AccountId: 011433970860
ContactId: 500603c1-68f3-47a9-8edc-e7cbd31dd277
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 319739 ms
Total Talk Time (AGENT): 178619 ms
Total Talk Time (CUSTOMER): 118335 ms
Interruptions: 1
Overall Sentiment: AGENT=1.4, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/26/500603c1-68f3-47a9-8edc-e7cbd31dd277_20250326T12:45_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, excuse me, I'm sorry. Hi, good morning, Miss [PII]. My, my name is [PII]. I'm calling from Doctor [PII]'s office, and I needed to verify, uh, eligibility and benefits for a member, please.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, well, I can help you with both the eligibility and the benefits. And how are you doing today?
[CUSTOMER][POSITIVE] I'm doing good and you?
[AGENT][POSITIVE] I'm doing good. I'm just a little sleepy. May I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, I have 02497629 ML 8.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] It is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] 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].
[AGENT][NEUTRAL] And what
[CUSTOMER][POSITIVE] I'm sorry, you said it was effective sense. I'm so sorry, Ms. [PII].
[AGENT][NEUTRAL] Oh, it's OK. Um, [PII].
[CUSTOMER][NEUTRAL] Of [PII]. OK, got it. I'm sorry.
[AGENT][POSITIVE] Yes, ma'am. So you're fine.
[AGENT][NEUTRAL] And what type of benefits did you want to go over?
[CUSTOMER][NEUTRAL] So she, I, I just needed to know, uh, she, uh, like she, she's gonna have ultrasounds. She's pregnant right now.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And she's gonna have ultrasounds and, and her delivery and everything, delivery, the place of service will be inpatient hospital. Uh, ultrasounds will be done in the specialist office and then she has uh a deductible. I called the primary insurance, which is Aetna, uh, to get benefits and everything, um, applies to her deductible.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So the patient, I, I didn't know if you covered uh any of that.
[AGENT][NEUTRAL] Oh, so you just want to know how our policy works with the primary for her for what she's doing.
[CUSTOMER][NEUTRAL] Anything done in office or?
[AGENT][NEUTRAL] Or needing, right? OK. So our policy pays towards the copay, deductible and co-insurance of covered charges after primary. So our um policy is broken down into inpatient and outpatient, so she won't use any of the inpatient until she gets ready to have the baby. That max calendar year max is $7900.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Did you want me to see, um, when I tell you the benefits, did you want me to see if she's used any for the year?
[CUSTOMER][POSITIVE] Yes please.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, hold on one second. So let me check for out I mean inpatient.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Oh, so she hasn't used any of the benefits at all, so she has everything. OK. So inpatient.
[AGENT][NEUTRAL] After she's admitted, the 7900, she still has that full balance for the year for outpatient her specialist visits. Now, the policy itself doesn't have any coverage for like the for like the facility charge, so like 99213, 99214, but she does have the office treatment rider, so any treatment done in the office can be covered.
[AGENT][NEUTRAL] Um, this, the outpatient max is also $7900 a year, so she still has that full balance too. So if you, it depends on the facility, if y'all, you know how some places charge a facility charge and then charge for the treatment.
[AGENT][NEUTRAL] If you, if you charge a facility or you bill us for a facility that will most likely be denied because there's no in-office coverage, but because of this rider, her treatment can be covered.
[CUSTOMER][NEUTRAL] For the street here.
[CUSTOMER][NEUTRAL] So her ultrasound, like she'll have it, she's gonna, she's scheduled to have an ultrasound on Monday.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Would, would, and she has a deductible. I mean, I, I don't know if you need the CPT codes or not, but I do have the CPT code for the ultrasound, um, and for her ultrasound, I'm sorry, I misspoke. I said it was deductible, but it's a co-pay. She has a copay for her ultrasound. Would you cover the copay or is that patient responsibility?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so how it works, so you'll go ahead and bill Aetna first, Aetna will apply. If the patient is required to pay the copay upfront to get the services, then on the back end, once you file the claim with us, um, the patient can be reimbursed for paying that co-pay out of that 7900 or something still owed to y'all after Aetna applies, you know, we have up until that $7900 to pay out to you or the or the patient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Autop patient got it OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it. OK.
[CUSTOMER][NEUTRAL] And then my last question is and is, may I have a reference number for our call, please.
[AGENT][NEUTRAL] Oh, sure. So there's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][POSITIVE] Got it thank you so much.
[AGENT][POSITIVE] You're welcome, Mr. [PII]. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No ma'am, that was it.
[AGENT][POSITIVE] Alright, well, thank you so much for calling [PII]. I hope you have a great day.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.