AccountId: 011433970860
ContactId: 49015282-95b0-4eeb-8b2d-06f98e107465
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 391850 ms
Total Talk Time (AGENT): 193576 ms
Total Talk Time (CUSTOMER): 161690 ms
Interruptions: 1
Overall Sentiment: AGENT=0.9, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/08/49015282-95b0-4eeb-8b2d-06f98e107465_20250108T22:05_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Good afternoon, [PII]. My name is [PII] and I am calling from a provider's office, and I just need to verify physical therapy benefits in an office setting.
[AGENT][NEUTRAL] In office. OK, well, I'll be more than happy to help you with the physical therapy benefits in the office setting. And [PII], may I have a good contact number in case we're disconnected and then the member's policy number?
[CUSTOMER][NEUTRAL] Certainly, um, it's a direct line, no extension, and that's [PII], and I'm sorry, what else did you ask for?
[AGENT][NEUTRAL] The member's policy number.
[CUSTOMER][NEUTRAL] 01888703.
[AGENT][POSITIVE] 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] [PII], [PII].
[AGENT][POSITIVE] Thank you for that and all 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]. And hold on one moment for me. I'm gonna get those um physical therapy benefits for you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You're welcome so I'm just waiting for it to come up here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So under outpatient, the the policy would pay up to $3000 per calendar year. There's no deductible.
[AGENT][NEUTRAL] Now, they do have physical therapy and a physical therapy facility. In an office visit setting, there is no coverage on this policy for any office visit settings. Um, they don't have the office treatment rider, which would have covered any treatment in the office as long as it should have covered any treatment in the office as long as it's not cosmetic, but they don't have that benefit here, so it's only physical therapy in a physical therapy facility.
[CUSTOMER][NEUTRAL] OK. Let me ask you this. Let me, and this, this is where it gets a little tricky, I think sometimes. Um, we are a, a physical therapy facility.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] However, we don't bill out patient we bill office setting but no office visit codes. In other words, we don't bill as a hospital because we're not a hospital or we're not associated with the hospital, um, so no office visit codes are billed it's strictly it's all physical therapy, nothing else. So I don't know if that means the same or.
[AGENT][NEUTRAL] Hospital.
[CUSTOMER][NEUTRAL] So it's not a, like a physician's office. It's a, it's a facility, a stand-alone facility, physical therapy, but
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] The coding
[CUSTOMER][NEUTRAL] Um, the coding, yes, it's it's professional charges.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] If that, you know, if that makes a difference.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] So the only way to honestly know is to go ahead and submit the claim and let the examiner um examine it because um I'm not a claims examiner, so I don't know what code they're looking for versus the other, but just for their policy, from what you're saying, it sounds like it should be fine because it is a physical therapy facility. We're looking more for like
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 99213 or 99214, you know, like those places service codes. So depending on how your coding is, I would say go ahead and submit the claim so that we can, we can process it because that's the only way we'll know for sure.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK, alright, um, OK, so pays, we'll let the patient know so pays up to $3000 for that's for all outpatient.
[AGENT][NEUTRAL] Yes, ma'am, for the whole year. Oh well, this is a plan year. So, hold on one moment.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] Alright, so the plan begins on [PII]. So [PII] of every year, it would, would uh restart.
[CUSTOMER][NEUTRAL] OK, so it started [PII].
[AGENT][NEUTRAL] 4.
[CUSTOMER][NEUTRAL] And then it will restart again on [PII].
[AGENT][NEUTRAL] Yes, that's correct. Um, did you want me to see if any of that 3000 has been used for this plan here?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, yes, please.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that's for all outpatient services, not just physical therapy, is that right?
[AGENT][POSITIVE] Right, that's correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So of the 3000, she she is $1,803 so she has $1,197 left for her plan year.
[CUSTOMER][NEUTRAL] Remaining. OK. All right. 1,197 remaining. OK. All right. Um, any authorization required?
[AGENT][NEUTRAL] No, ma'am, we don't require prior off um because we're not a major medical insurance.
[CUSTOMER][NEUTRAL] Got you. OK. um, and I'm probably there's not, this is probably a silly question, but are there any network restrictions or you just follow the primary insurance?
[AGENT][NEUTRAL] We're 2nd to the primary insurance, but in terms of following them, like our policy has its own, our policy has its own benefits, but yes, we are second to their primary, if that's what you mean.
[CUSTOMER][NEUTRAL] Guidelines.
[CUSTOMER][NEUTRAL] OK, but we don't have to see if we're in network with you.
[AGENT][NEGATIVE] Oh, no, no, no, for this policy, there's no network.
[CUSTOMER][NEUTRAL] OK. Oh, got you. All right. All right, [PII]. Well, I think you've answered all of my questions. Is there a reference number for our call today?
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name in today's date. Um, the first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] And again, just for the call, all the information provided was a verification of benefits, not a guarantee of payment. And [PII], was there anything else I can help you with today?
[CUSTOMER][POSITIVE] I think that covers everything, [PII]. I appreciate it. Thank you very much.
[AGENT][POSITIVE] Well, you're very welcome and thanks for calling APL and have a great day and happy New Year.
[CUSTOMER][POSITIVE] Thank you. Happy New Year, [PII]. Thank you. Bye-bye. Uh-huh. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye bye.