AccountId: 011433970860
ContactId: 2eb03967-6e29-4d72-9004-dbf990fdf69d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 831190 ms
Total Talk Time (AGENT): 349091 ms
Total Talk Time (CUSTOMER): 174897 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/2eb03967-6e29-4d72-9004-dbf990fdf69d_20250213T20:55_UTC.wav
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[AGENT][NEUTRAL] Afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello, my name is [PII], and I'm calling from Botox one. I need to inform you that this call is being recorded for quality and training purposes. And I'm calling at the request of the provider [PII] call.
[CUSTOMER][NEUTRAL] To obtain benefits for the physician administrative medication butox. So what information do you need from me before we begin?
[AGENT][NEUTRAL] OK, so you're needing to verify benefits for a member, is that correct?
[CUSTOMER][NEUTRAL] Yes, benefits and eligibility information.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] Yes, I can help you with both of those. Can you please uh spell your name for me?
[CUSTOMER][NEUTRAL] Yes, it is [PII].
[CUSTOMER][NEUTRAL] It's my last initial.
[AGENT][POSITIVE] OK, [PII], thank you. Yes, ma'am. Thank you. And your callback number, please?
[CUSTOMER][NEUTRAL] [PII] and option 1.
[AGENT][NEUTRAL] Thank you. And what is your patient's policy number, please, [PII]?
[CUSTOMER][NEUTRAL] That is 02141802.
[AGENT][POSITIVE] Thank you. One moment, please.
[AGENT][NEUTRAL] Give me one moment, [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] be
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And any information I that I do provide for you today will be a verification of benefits and not a guarantee of payment. What is your patient's name please and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. One moment please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So I did show she is the excuse me, the spouse of the subscriber on this supplemental policy.
[AGENT][NEUTRAL] And the supplemental policy is active with an effective date of [PII].
[AGENT][NEUTRAL] And again, what type of benefit information are you needing?
[CUSTOMER][NEUTRAL] It is a supplemental plan?
[AGENT][NEUTRAL] This is a supplemental plan to her primary health care insurance.
[AGENT][NEUTRAL] Well, you're not a major medical insurance company.
[AGENT][NEUTRAL] Under her plan with APL office visits are not covered.
[AGENT][NEUTRAL] She does have an office treatment writer on her plan.
[CUSTOMER][NEUTRAL] And what is the plan name?
[AGENT][NEUTRAL] In which we can review Medin.
[AGENT][NEUTRAL] In which we can review outpatient.
[AGENT][NEUTRAL] I'm sorry, office treatment under her outpatient benefit and she has a $1000.
[CUSTOMER][NEUTRAL] It is a Medicaid supplement plan?
[AGENT][NEUTRAL] No, no, it is not. This is a supplemental policy to their private healthcare insurance.
[CUSTOMER][NEUTRAL] What is the plan type?
[AGENT][NEUTRAL] Medlink
[CUSTOMER][NEUTRAL] Ming.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Oh, the plan type, it is HMO BPO.
[AGENT][NEUTRAL] Neither.
[AGENT][NEUTRAL] It is a supplemental policy. We are not a major medical insurance company.
[CUSTOMER][NEUTRAL] OK, what is the group name?
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The group name is Me, M E N N E, Tool and die.
[CUSTOMER][NEUTRAL] Tulan Da.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, and the group number?
[AGENT][NEUTRAL] 251-84.
[CUSTOMER][NEUTRAL] OK. And um is there any renewal date for this plan?
[AGENT][NEUTRAL] I'm sorry. Is there any what?
[CUSTOMER][NEUTRAL] Renewal date.
[AGENT][NEUTRAL] This plan is currently active with an effective date of [PII].
[CUSTOMER][NEUTRAL] And is there any, I mean, does this plan runs under your calendar or a benefit here?
[AGENT][NEUTRAL] Calendar year.
[CUSTOMER][NEUTRAL] And what is the coordination of benefits?
[AGENT][NEUTRAL] There is no coordination of benefits?
[AGENT][NEUTRAL] We're not a major medical insurance company.
[CUSTOMER][NEUTRAL] OK, can you please obtain me the network status of the provider, whether the provider is in network or out of network?
[AGENT][NEUTRAL] We do not have a network. It would follow her primary healthcare insurance.
[CUSTOMER][NEUTRAL] OK. Can you let me know if the referral is required for this plan or not?
[AGENT][NEUTRAL] I'm sorry, is what required?
[CUSTOMER][NEUTRAL] Referral PCP.
[AGENT][NEUTRAL] No.
[AGENT][NEGATIVE] It is not.
[CUSTOMER][NEUTRAL] OK, so both of there is a specific code that is J as in Juliet 0585 with the CPT code of [PII] and the d.
[AGENT][NEUTRAL] No, ma'am, I can't, won't be able to give you benefit. I will not be able to tell you if that is covered or not. We will have to receive the claim along with her primary insurance company's explanation of benefits for review.
[CUSTOMER][NEUTRAL] You said something, uh, what needs to be submitted?
[AGENT][NEUTRAL] The claim along with her primary insurance company's explanation of benefits.
[CUSTOMER][NEUTRAL] Uh, the provider needs to submit that?
[AGENT][NEUTRAL] Whomever files the claim with APL will need to include a copy of her primary insurance company's explanation of benefits as well.
[CUSTOMER][NEUTRAL] You are secondary to the Medicare?
[AGENT][NEUTRAL] No, ma'am. We are secondary to the private major medical insurance.
[CUSTOMER][NEUTRAL] So what does the, uh, what is the supplement plan like?
[AGENT][NEUTRAL] I'm sorry, what is, again, what was your question?
[CUSTOMER][NEUTRAL] What is the plan name or the letter of the supplement plan?
[AGENT][NEUTRAL] OK, [PII], I've explained to you multiple times. This is a supplemental policy. We are not a major medical insurance carrier.
[CUSTOMER][NEUTRAL] Yeah, I, I got that information. I'm asking that.
[AGENT][NEUTRAL] Yes, so there is no, right, and, and there is no letter. This is a supplemental meddling plan.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] And is there anything else I can help you with today, [PII]?
[CUSTOMER][NEUTRAL] So you said you won't be able to provide me the information for the uh benefits, right?
[AGENT][NEGATIVE] I have asked you what type of benefit information you needed, and I explained to you office visits are not covered.
[AGENT][NEUTRAL] She does have an office treatment rider in which we can review under her outpatient benefit and her outpatient.
[CUSTOMER][NEUTRAL] Yes, it is an office visit.
[AGENT][NEUTRAL] Office visits are not covered under this supplemental policy. She has an office treatment writer and that can be reviewed for treatment rendered in the office under her outpatient benefit maximum, which is $5000 per covered person per calendar year for covered outpatient services.
[AGENT][NEUTRAL] And there is a $1000 outpatient deductible per cover person per calendar year.
[CUSTOMER][NEUTRAL] Is there any individual deductible or individual out of pocket? What is the individual deductible amount?
[AGENT][NEUTRAL] The outpatient deductible is $1000 per covered person per calendar year.
[CUSTOMER][NEUTRAL] And the accumulation?
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] As of now, she has used $92.37.
[CUSTOMER][NEUTRAL] $92.37.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And what is the uh out of pocket, individual out of pocket uh deductible, it is 5000.
[AGENT][NEUTRAL] Again.
[AGENT][NEUTRAL] There is
[AGENT][NEUTRAL] The maximum outpatient benefit on this plan is $5000 per covered person per calendar year for covered outpatient services. There is no there is no co-pay or any of that on this policy because it is a supplemental policy only.
[CUSTOMER][NEUTRAL] So, will you be able to provide me the in-network benefits for this plan, for this?
[AGENT][NEUTRAL] No, ma'am, because there's not a network affiliated with APL that would be something you would need to speak to her. There's no network with our company.
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] This would follow her primary health care insurance.
[CUSTOMER][NEUTRAL] So if uh we need the in-network information, we need to follow with the primary insurance, right?
[AGENT][NEUTRAL] Correct, because we do not have a network for this policy.
[CUSTOMER][NEUTRAL] I think
[AGENT][NEUTRAL] This policy only helps with co-pays, deductibles, and co-insurance amounts of covered services.
[CUSTOMER][NEUTRAL] You're saying that it is not covered, right? This policy is not covered?
[AGENT][NEUTRAL] I don't understand your question. I've given you all of the information, [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I explained to you office visits are not covered. I explained to you that there there is an outpatient benefit max that we can review claims under and gave you her outpatient deductible, and I explained that you would need to also submit.
[AGENT][NEUTRAL] Along with the claim, her primary insurance company's explanation of benefits for our review.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And once the claim has been submitted to APL for review and we have processed the claim, then you all can access our explanation of benefits at that time by going to our portal at [PII].
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Is there any cost, sir?
[AGENT][NEGATIVE] Not with this plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is there any copays, co-insurance?
[AGENT][POSITIVE] This policy helps with those things. OK, [PII]. OK.
[CUSTOMER][NEUTRAL] For a network?
[AGENT][NEGATIVE] Not with this policy.
[CUSTOMER][NEUTRAL] OK. is an authorization is required for this plan?
[AGENT][NEGATIVE] No it is not.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, can you please spell out your name for me?
[AGENT][NEUTRAL] [PII] and my name along with today's date will be your call reference number.
[CUSTOMER][NEUTRAL] What is the uh initial of your name?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And is there anything else that I can help you with today, [PII]?
[CUSTOMER][POSITIVE] Uh, no, [PII], that's it for today. Thank you so much. Have a nice day. Bye bye.
[AGENT][POSITIVE] Oh, you're, yes, ma'am, you're very welcome and thank you again for calling APL. I hope you have a nice evening also.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][POSITIVE] Thank you. Bye-bye.