AccountId: 011433970860
ContactId: 36d11962-d774-4375-b0fc-5c01eeeb19e4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 380220 ms
Total Talk Time (AGENT): 202548 ms
Total Talk Time (CUSTOMER): 154823 ms
Interruptions: 2
Overall Sentiment: AGENT=0.5, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/24/36d11962-d774-4375-b0fc-5c01eeeb19e4_20250124T17:09_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling um from a provider's office. I have a patient here. Uh, she is stating that you guys cover 5 copays um with her policy, and I'm just trying to verify that because it looks like it's a hospital, uh, coverage.
[AGENT][NEUTRAL] Plan. OK. Yeah, let's take a look, [PII]. Do you have their policy number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I do. Um, did you want the in hospital or outpatient um ID number?
[AGENT][NEUTRAL] Honestly, either one works.
[CUSTOMER][NEUTRAL] OK, it's 02505772. M as in Mary, L as in Lima, 7.
[CUSTOMER][NEUTRAL] 7 or 8.
[AGENT][POSITIVE] Alright, let's see here. Thank you for that.
[CUSTOMER][NEUTRAL] Mhm, sure.
[AGENT][NEUTRAL] All right. And then if I could just verify patient's name and date of birth.
[CUSTOMER][NEUTRAL] Sure it looks like it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, date of birth is [PII].
[AGENT][POSITIVE] Alright, thank you so much. So patient plan is active. The effective date is [PII]. It is a secondary plan. I'm just gonna double check and see, we're looking for office visit fee, correct?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Correct for a specialist, yep.
[AGENT][NEUTRAL] OK. Yeah, some of these will cover the fee and some won't, so let me double check.
[CUSTOMER][NEUTRAL] Mhm. Sure.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] All right, so yeah, it looks like the plan does cover treatment in an office, however, it does not cover the physician office visit fee, so they would be responsible for that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] So it does not cover the copays.
[AGENT][NEUTRAL] Correct, it does not cover office visit fee, yes.
[CUSTOMER][NEUTRAL] OK, so what I'm not sure what she would be referencing where she has 5 visits. Do you see anything about that?
[AGENT][NEUTRAL] Um, sometimes it will like have a limitation.
[AGENT][NEUTRAL] One visit for me.
[CUSTOMER][NEGATIVE] Cause I'm gonna be honest with you, she's not the nicest person and she's like causing a scene in our waiting room saying, and that's OK.
[AGENT][POSITIVE] Oh, I'm sorry. Oh gosh.
[CUSTOMER][NEGATIVE] And I just, you know, I just wanna make sure before, you know, before I like tell her like, hey, I even talked to your insurance, you know, they're, they're definitely stating that no copay is covered.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, yeah, I mean, why, yeah, um, OK.
[CUSTOMER][NEUTRAL] I mean yeah.
[AGENT][NEUTRAL] I mean, we do have some plans that like, I wonder, let me just see if she ever had anything else with us.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Yeah, I mean, we do have some, I know that will, we do have some that cover the fee, you know, and they have like a limitation on like how many visits they can be seen for the year.
[CUSTOMER][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] If she's not completely.
[AGENT][NEUTRAL] You know,
[CUSTOMER][NEGATIVE] Yeah, right, but it definitely does not cover that, that's like she has a $60 co-pay with her primary insurance.
[AGENT][NEUTRAL] Um,
[AGENT][NEGATIVE] Right. No.
[CUSTOMER][NEUTRAL] She's stating that you guys pay that.
[AGENT][NEUTRAL] Yeah, and physician covered charges, it states incurred by a covered person because of an accident or sickness.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For necessary treatment, services, and supplies recommended by a physician incurred in a physician's office.
[AGENT][NEUTRAL] Physician cover charges do not include durable medical equipment, physical therapy, or physician office visit fee.
[CUSTOMER][NEUTRAL] That's the co-pay to me is what I would understand what a physician office visit fee is.
[AGENT][NEUTRAL] Yeah. Yeah. I mean, that's how I, right. And it defines physician office visit fee. The professional fee for the office visit when billed by a physician and incurred in a covered place or covered person's, yeah, office. So to me, that's stating it does not cover it. It's only gonna cover any treatment that she has like in the office, you know.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] So, um, um, what, what would that treatment fall under? like if she had like a biopsy or an ultrasound or something done here, not like a copay?
[AGENT][NEUTRAL] Right, exactly, um, or
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Because we would always bill an office visit every single time that she would be seeing us. We wouldn't just bill for like a a biopsy and ultrasound.
[AGENT][NEUTRAL] to think
[AGENT][NEUTRAL] Right, so
[CUSTOMER][NEUTRAL] There'd always be an office visit built.
[AGENT][NEUTRAL] Like you could bill us for the entire thing, whatever she had done in the office and the fee. We're gonna deny the fee though and just cover anything she had done in the office. Does that make sense?
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Gotcha. Well, I mean, kind of only because she has a primary insurance, so you guys wouldn't make a payment at all then there would be no covered because that would only be her responsibility left over and if you don't cover that, then.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] There's nothing else for you guys to pay, right?
[AGENT][POSITIVE] Yeah, true, correct.
[CUSTOMER][NEUTRAL] OK, so perfect then I just wanted to get that information so we have that on file um if I could just get a reference number.
[AGENT][NEUTRAL] References my name with my last initial and then today's date. My name is [PII], that's spelled [PII] Last initial to my name is [PII].
[CUSTOMER][NEUTRAL] My
[CUSTOMER][POSITIVE] OK perfect thank you so much.
[AGENT][POSITIVE] You're welcome. Have a good one, [PII].
[CUSTOMER][POSITIVE] Thanks you too.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.