AccountId: 011433970860
ContactId: 50efa6a5-d8b7-4771-9082-2b02ee56c35a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 302420 ms
Total Talk Time (AGENT): 139051 ms
Total Talk Time (CUSTOMER): 130568 ms
Interruptions: 0
Overall Sentiment: AGENT=1.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/07/50efa6a5-d8b7-4771-9082-2b02ee56c35a_20250107T14:28_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, we have some questions regarding um benefits and eligibility on the patient.
[AGENT][POSITIVE] It would be my pleasure to assist you. May I ask your name?
[CUSTOMER][NEUTRAL] My name is [PII]
[AGENT][POSITIVE] Thank you, [PII] and what is a good callback number?
[CUSTOMER][NEUTRAL] Um, it is.
[CUSTOMER][NEUTRAL] Sorry, [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, [PII]. And what is the policy number for the patient?
[CUSTOMER][NEUTRAL] The policy number is
[CUSTOMER][NEUTRAL] Hold on one second 02030118.
[AGENT][NEUTRAL] Thank you. And the patient's name and date of birth, please, ma'am?
[CUSTOMER][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] And date of birth is [PII].
[AGENT][POSITIVE] All right, thank you, and it would be my pleasure to assist you with benefits from Mr. [PII]. I am showing that his policy is active.
[AGENT][NEUTRAL] Effective date is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this is a secondary policy to his primary insurance.
[CUSTOMER][NEUTRAL] OK, so how will this work?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] So what type of benefits are you needing?
[CUSTOMER][NEUTRAL] So it's for ambulatory Surgery Center CPT code 37224.
[AGENT][NEUTRAL] OK, so he does have outpatient coverage up to 1, I'm sorry, $5000 per calendar year.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that is what we can pay toward his deductible, co-pay or co-insurance of his major medical.
[AGENT][NEUTRAL] Now there's also a $100 deductible that has to be met prior to those benefits being paid.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that is a verification of coverage and not a guarantee of payment. So once the primary has processed the claim, then you would send the claim documents to APL with the primary EOB showing what was applied to his deductible co-pay or co-insurance.
[CUSTOMER][NEUTRAL] OK, so once the primary process process the claim, please send EOB and documents to APL. OK, um.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] So with his Blue Cross, he has Blue Cross Primary, and with his Blue Cross plan, he has a $5000 deductible and a 30% co-insurance. So based off of that information, our estimate for him, he has not met anything on his deductible and he's met very little on his co insurance, so he still owes that 30% and so um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] We're showing that the patient responsibility is $4830 and so y'all cover up to $5000 of the plan, would we just submit everything to Blue Cross and then submit everything to y'all and y'all would cover that $4800? Is that how that would work?
[AGENT][NEUTRAL] Uh, if it's payable, yes, ma'am.
[CUSTOMER][NEUTRAL] How can we confirm whether or not it's payable?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Well I can't guarantee payment until we have processed the claim, but I can guarantee the benefits on his plan.
[CUSTOMER][NEUTRAL] OK, so, um, so essentially we should probably just collect $100 from him.
[CUSTOMER][NEUTRAL] To meet y'all's uh y'all's deductible correct?
[AGENT][NEUTRAL] Um, that would, we can't tell you what to collect. I'm sorry.
[CUSTOMER][NEUTRAL] So y'all has he had anything on his deductible with y'all?
[AGENT][NEUTRAL] He has not nothing met nothing used at this time for [PII].
[CUSTOMER][NEUTRAL] OK, um, and so you all will cover up to $5000 per calendar year for payable claims, um, and that's for coinsurance and deductible.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] And that is after that $100 deductible has been met.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I think we're good. Are you able to check CPT codes to see if it's payable?
[AGENT][NEUTRAL] Uh, this policy pays towards sickness or injury.
[CUSTOMER][NEUTRAL] Hm. What about medical procedures?
[AGENT][NEUTRAL] And if the pri
[AGENT][NEUTRAL] Yeah, that, that would be a sickness. And if the primary covers it and applies something to the deductible co-pay or co-insurance for sickness or injury procedure, then we can consider benefits as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you, can we have a reference.
[AGENT][NEUTRAL] It's been my
[AGENT][POSITIVE] Mhm. Reference number is my name and today's date, and I spell my name [PII], and it has been a pleasure to assist you with those benefits. Anything else I can help you with today, [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and it's 17:25.
[AGENT][NEUTRAL] Already, yes ma'am.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] It's been my pleasure to assist you, [PII]. Thank you for calling APL and have a wonderful day.
[CUSTOMER][NEUTRAL] OK, bye.