AccountId: 011433970860
ContactId: 4858a4a9-5f70-40b1-8501-07acda9b88b8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1207319 ms
Total Talk Time (AGENT): 397401 ms
Total Talk Time (CUSTOMER): 432994 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/14/4858a4a9-5f70-40b1-8501-07acda9b88b8_20250314T15:23_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Good morning, good morning. Sorry. Hi, [PII]. My name is [PII]. I'm calling from Pediatric Associates.
[CUSTOMER][NEUTRAL] Trying to check um.
[CUSTOMER][POSITIVE] I would say benefit for a couple of patients.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the benefits and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] OK. The first one is 01982130 ML.
[CUSTOMER][NEUTRAL] 8, the number 8.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], let me see what is [PII], I don't know.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So, for this particular policy, it's no longer policy number. Um, it's no longer active as of [PII], but there is an active policy. Let me get that policy number for you. Hold on one moment.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] OK, so policy number 2502676.
[AGENT][NEUTRAL] Um, has been active since [PII].
[CUSTOMER][NEUTRAL] OK. OK. Can you, I need to verify if I know you usually cover deductible and co-insurance, sometimes it's only for hospital, but in this plan in particular, do you cover visit like office visit, deductible?
[AGENT][NEUTRAL] So if you bill in terms of like facility or place of service, there will be no coverage, but the insured has the office treatment rider, which the treatment in the office would be covered up to $2500 per calendar year. And you know what, this one actually may have the office visit fee. Hold on one second, let me pull up the whole um breakdown.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so they have the office treatment rider which would pay up to that $2500 per year, and then they also have the office visit fee rider, so the um for phys you said physician or specialist.
[CUSTOMER][NEUTRAL] Um, we have both. We have a physician and sometimes a specialist too.
[AGENT][NEUTRAL] So for a physician, um, it would be up to $25 per visit towards the facility charge. Um, we would pay up to 4 visits per calendar year. For the specialist it's the same, but up to $50 per visit.
[CUSTOMER][NEUTRAL] OK, but you do cover cause I know most of the time you don't. That's why I'm checking. I have 4 different patients that I need to check. So this one is a yes. You do cover. I called before with 4 patients or none of them have um visit.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Had it, oh Lord.
[CUSTOMER][NEUTRAL] Oh, OK. So let me go to my next one. Give me a second.
[CUSTOMER][NEUTRAL] The next ID number. Let me know when you're ready for the next ID.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, the next member's policy number?
[CUSTOMER][NEUTRAL] I'm sorry. It's 018.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 41849.
[CUSTOMER][NEUTRAL] ML 7.
[AGENT][NEUTRAL] Thank you. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] Thank you. And again, just for the call, the information provided is a verification of benefits, not a guarantee of payment. And I am showing the policy is active, it's been effective since [PII].
[AGENT][NEUTRAL] Yeah, let me look for this one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] So for this one, it doesn't have any coverage at all. It doesn't have the office treatment rider or the um physician office fee rider.
[CUSTOMER][NEUTRAL] Just hospital, not that one.
[AGENT][NEUTRAL] Inpatient and outpatient mhm.
[CUSTOMER][NEUTRAL] OK. On patient.
[CUSTOMER][NEUTRAL] OK. Let's go to the next one because I have 4 patients.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, the next one is [PII], and her, oh sorry, the ID number is [PII] and the number 5.
[AGENT][NEUTRAL] OK, hold on one moment. Let me note this policy and then I can move on to the next one.
[AGENT][NEUTRAL] OK, and then can you verify the member's date of birth?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Birthdays for [PII], [PII].
[AGENT][POSITIVE] Thank you for that. And let me see, this policy.
[AGENT][NEUTRAL] This policy is no longer active. It was effective from um [PII].
[AGENT][NEUTRAL] And there's no other policies with APL.
[CUSTOMER][NEUTRAL] What? [PII]? Wow.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Oh wow.
[CUSTOMER][NEUTRAL] So terminated by [PII]. This one is for [PII].
[CUSTOMER][NEUTRAL] On [PII]. 0 my goodness.
[CUSTOMER][NEUTRAL] This is crazy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, let me move on to, let me see who's the next one. Hold on.
[CUSTOMER][NEUTRAL] Um, where are you?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And then the next one is this one.
[CUSTOMER][NEUTRAL] Uh, next one, the ID number is 01611.
[CUSTOMER][NEUTRAL] 564 ML and the number 8.
[AGENT][NEUTRAL] Thank you. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] Thank you for that. And let me see, this policy has been active for a scholar since [PII]. It's still active. And let me look at the coverage. Hold on one moment.
[AGENT][NEUTRAL] OK, so this, um, so for the facility charge itself, there's no um office visit rider, but they do have the office treatment rider. So the treatment in the office as long as it's not cosmetic, could be covered up to the $1500 per calendar year.
[CUSTOMER][NEUTRAL] So, like, like a sick office visit, I would say that would be covered.
[AGENT][NEUTRAL] So, in terms of the office visit, is not the service, it's not the place of service, it's what's being done. So as long as it's treatment and not cosmetic, if it's in the office, the office treatment writer will help.
[CUSTOMER][POSITIVE] Yeah, perfect.
[CUSTOMER][POSITIVE] So say yes for this one.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I probably have more, but I don't wanna keep doing so many.
[CUSTOMER][NEUTRAL] Up to how many claims can you check for me?
[AGENT][NEUTRAL] Claims, um, well, however many you need.
[CUSTOMER][NEUTRAL] I mean, no claims, sorry, like eligibility.
[CUSTOMER][NEUTRAL] Uh, I have like
[CUSTOMER][NEUTRAL] 3 more.
[AGENT][NEUTRAL] OK. And what's the policy number?
[CUSTOMER][NEUTRAL] Give me 1 2nd, hold on.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, let me bring that up because I wasn't gonna do all of them, just 4 because.
[CUSTOMER][NEUTRAL] But I only see 3 more left, so probably I can just do those 3.
[CUSTOMER][NEUTRAL] 51, hold on one second.
[CUSTOMER][NEUTRAL] OK. The next ID number that I have is 02141662ML and the number 8.
[CUSTOMER][NEUTRAL] S for [PII].
[CUSTOMER][NEUTRAL] Hi, [PII].
[CUSTOMER][NEUTRAL] And birthday is [PII].
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][POSITIVE] All righty. Thank you so much for verifying his information and let me see.
[AGENT][NEUTRAL] So this particular policy is no longer active. Um, it was effective from [PII], but there is an active policy. Um, let me get that number for you.
[AGENT][NEUTRAL] OK, so it's 249-768-6.
[AGENT][NEUTRAL] And let me pull up the big one also for this one because this one has both the office treatment rider and the office visit fee.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The calendar year max for this policy is 7900.
[AGENT][NEUTRAL] And let me see what the, if the dollar amount is different from the other. Hold on one moment.
[AGENT][NEUTRAL] OK, so yes, it's the same, 25 for physician office visit fee and then for um the specialist is up to 50.
[CUSTOMER][NEUTRAL] OK, and you said the new policy effective is [PII].
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That was for [PII].
[CUSTOMER][NEUTRAL] Now, 2 more. OK. My next 1, 01.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Next one is [PII].
[AGENT][NEUTRAL] All right. And the next policy number?
[CUSTOMER][NEUTRAL] It's 00192.
[CUSTOMER][NEUTRAL] 3355 ML, then number 7.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] S for [PII] [PII].
[AGENT][POSITIVE] Thank you for that. Hold on one moment.
[AGENT][NEUTRAL] So this policy has been effective since [PII].
[AGENT][NEUTRAL] I'm sorry, since
[AGENT][NEUTRAL] Hold on.
[AGENT][NEUTRAL] The screen switch right when I was saying the date. Sorry. Um, for [PII], the policy has been effective since [PII], his birthday. Um, and let me look at the benefits for you.
[CUSTOMER][NEUTRAL] [PII] of saint's birthday [PII].
[AGENT][NEUTRAL] So for this policy, they have the office treatment rider, but not the office visit fee rider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And their calendar.
[CUSTOMER][NEUTRAL] OK, so it's a no.
[AGENT][NEUTRAL] Well, I mean, it's not a no. If you bill for treatment, you can use the treatment rider.
[AGENT][NEUTRAL] If you bill for the
[CUSTOMER][NEUTRAL] But I mean,
[CUSTOMER][NEUTRAL] We're gonna be for an office visit. This is all we do here, like sick and well visit.
[AGENT][NEUTRAL] Right, but that's just a code 99213 or whatever the place of service code is. So that code could be denied by all the treatment that you're doing in the office you can bill for and use the rider.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah, I know, but
[AGENT][NEUTRAL] So it would be up to.
[CUSTOMER][NEUTRAL] Yeah, but what I
[CUSTOMER][NEUTRAL] See, the thing is that everything that I, well, yeah, I have a treatment for one. OK. Yeah. Mhm.
[CUSTOMER][NEGATIVE] Oh, what a mess. So this one is for the treatment, but not all, but not the visit.
[CUSTOMER][NEUTRAL] Yeah, I know, but most of the times, we only do like the regular office visit, well, there's a vaccine, um, treatment, we don't really do that much.
[CUSTOMER][NEUTRAL] That's why.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Yeah, it's mostly office visit.
[CUSTOMER][NEUTRAL] That's it. Well, I'm sick, they said, and vaccines.
[CUSTOMER][NEUTRAL] But in this one, I see we did an X-ray.
[CUSTOMER][NEUTRAL] I don't know if that one is gonna be part of the.
[CUSTOMER][NEUTRAL] Treatment.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, if it's, if it's an X-ray, um, I mean,
[AGENT][NEUTRAL] Yeah, that's a part of treatment. It's just diagnostic testing, but that's what you did to treat or help the, the patients. So, um, I mean, the only thing that would guarantee it is to, to file the claim, but they do have the office treatment writer and $1000 per day.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, I'm gonna do, gonna just build both the visit and this one and
[CUSTOMER][NEUTRAL] If it's dinner, it's dinner.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] We build the patient. Oh, I mean, I did 4 before, none of them has it, and now I'm checking and most of them do have it, so it's like, wow.
[AGENT][NEUTRAL] So it depends on the day.
[CUSTOMER][NEUTRAL] I see. Uh, OK. So I have a last station. Give me a second. Uh it's for me.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 37 82 190.
[CUSTOMER][NEUTRAL] OK, this one is 02272799 ML and the number 8.
[CUSTOMER][NEUTRAL] And the patient is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And her date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And again, just for the call, all the information provided is a verification of benefits, not a guarantee of payment. And so the policy for [PII] has been active since [PII]. And let me see her benefits. Hold on one second.
[AGENT][NEUTRAL] Um, so, so this policy has the office treatment rider, but it doesn't have the office fee rider.
[CUSTOMER][NEUTRAL] Mm, they sent us the other one.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Let me see, do I have any treatment on this one?
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Only visit. OK, so this one is patient responsibility.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] OK. And I guess the reference number for you is usually your name and date, right?
[AGENT][NEUTRAL] Yes, and the first initials of my last name is [PII].
[CUSTOMER][NEUTRAL] Uh, what is your timely filing?
[AGENT][NEUTRAL] There's no timely filing limit as long as the policy is active on the data service, you can file at any time.
[CUSTOMER][POSITIVE] Oh wow.
[CUSTOMER][NEUTRAL] No timely [PII]. Uh, how can we send the claim? Can we fax it to you? Or it's an email?
[AGENT][NEUTRAL] No, you can fax it, you can send it electronically or you can mail it to us.
[CUSTOMER][NEUTRAL] Oh email.
[AGENT][NEUTRAL] Did you need the fax number?
[CUSTOMER][NEUTRAL] OK, please.
[AGENT][NEUTRAL] OK, so it's 877.
[AGENT][NEUTRAL] 365.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 942 3.
[AGENT][NEUTRAL] And that's attention, APL claims department.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][POSITIVE] Perfect. Thank you so much and have a good day.
[AGENT][POSITIVE] You're very welcome, [PII]. Was there anything else I can help you with?
[CUSTOMER][POSITIVE] Nope, you helped me more than enough. Thank you, thank you, thank you. Enjoy your weekend.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] You're welcome. Well, thanks for calling ACL. You also have a great weekend. Bye-bye.
[CUSTOMER][POSITIVE] Thanks. Bye-bye.