I get a reference number for our call, please?
[AGENT][NEUTRAL] Yes, my name is [PII]. The first letter of my last name is [PII], and we're gonna use that today's date as a reference. Is there anything else at all that I can help with?
[CUSTOMER][POSITIVE] Uh, no, ma'am, that's all, thank you.
[AGENT][NEUTRAL] On the policy.
[AGENT][POSITIVE] OK, thanks for contacting API.