AccountId: 011433970860
ContactId: 33aba86c-e355-4dc2-b138-b3d591d22cd3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 316119 ms
Total Talk Time (AGENT): 137863 ms
Total Talk Time (CUSTOMER): 131099 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/02/33aba86c-e355-4dc2-b138-b3d591d22cd3_20250402T15:51_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] Hi, [PII]. My name is [PII]. I'm calling from Texas Children's Hospital. I need to verify a patient's coverage, please, and benefits.
[AGENT][POSITIVE] OK, well, I can definitely help you with the benefits and eligibility. And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure, [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] 02415364
[CUSTOMER][NEUTRAL] M as in Mike, L as in Lima, 7.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] Thank you, and all the information provided is a verification of benefits, not a guarantee of payment, and I am showing the policy is active um as of [PII]. And what type of benefits did you want to go over?
[CUSTOMER][NEUTRAL] This was outpatient hospital. I am showing.
[CUSTOMER][NEUTRAL] That the patient has commercial Cigna as primary, so this plan.
[CUSTOMER][NEUTRAL] Would be a secondary, like I said this was outpatient hospital.
[CUSTOMER][NEUTRAL] I do see one particular surgery code outpatient hospital that we may wanna check if you can do that, but.
[AGENT][NEUTRAL] So what's, what are we trying to figure out? You're wanting to know the outpatient benefits?
[CUSTOMER][NEUTRAL] Yeah, I think so we haven't filed a claim yet um so I need to see if the patient has hospital outpatient medical coverage.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so under outpatient, the policy will pay up to $2000 per calendar year.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] So is it like a procedure being done in an outpatient facility or like
[CUSTOMER][NEUTRAL] Calendar.
[CUSTOMER][POSITIVE] Yes, it was a procedure, yeah, yes ma'am.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So hold on one second.
[CUSTOMER][NEUTRAL] But this is a medical plan, right?
[AGENT][NEUTRAL] Mhm. It's second only to Cigna. Yes, ma'am. We pay towards the copay, deductible and co-insurance after primary.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK, so yes, there was a $3000 deductible, it's like I said we haven't filed yet, um, before verifying eligibility, but it does look like Cigna applied $3000 to deductible copay after processing.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, um, if
[AGENT][NEUTRAL] So you're saying they applied it to the deductible, or they're charging a deductible? OK.
[CUSTOMER][NEUTRAL] Mhm. 3 they applied $3000 of the total bill. They did pay an amount.
[AGENT][NEUTRAL] OK, OK, that's what I was trying to figure out, OK.
[CUSTOMER][NEUTRAL] Um, but then they applied 3 out the patient, yeah, yeah.
[AGENT][NEUTRAL] Well, yes, as long as primary applies to the claim, then we a second can and it would just be um like there's no percentage or anything. It's just up to that $2000 per calendar year. Did you want me to see if they've used any of the $2000?
[CUSTOMER][POSITIVE] Yes, please. Thank you.
[AGENT][NEUTRAL] OK, hold on one second. You're welcome.
[AGENT][NEUTRAL] And they have not used any of the um 2000 for [PII], so they still have that full balance.
[CUSTOMER][NEUTRAL] OK, this was a [PII] date of service.
[AGENT][NEUTRAL] Oh, let's see what they use in 24.
[CUSTOMER][NEUTRAL] Can we check [PII]? Yeah, yeah.
[AGENT][NEUTRAL] So [PII] has $1000 left for [PII]. He's used $2000. 0, hold on one second. Was the balance was the max 2 or 3?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh no, the max is 2, so he's used all the benefits for [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Which we'll probably go ahead and file just to get that denial um can we, let me see, let me make sure I've got the right claims address um can you provide the claims address or payer ID please?
[AGENT][NEUTRAL] Sure, um, so our payer ID is 60801.
[AGENT][NEUTRAL] And our claims mailing address is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 950.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] OK, alright, um, can I get a call reference number please?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name and today's date, and the first initial to my last name is [PII].
[CUSTOMER][POSITIVE] OK perfect OK thank you so much.
[AGENT][NEUTRAL] You're welcome, [PII]. And again, all the information provided was a verification of benefits, not a guarantee of payment. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] No, that is all thank you.
[AGENT][POSITIVE] All right, thanks for calling APL. Have a great day.
[CUSTOMER][NEUTRAL] Mhm you too bye.
[AGENT][POSITIVE] Thank you. Bye bye.