AccountId: 011433970860
ContactId: 5376aa9b-9e2f-4148-9636-845ed7edc901
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 349859 ms
Total Talk Time (AGENT): 175216 ms
Total Talk Time (CUSTOMER): 117916 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/5376aa9b-9e2f-4148-9636-845ed7edc901_20250109T19:03_UTC.wav
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[AGENT][NEUTRAL] Good afternoon, thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] What is Apia?
[CUSTOMER][NEUTRAL] I see, see them.
[CUSTOMER][NEUTRAL] Hi, good afternoon, I'm calling from Gastro Health. Um, if you don't mind pulling up, um, a mutual patient account and see if you guys cover in office procedures, please.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, you're needing to see if the member has benefits for office procedure, procedures done in the office rather?
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Right.
[AGENT][POSITIVE] Yes, ma'am. I can help you with that. And who am I speaking with?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And [PII], what is your callback number?
[CUSTOMER][NEUTRAL] Um, [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And what is the member's policy number, please?
[CUSTOMER][POSITIVE] Oh, so you're ready now.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] 02006460.
[CUSTOMER][NEUTRAL] ML 7.
[AGENT][NEUTRAL] OK, thank you. One moment, please.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And [PII], any information that I do provide for you today will be a verification of benefits and not a guarantee of payment. What is your patient's name and their date, excuse me, and their date of birth?
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] Um, name is.
[AGENT][NEUTRAL] Can you put out.
[CUSTOMER][NEUTRAL] [PII], last name [PII].
[CUSTOMER][NEUTRAL] Date of birth [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And you said that you didn't need eligibility, you only needed?
[AGENT][NEUTRAL] Tone benefits, is that correct? OK.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] Yes ma'am, thank you.
[AGENT][POSITIVE] Uh huh you're welcome.
[AGENT][NEUTRAL] Uh, bear with me just one moment, [PII].
[AGENT][NEUTRAL] Waiting on one of my screens.
[CUSTOMER][NEUTRAL] And with that
[AGENT][NEUTRAL] OK, so on this member's plan.
[CUSTOMER][NEUTRAL] So yeah your thing.
[CUSTOMER][NEUTRAL] I'm sorry, I'm here.
[AGENT][NEUTRAL] That's OK. So on this member's plan, yes, ma'am, he does have a rider for treatment.
[AGENT][NEUTRAL] Office treatment. He does have an office treatment writer on the policy and the outpatient this would fall under.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is outpatient benefit.
[AGENT][NEUTRAL] And that
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm talking in my system is is not moving at the same pace that I'm trying to give you your information. So the outpatient benefit maximum per calendar year for covered outpatient services is $6350 and there is no outpatient deductible.
[CUSTOMER][NEUTRAL] 6500.
[AGENT][NEUTRAL] Mhm, 6350.
[CUSTOMER][NEUTRAL] No, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And again there is no outpatient deductible.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And when the claim is submitted to APL Janea, we do have to have a copy of the primary insurance company's explanation of benefits as well.
[AGENT][NEUTRAL] For review
[AGENT][NEUTRAL] And then also we have a portal at APL that once we have processed the claim you can check claim status and have access to the EOBs.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] By going to [PII].
[CUSTOMER][NEUTRAL] So question um because it's not really like an.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I understand the information which is great because I'm gonna put it onto his file, but my question is, um, because he's here for an appointment, he's gonna see a colorectal surgeon. If the doctor decides to do any last minute procedures here in the office, I just wanna make sure, um, because his deductible on his primary.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And again, I can't guarantee.
[AGENT][NEUTRAL] Uh-huh. Go ahead.
[CUSTOMER][NEUTRAL] No, because, um, because we have a set fee, so I, um, he wanted to know if his secondary insurance covers.
[CUSTOMER][NEUTRAL] His primary deductible fee that we're, you know.
[AGENT][NEUTRAL] Yes, ma'am, and I cannot, right, and I cannot guarantee payment of benefits over the phone that would be processing a claim. We will have to receive the claim.
[CUSTOMER][NEUTRAL] um asking for.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Along with his primary insurance company's explanation of benefits for that to be reviewed.
[AGENT][NEUTRAL] Uh, the office visit isn't covered under this policy, but we can review treatment.
[CUSTOMER][POSITIVE] Got it OK.
[AGENT][NEUTRAL] That's done in the office under that outpatient benefit max that I provided for you.
[CUSTOMER][POSITIVE] Got it. OK, no problem.
[AGENT][NEUTRAL] OK. Well, is there anything else that I can help you with today, [PII]?
[CUSTOMER][NEUTRAL] No, ma'am, is there a reference number to this call?
[AGENT][NEUTRAL] Yes, ma'am, you would use my name that I gave you along with today's date.
[CUSTOMER][NEUTRAL] I'm so sorry, what was your name again?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Thank you Ms. [PII] you have a great rest of your shift, OK?
[AGENT][NEUTRAL] Hm
[AGENT][POSITIVE] Yes, ma'am. Uh, yes, you too, [PII], and thank you again for calling APL.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You too, bye.