AccountId: 011433970860
ContactId: 40d676ae-b565-4e69-bd6f-07e31bee58b1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 388369 ms
Total Talk Time (AGENT): 190747 ms
Total Talk Time (CUSTOMER): 152640 ms
Interruptions: 3
Overall Sentiment: AGENT=1.2, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/40d676ae-b565-4e69-bd6f-07e31bee58b1_20250219T16:14_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, uh, my name is [PII], last initial [PII], and I'm calling from a provider's office to verify eligibility and benefits for patients.
[AGENT][NEUTRAL] OK, I see you're needing eligibility and benefits, is that correct?
[CUSTOMER][POSITIVE] That's correct.
[AGENT][POSITIVE] Yes ma'am, I can help you with those things. and [PII], what is the callback number for you please?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Thank you. And the member's policy number please, [PII].
[CUSTOMER][NEUTRAL] It's 01636012.
[AGENT][POSITIVE] Thank you one moment.
[AGENT][NEUTRAL] And any information [PII] that I do provide for you today would be a verification of benefits and not a guarantee of payment. What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] It's [PII]. Date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so I do show that she is the spouse of the subscriber of the supplemental policy, and this supplemental policy is active with an effective date of [PII].
[AGENT][NEUTRAL] And what type of benefit information do you need for her?
[AGENT][NEUTRAL] Or inpatient, outpatient or office?
[CUSTOMER][NEUTRAL] OK, um
[CUSTOMER][NEUTRAL] Um, it would be for, um, both office and for outpatient procedure.
[AGENT][NEUTRAL] OK, when you say for office this is for a procedure done in the office or an office visit?
[CUSTOMER][NEUTRAL] Yeah, she's coming in for a
[CUSTOMER][NEUTRAL] Yeah, she's coming in for a cataract evaluation. Um, so she would have a, uh, exam and testing for the cataract evaluation and then if she has cataracts, then it would be an outpatient procedure, um, for cataract surgery.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so office visits are not covered under this supplemental policy.
[AGENT][NEUTRAL] She does have an office treatment writer in which we could review the treatment rendered in the office under her outpatient benefit.
[AGENT][NEUTRAL] And as well as the surgery, the outpatient benefit max.
[AGENT][NEUTRAL] Per cover person is a per calendar day benefit and the max is $1500.
[AGENT][NEUTRAL] And there is no outpatient deductible per covered person per calendar day.
[CUSTOMER][NEUTRAL] OK, um, so her office visits.
[AGENT][NEGATIVE] Would not be covered.
[CUSTOMER][NEUTRAL] He would not be covered. Um, and then as far as the surgery, she's got a rider where it will be reviewed and if
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] Accepted then they would pay up to $1500 for anything done hospital outpatient.
[AGENT][POSITIVE] That would be, that is correct.
[CUSTOMER][NEUTRAL] And that would be per day because with cataract surgery, they're done.
[AGENT][NEUTRAL] The output per calorie.
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] I'm sorry. Um, for cataract surgery, each eye is done on a different date of service. So they'll come in and have the first eye done and then two weeks later, they'll have the second. So, is it only gonna cover one of the eyes per calendar year or will it cover both?
[AGENT][NEUTRAL] Oh, go ahead.
[AGENT][POSITIVE] Correct.
[AGENT][NEGATIVE] This is not a per calend OK this is not a per calendar year benefit on her outpatient. He outpatient is a per calendar day.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] So it would be one that would be the max.
[CUSTOMER][NEUTRAL] They're done separate days.
[CUSTOMER][NEUTRAL] OK, up to 1500.
[AGENT][NEUTRAL] That would be the max benefit per calendar day, yes ma'am, and because it is a supplemental policy [PII] to her primary insurance, when the claim is submitted to us for review, you must also send us a copy of her primary insurance company's explanation of benefits as well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then once we have processed our claim we do have a portal in which you should be able to check claim status and have access to our explanation of benefits for our review and our website for that is secured.
[AGENT][NEUTRAL] [PII].
[AGENT][POSITIVE] And I apologize about the scratchy voice.
[CUSTOMER][NEUTRAL] OK, and
[CUSTOMER][NEUTRAL] No, no, you're fine. Um, so another question, um, the surgeon's bill is separate than the facility bill?
[CUSTOMER][NEUTRAL] Um, is that $1500 total would be split with the surgeon and with the facility, or, um, would the surgeons not be covered?
[AGENT][NEUTRAL] Claims are processed.
[AGENT][NEUTRAL] Claims are processed in the order that they are received.
[AGENT][NEUTRAL] So that benefit, again, the max benefit would be $1500 per calendar day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so that, that would essentially be whoever gets the claim in first. So if, if surgeon gets in, then it would cover the surgeons first, um, as opposed to if the hospital gets their claim in.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Correct, but we will have to have a copy of the primary insurance explanation and benefits in order to review, uh-huh.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alrighty, so and and the benefits are paid to the provider and not directly to the patient, correct?
[AGENT][NEUTRAL] Correct, unless there's something different on the assignment of benefits.
[CUSTOMER][NEUTRAL] OK, alright, is there a reference number for the call?
[AGENT][NEUTRAL] Sure, you would use my name along with today's date.
[CUSTOMER][NEUTRAL] OK, and I'm sorry, what was your name again?
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, thank you so much. I appreciate it.
[AGENT][POSITIVE] Well, you are so yes ma'am, you're very welcome. So if that's all I can help you with, [PII], then thank you again for calling APL and I hope you have a great day.
[CUSTOMER][POSITIVE] You too, thank you.
[AGENT][POSITIVE] Yes ma'am thank you bye bye.
[CUSTOMER][NEUTRAL] Mhm bye bye.