AccountId: 011433970860
ContactId: 276f76eb-1a91-4d37-9f7b-f6ca5470380d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 491220 ms
Total Talk Time (AGENT): 327328 ms
Total Talk Time (CUSTOMER): 145750 ms
Interruptions: 2
Overall Sentiment: AGENT=1.6, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/11/276f76eb-1a91-4d37-9f7b-f6ca5470380d_20250611T18:18_UTC.wav
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[AGENT][POSITIVE] Thank you for contacting ATL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] This particular
[CUSTOMER][NEUTRAL] Hi, I'm calling on behalf of uh one of my employees, [PII]
[CUSTOMER][NEUTRAL] And she needed some information.
[CUSTOMER][NEUTRAL] About coverage with the provider.
[AGENT][NEUTRAL] OK, I can
[CUSTOMER][NEUTRAL] Let me get you our number here off that.
[AGENT][POSITIVE] Yes, I can certainly have the benefits and I'm sorry, I didn't catch your name.
[CUSTOMER][NEUTRAL] My name is [PII]. I'm with Ventry Medical Associates.
[AGENT][NEUTRAL] Right, OK, thank you. And um you said that there was a policy number that I can look up for [PII]?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] 025.
[CUSTOMER][NEUTRAL] I don't know if you can hear her.
[AGENT][NEUTRAL] 025
[CUSTOMER][NEUTRAL] 025.
[CUSTOMER][NEUTRAL] 792.
[CUSTOMER][NEUTRAL] 59.
[CUSTOMER][NEUTRAL] That's her member ID. I'm sorry.
[AGENT][NEUTRAL] Thank you. If I could just verify your date of birth and the phone number, please?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Do you have my phone number on there or is it?
[AGENT][NEUTRAL] Uh, your phone number.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you. And um what, what uh what benefit um information can I tell you about [PII]'s policy?
[CUSTOMER][NEUTRAL] Um, well, so [PII] went for, uh, to see a plastic surgery, and there was about a growth that she had, and they said it was endometriosis, um, and that she would need a little surgery, but they said they do not accept gap insurance. Um, is that, is that, is there any kind of chance that she could submit?
[CUSTOMER][NEGATIVE] Her bill after getting the service and you guys could pay her directly or if they think they don't take your insurance, is that just um the bottom line they're not gonna take the insurance.
[AGENT][NEUTRAL] No, no, that's, that's fine. Um, sometimes they, they just don't have the staff to, to file the claim twice, so that's fine. Now, for outpatient surgeries such as the type that we're talking about, um, uh.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You have up to $1500 for that. To submit the claim yourself, uh, what we would need is the documentation from the doctor's office. So the doctor or whoever it is who's who is doing the surgery.
[AGENT][NEUTRAL] So is this, is this going to be in the doctor's office? Is it, is it her physician, uh her uh primary physician going to be doing this or?
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] She I think she.
[CUSTOMER][NEUTRAL] She was, it's gonna be a plastic surgeon. Um, they offered her the office, but there was possible complications, so they also offered her to have it done in the hospital and she prefers to have it done in the hospital because it's near a bunch of blood vessels and there's a degree of risk.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Of course, I understand. So what we would need is that.
[CUSTOMER][NEUTRAL] Yeah, but it's just, it's not cosmetic, it's not at all cosmetic, it's
[AGENT][NEUTRAL] No. Oh no, no, no, I, I, I didn't know, I know what it, yeah, I know what it is. Um, so what we would do in, in a case like this is we will get something from the provider letting us know, and they, they will give you this information and usually you can log into.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] their portal, uh, like, uh, here we have Integris Health, uh, anytime you see a doctor for anything, they, they have a follow up with you or you can go online. You can either get it from the physician himself or you can go on the online portal and get this. So what, what it will do is it will, um, the online portal will show or or the or the physician will give you a walkout paper that shows, you know, we're doing this surgery because of endometriosis, uh, we're doing it, uh, on this day at this outpatient facility.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] And it will, it will have that information on there now.
[AGENT][NEUTRAL] We will also have the
[AGENT][NEUTRAL] Explanation of benefits from her primary insurance that will show the deductible, co-payment or co-insurance. So basically what we will do is we will have um what we've done.
[AGENT][NEUTRAL] Uh, who did it, the the the the health reason or diagnosis for what it was done, and also the explanation of benefits from the major medical showing with the deductible, co-payment or co-insurances for this surgery.
[CUSTOMER][NEUTRAL] So
[AGENT][POSITIVE] Now, you will, all those things are available to you, and once you get them, you, you have several options on how to file a claim with us, probably the fastest way to do it.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] I have to go online.
[AGENT][NEUTRAL] At [PII].
[AGENT][NEUTRAL] And uh you can very quickly uh can uh create an account with a username and a password. It just takes a few moments. You can submit all those documents online. Now the, the benefit of doing that is that you'll be able to track the claim from the that time that we get it to the time it's being processed to the time it's being paid. There's also a.
[AGENT][NEUTRAL] Direct deposit form if you wish to do that rather than getting a check.
[AGENT][NEUTRAL] Uh, if you don't want to go online.
[AGENT][NEUTRAL] You can also mail it to us or fax it to us.
[AGENT][NEUTRAL] Whichever you prefer.
[CUSTOMER][NEUTRAL] I think she's fine, yeah, I think she's fine with online. That shouldn't be a problem. Are you saying that there's anything she can, is there anything she can upload prior to the procedure?
[AGENT][NEUTRAL] OK, so on her card.
[AGENT][NEUTRAL] Not really, because the reason for that, the reason for that is because it, we have to have that, that explanation of benefits from the major medical in order for us to pay out. So it's got to go through them first.
[CUSTOMER][NEUTRAL] This way?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It must go through the first and then once that happens, um, then, then you can submit everything but unfortunately we it would be great if we could be proactive on this, but we've got to have that major medical uh ELB.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Right, that would be OK, Blue Cross, yeah, OK.
[AGENT][NEUTRAL] Yeah. Is there anything else?
[AGENT][NEUTRAL] Now is there anything else that I can help with, um, uh, as far as benefits?
[CUSTOMER][NEGATIVE] So then I would have to pay out of pocket and when they reimburse me.
[CUSTOMER][NEUTRAL] Yeah, that that is the the problem. Do you know how long it takes to get the EOB?
[AGENT][NEUTRAL] Well, you, I'm not really sure, um, let's see what have you got, uh.
[AGENT][NEUTRAL] We don't really know. I mean, Blue Cross and Blue Shield, it shouldn't take that long, um, uh, but I don't really know the exact time timing that it will take to do that, um, because of course they, they will have to process it. They, they've got to put the whatever the bill is towards the deductible co-payment or contract. One of the things that you could do there, Blue Cross and Blue Shield does have, uh, an online portal as well, and you can get that EOB faster if you want. Yeah, I would go through their customer, um.
[CUSTOMER][NEUTRAL] Blue Cross, Florida.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, advocates, uh, or, or go online and what you can do is you can, um, find out how to go online and get that EOD that much faster that way you're not just hanging around waiting in the mail.
[AGENT][POSITIVE] If you can go online to any of these and you don't mind doing that, you can get this information a lot faster.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] I encourage
[AGENT][POSITIVE] That would be perfect.
[CUSTOMER][POSITIVE] I encourage them all to get my house, yeah, it's it's much better.
[AGENT][POSITIVE] And, and you know something you can also download that when you're downloading things you can just put it into a PDF file and send it on to us and you never even have to worry about, um, uh, you know, waiting for that or waiting for paper, a paper trail. So, uh, but I'm just, I'm sorry, I just don't know exactly how long it takes, but I've got Blue Cross and Blue Shield myself. It takes about a month, set up for me, but I don't know about anybody else.
[CUSTOMER][NEUTRAL] OK, that's fine.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] OK, thank you. Appreciate it.
[AGENT][POSITIVE] OK, well, there's nothing else I can help with, uh, once, once she does go online to, to do that, if you have any questions at all, um, [PII], please let us know. Uh, we will be glad to walk you through the process and, um, if you do have any questions about your, uh, um, gap insurance, just let us know we're, we're here to help.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] OK, thanks for contacting APO.