AccountId: 011433970860
ContactId: 34a599bc-e227-462a-997c-092c8c0ebf83
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 398579 ms
Total Talk Time (AGENT): 194862 ms
Total Talk Time (CUSTOMER): 165140 ms
Interruptions: 4
Overall Sentiment: AGENT=0.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/13/34a599bc-e227-462a-997c-092c8c0ebf83_20250613T18:04_UTC.wav
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[AGENT][NEUTRAL] Calling APL, my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] Yes, hi [PII]. I have a patient, um, who is telling me that Medlink will cover her copay from her primary. Are you able to assist me with verifying her benefits and if we are in network?
[AGENT][POSITIVE] I'd be happy to assist with benefits and eligibility today if I can get a good call back number for you.
[CUSTOMER][NEUTRAL] [PII] option one.
[AGENT][NEUTRAL] And what is the policy number?
[CUSTOMER][NEUTRAL] The policy number is 02545746.
[AGENT][NEUTRAL] Patient's name and date of birth.
[CUSTOMER][NEUTRAL] Patient's name is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Thank you for that information. Please be advised the verification of coverage is not a guarantee of payment. I do show the policy is currently active. Effective date is [PII]. Now I do show with her policy, um, only the treatment and procedures at the visit would be covered. The physicians, the co-pay associated with the physician's charges is not.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, say that one more time to me.
[AGENT][NEUTRAL] Treatment and procedures at the visit is covered. The the copay that's associated with the physician's charges is not.
[CUSTOMER][NEUTRAL] OK, the patient seems to think that you cover her copay.
[CUSTOMER][NEUTRAL] So I, I just wanna make sure I understand you. She's a physician herself and so what you're telling me is that the treatment and the procedures would be paid for in the set in the event her primary.
[CUSTOMER][NEUTRAL] Um, whether she exhausts her benefits or whether or not the pri primary, uh, denies, then you would cover the treatment and procedures, however, the co-pay.
[CUSTOMER][NEGATIVE] Is not covered.
[AGENT][NEUTRAL] So she's a physician, so just explain to her when she submits the bill and she say she submits it with 99213 and CPT code 45381. We're gonna cover the 45381. We're gonna deny the 99213 because the 99213 is the physician's charges and that's normally associated with her co-pay. She has, I don't know what her co-pay is for office visits, but that's what's not covered. But anything that's done, OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][MIXED] OK, it's $40 but OK.
[AGENT][NEUTRAL] So she would pay that $40 now if there's something done at the visit that you're billing for, so whatever other CPT code that you're billing for that if if something happens at the visit, that's what we're gonna cover.
[CUSTOMER][NEUTRAL] OK, so she has primary insurance that will cover.
[CUSTOMER][NEUTRAL] So when would the secondary pick up?
[CUSTOMER][NEUTRAL] When would meddling pick up, so she has Aetna as her primary, and then she handed me this other card and said this should take care of everything else.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] That's what she's claiming.
[AGENT][NEUTRAL] OK, so the best way I can explain it is you bill Aetna, so she's coming in for just a visit, nothing else, just.
[AGENT][NEUTRAL] Just a visit.
[CUSTOMER][POSITIVE] Correct, she's coming in for physical therapy.
[AGENT][NEUTRAL] Oh, wait, now that's something different.
[CUSTOMER][NEUTRAL] So we build 4 CPT codes mhm.
[AGENT][NEUTRAL] OK, now, OK, that's different, that's different. So for physical therapy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, we're gonna pay, we're gonna, so that, but I mean the same.
[AGENT][NEUTRAL] The same, it it applies the same thing applies.
[AGENT][NEUTRAL] Everything is covered at the office visit?
[CUSTOMER][NEUTRAL] So the patient is responsible for her co-pay?
[AGENT][NEGATIVE] Co-pay meaning associated with physicians charges like 99213, 99214, but you're talking about her having physical therapy. That, that's not.
[AGENT][NEUTRAL] Uh, that's not anything associated with physician's charges. That's treatment.
[CUSTOMER][NEUTRAL] So the copay is associated with her primary plan.
[AGENT][NEUTRAL] OK, what, so when you send the bill, what CPP card, just answer me this.
[CUSTOMER][NEUTRAL] So the plan will pay mhm.
[CUSTOMER][NEUTRAL] What CPT codes? Yes.
[AGENT][NEUTRAL] What CPT code are you gonna bill Aetna? Let's start there.
[CUSTOMER][NEGATIVE] OK, 90 my god, I just totally lost my train of thought. 90 my god, what's wrong with me?
[CUSTOMER][NEUTRAL] Hold on one second, OK, 971-61.
[AGENT][POSITIVE] That's covered 100%.
[CUSTOMER][NEUTRAL] 971-1 and then very.
[CUSTOMER][NEUTRAL] OK, and then 97112.
[AGENT][POSITIVE] That's covered at 100%.
[CUSTOMER][NEUTRAL] 9 97,110.
[AGENT][NEUTRAL] That's covered at 100%?
[CUSTOMER][NEUTRAL] And 971-40.
[AGENT][NEUTRAL] That's covered at 100%. Now had you included 99213?
[AGENT][NEUTRAL] I would have said no that would be denied.
[AGENT][NEUTRAL] Because that is the office visit charges, the physician's charges, we don't cover that, but anything else that is done at the visit that is considered treatment or procedures is covered at 100% up to her out of patient max of $2500.
[CUSTOMER][NEUTRAL] OK, so we don't mhm.
[CUSTOMER][NEUTRAL] OK, so I completely understand you, however, we're going to bill Aetna first.
[AGENT][NEUTRAL] Exactly. We're, we're her gap.
[CUSTOMER][NEUTRAL] Aetna will leave a patient responsibility of $40 that is her co-payment according to the plan that she has purchased. So what she's telling me is that you all are responsible for the $40 copayment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So after you receive the EOB from Aetna, you're gonna bill us you're gonna send us a claim form and that explanation of benefits and then we're gonna pay that $40.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, so then she's correct. OK, great. And do we need to be in network with you or you only pick up what Aetna does not? OK, perfect.
[AGENT][NEUTRAL] We don't have a network.
[AGENT][NEUTRAL] We
[AGENT][NEUTRAL] We don't have a network we work in conjunction with them so if you're in network with them, you're in network with us.
[CUSTOMER][NEUTRAL] Got it. What is your name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh, [PII], and is there a reference number I can have for this call?
[AGENT][NEUTRAL] Reference is just my name and today's date and time.
[CUSTOMER][POSITIVE] OK great I really appreciate your help.
[AGENT][NEUTRAL] OK, was there anything else I could assist with today?
[CUSTOMER][NEUTRAL] No, that's everything.
[AGENT][POSITIVE] OK, thank you for calling APL you have a good day.
[CUSTOMER][NEUTRAL] OK, you too.
[AGENT][NEUTRAL] Mhm. Bye bye.