AccountId: 011433970860
ContactId: 377cd9ff-d1a3-4ba7-a329-52f98465336e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 331260 ms
Total Talk Time (AGENT): 182045 ms
Total Talk Time (CUSTOMER): 155104 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/24/377cd9ff-d1a3-4ba7-a329-52f98465336e_20250124T17:06_UTC.wav
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[AGENT][POSITIVE] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, hi, my name is [PII], and I'm a member of APL and I need to verify my benefits.
[AGENT][POSITIVE] I'm sure, [PII], I can assist you with your benefits. And first, I'll need a good callback number in case we're disconnected.
[CUSTOMER][NEUTRAL] Sure, [PII].
[AGENT][NEUTRAL] Thank you. Now, I need your policy number, please.
[CUSTOMER][NEUTRAL] I have a group number and I have a payer ID number.
[AGENT][NEUTRAL] Do you see the um outpatient certificate number on the card or maybe a benefit number?
[CUSTOMER][NEUTRAL] Which one
[CUSTOMER][POSITIVE] Yes, I do.
[AGENT][NEUTRAL] OK. What's that number?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] That I have two numbers. One is 02505772 M as in Mary, L as in Larry 8.
[AGENT][NEUTRAL] OK, that one pulled up your policy. And please verify your first and last name and your date of birth, please.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. Thank you. Now, please verify your mailing address and your email address to make sure that we have the correct ones on file.
[CUSTOMER][NEUTRAL] 8
[CUSTOMER][NEUTRAL] Sure, [PII].
[CUSTOMER][NEUTRAL] You need anything else?
[AGENT][NEUTRAL] Your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, ma'am. I'm showing the effective date on your policy was [PII] and the policy is still active.
[AGENT][NEUTRAL] And you have benefits for inpatient and outpatient hospital. Also benefits for the doctor's office visits, um, office treatments, and office co-pay. Um, which benefit do you need information on?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Well, first of all, the, um, in hospitals, what is the max and the outpatient, what is the max?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] For inpatient hospital, if you're ever admitted, um, we cover up to 7900 per calendar year and that's for the co-pay, co-insurance, and deductible after your primary insurance processes the claim. And let's see, for outpatient hospital services, um, if you go to the hospital but you're not admitted, we cover up to 2500 per calendar year and that's for the co-pay, the co-insurance, and the deductible.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] After your primary insurance. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] OK, perfect. And uh for doctor visits, I'm currently in a doctor's office and an endocrinologist, and I gave them the card and they pretty much didn't even want to accept it. They told me that it's not covered for any uh uh what is it, deductibles.
[CUSTOMER][NEGATIVE] And that they don't accept it, and that, you know, they were very rude to me here in the office, and I need somebody to call them and let them know that they're supposed to accept it, that they do pay for it.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] What is $60 or something like that?
[AGENT][NEUTRAL] OK. Yeah, I apologize. We don't, I apologize, we don't call the providers. They have to call us to verify the benefits, but I am showing that services provided in office is covered under your policy. And if they don't accept it, what, what you can do is pay upfront and then file the claim with us and we'll reimburse.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] You directly, but you must make sure that the services you're getting is related to an illness or an injury and that it is covered by your primary insurance company. Because if your primary insurance denied, then we automatically deny it. And again, it must be related to an illness or an injury.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes it is but.
[CUSTOMER][NEUTRAL] Yeah, it is, it's just that, you know, apparently they think that they have the same insurance and I guess they're they don't, you know, like the employees.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And that they don't accept, they don't have that coverage. So she didn't even call you guys or anything, she just, you know, took the card and said no we don't accept it, they don't pay for that. You need to pay the $60 which is not a big deal. I paid the $60. But it was the point that they're telling me that you guys don't even pay the, and I said yes, I think I have like $5 a year or something like that, that I get reimbursed, is that correct? Right. OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You have 4, you have 4 per calendar year and for specialist office visits, we cover up to 50 for your PCP we cover up to 25.
[CUSTOMER][NEUTRAL] Correct, and that's where I'm at in a specialist. I'm at a South Florida endo endocrine center. So, OK, no problem. What do I need to do to make sure that I get the money that the company, the, the doctor's office? How do I file the claim?
[AGENT][NEUTRAL] For the office visits.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK. Well, after um they file a claim with your primary insurance company, once you receive a copy of the explanation of benefits from your primary insurance company for this date of service, you'll need to send that to us along with your diagnosis code. The
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm mhm.
[AGENT][NEUTRAL] Diagnosis code is not preprinted on the explanation of benefits. So you can get that information from your doctor today and write it on the explanation of benefits and you could either mail us the information, you can fax it to us or you can file the claim online.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] sitting on this year.
[CUSTOMER][POSITIVE] OK, thank you very much. Thank you.
[AGENT][NEUTRAL] OK. Is there anything else that I can assist you with?