AccountId: 011433970860
ContactId: 25265891-9a1c-4fd1-8149-912917189868
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 826239 ms
Total Talk Time (AGENT): 303904 ms
Total Talk Time (CUSTOMER): 263286 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/04/25265891-9a1c-4fd1-8149-912917189868_20250204T15:50_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, um, good, good morning, [PII]. My name is [PII]. I'm calling from Clear Vision Ophthalmology, and I'm trying to verify patients eligibility and benefit coverage, but before we get started, I'd like to know if our providers and outpatient ambulatory surgical center is contracted with members plan.
[AGENT][NEUTRAL] I'm sorry, [PII], may I have your callback number if we are disconnected please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] What is the policy number for the patient, please?
[CUSTOMER][NEUTRAL] Yes, um, policy number for the patient is, um, sorry, just had it, it is uh 02584921.
[AGENT][NEUTRAL] I'm so sorry, that was 02584921?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, let me get that pulled up.
[CUSTOMER][NEUTRAL] 25.
[CUSTOMER][NEUTRAL] Or
[AGENT][NEUTRAL] And verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] [PII] [PII].
[CUSTOMER][NEUTRAL] [PII], sorry.
[AGENT][POSITIVE] OK, no problem, no problem.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I can provide you a website to check to see if you are a participating provider. Uh, we wouldn't have the information at actually here in regards to, um, if you are a member.
[AGENT][NEUTRAL] Or not.
[CUSTOMER][NEUTRAL] OK, what is the website?
[AGENT][NEUTRAL] OK, one moment please.
[AGENT][NEUTRAL] OK, it is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And are you able to provide me the eligibility information?
[AGENT][NEUTRAL] Oh, certainly, OK, you want benefits as well, is that correct?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][POSITIVE] OK, all right, thank you.
[CUSTOMER][NEUTRAL] On the specialist medical
[AGENT][NEUTRAL] OK. The policy shows effective as of [PII], and this policy shows active for the member. One moment please, [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Thank you. This is for a specialist office visit, and please note verification of things provided as not guaranteed payment for a physician's office, was with a PCP or a specialist, we pay up to $50 max per visit. That's $50 max per visit.
[AGENT][NEUTRAL] And the members allowed 4 visits per year.
[AGENT][NEUTRAL] And currently the member has not used any visits.
[CUSTOMER][NEUTRAL] And the $50 is that the co-pay for specialists?
[AGENT][NEUTRAL] And with this policy, there is no co-pay, deductible or co-insurance. It's just based on coverage and for that visit, we will pay a max of $50.
[CUSTOMER][NEUTRAL] OK, so it's not a no, no deductible, no copay, and no out of pocket, it's just uh.
[CUSTOMER][NEUTRAL] What you guys paid for?
[AGENT][NEUTRAL] Yeah
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] OK, and that's just the office visit if they are rendered for any diagnostic testing and office procedures or outpatient ambulatory surgical center, that would be the patient's responsibility.
[AGENT][NEUTRAL] Um, APL does not determine patient's responsibility, um, in regards to any diagnostic testing. Uh, give me one second, see what the benefit is for that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Bear with me, thank you.
[AGENT][NEUTRAL] OK, the member does have a diagnostic benefit which is $100 per day with a max of just 1 day per year. Give me one moment just to check to see which covered.
[AGENT][NEUTRAL] I acid tests are covered on this policy at the moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That shows MRI, CAT scan, CT scan, PET scan, and RAI scan.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Um, can I give you the CPT code?
[AGENT][NEUTRAL] There are no pre-certs or pre-authorizations required.
[CUSTOMER][NEUTRAL] And the plan pays up to $100.
[AGENT][NEUTRAL] Yes, it pays a max of $100 per day, and we'll pay that just one time.
[AGENT][NEUTRAL] Throughout the year.
[CUSTOMER][NEUTRAL] So only one testing?
[AGENT][NEUTRAL] Correct, 1 test per year, um, and that's $100 that we pay.
[CUSTOMER][NEUTRAL] OK, what if the patient needs multiple testings, uh, would that be patient's responsibility?
[AGENT][NEUTRAL] APL does not determine patients responsibility. We're not contractually involved, um, but we'll pay based on what is covered and for diagnostic testing, we pay that $100 max per day.
[CUSTOMER][NEUTRAL] I'm sorry, can you repeat that one more time just so I can write it down?
[AGENT][NEUTRAL] Of course, APL pays $100 max per day for diagnostic testing and the test that I mentioned earlier.
[AGENT][NEUTRAL] And that's one time per year?
[AGENT][NEUTRAL] And APL does not determine patients' responsibility.
[CUSTOMER][NEUTRAL] And APL does not determine.
[AGENT][NEUTRAL] Patients responsibility.
[CUSTOMER][NEUTRAL] OK no
[CUSTOMER][POSITIVE] Bear with you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We're not and we're not contractually involved, of course, in the handling of any remaining balance.
[CUSTOMER][NEUTRAL] You're not contractually involved in paying.
[AGENT][NEUTRAL] In the handling of in the handling of any so we can't determine yeah so we're not contractually involved.
[CUSTOMER][NEUTRAL] Any balance?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Handling
[CUSTOMER][NEUTRAL] Sorry, I just got to the point we are we're not contracting involved in the handling of.
[AGENT][NEUTRAL] Any remaining balance?
[CUSTOMER][NEUTRAL] Any balance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and then, uh, for in office procedures do you guys cover that, uh, for example, amniograph Tidium.
[AGENT][NEUTRAL] We will pay only for the office visit and that's $50 max.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK, and then cataract surgery and outpatient ambulatory surgical center, you guys, um, don't pay, don't pay that.
[CUSTOMER][NEGATIVE] As well you just don't handle the.
[AGENT][NEUTRAL] Not as far as I'm sorry?
[CUSTOMER][NEGATIVE] You guys don't handle the responsibility?
[CUSTOMER][NEUTRAL] For the remaining balance for any outpatient ambulatory surgical center for professional and outpatient facility.
[AGENT][NEUTRAL] OK, for outpatient benefits. One moment.
[AGENT][NEUTRAL] Remember it has the benefit for outpatient accident and sickness treatment if it's done in a facility, actually has to be an excuse me, emergency room. You mentioned surgery, is that correct?
[CUSTOMER][NEUTRAL] Yeah, it's not under in the emergency room.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, for the surgery, show surgery in a hospital outpatient facility or a free-standing outpatient surgery center, the max is 250 per day, with a max of 1 day per year.
[CUSTOMER][NEUTRAL] And that's just for the facility?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] If the surgery is performed in the, in a physician's office, that is $125 per day, a max of 2 days per year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that's for in-office $125 charged for in office procedures allowed only $2 per year.
[AGENT][NEUTRAL] For surgery in a physician for surgery in a physician's office, 125 per day, with a max of 2 days per year.
[CUSTOMER][NEUTRAL] One per day.
[CUSTOMER][NEUTRAL] And loan OK.
[CUSTOMER][NEUTRAL] And if it's the surgery for the professional side for the surgery, um.
[CUSTOMER][NEUTRAL] That would also be 250 as well copay.
[CUSTOMER][NEUTRAL] If they sell in an outpatient?
[AGENT][NEUTRAL] There's no copay with this plan. It pays based on coverage, no, no problem. No, but we pay $250 per day and that's.
[CUSTOMER][NEUTRAL] I'm sorry.
[AGENT][NEUTRAL] Just to max we pay $250 per day.
[CUSTOMER][NEUTRAL] OK, and that's for the.
[CUSTOMER][NEUTRAL] Professional?
[AGENT][POSITIVE] It just saves $250 per day with a max of 1 day, and we process and claims are processed and the orders that they are received.
[CUSTOMER][NEUTRAL] OK, I'm just a little bit confused on that one, so for I know it's 250 for the facility that you guys would cover per day.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, however, for the professional, would that be for the surgery done professional, not for the outpatient, but for the professional, that would be also 250.
[AGENT][NEUTRAL] It just states that it's $250 per day with a max of 1 day um per year. Again, we process claims if it comes in if the professional sends in his claim first that may go to the professional if not the facility, it depends on who submits the claim first. So it's $250 per day with a max of 1 day per year.
[CUSTOMER][NEUTRAL] OK, so there's no charge for the professionals because it's one.
[AGENT][NEUTRAL] It's one day, one day per year for the surgery if it's.
[CUSTOMER][NEUTRAL] One day.
[CUSTOMER][NEUTRAL] OK, OK, I was just a little bit confused.
[CUSTOMER][NEUTRAL] On that one, OK and then um.
[CUSTOMER][NEUTRAL] And you mentioned there's no out of pocket, no deductible, or no copays.
[AGENT][NEUTRAL] The plan has no deductible, no copay, no co-insurance. We just pay based on coverage.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, do, do any of those, um, that I mentioned require any authorization, for example, the outpatient facilities, outpatient, uh, professional surgeries, um.
[AGENT][NEUTRAL] There are no pre-certs or pre-authorizations required on the policy. Um, what the member has is a limited indemnity policy. It's not a major medical, so there are no pre-certs or pre-authorizations required.
[AGENT][NEUTRAL] And I'm not sure if that member has another insurance or not. Of course, you'll need to ask the member in regards to that because we do not uh coordinate benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, uh, the member who resides in the state of [PII], if services are rendered in the state of [PII], would that also apply, or would, uh, or would the patient have no coverage?
[AGENT][NEUTRAL] Well, we pay based on coverage. So we pay based on as far as the benefits that we're given, that's what we pay.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is there a reference number? Are you guys a third party correct?
[AGENT][NEUTRAL] We are not a third party. We are the members limited indemnity policy. Um, we are not a third party.
[AGENT][NEUTRAL] APL is not a third party, uh, but we do not provide reference numbers. You can use my name [PII], my last initial is [PII], and today's date for the reference.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So and then to check the network status I would have to go to the multi plan correct website?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alrighty thank you very much [PII].
[AGENT][POSITIVE] You're welcome, [PII]. Thank you for calling APL. You have a great day.
[CUSTOMER][POSITIVE] You too thank you bye.
[AGENT][POSITIVE] Thank you, bye.