AccountId: 011433970860
ContactId: 54aee03f-618d-4b23-a652-a89041a34505
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 316239 ms
Total Talk Time (AGENT): 153052 ms
Total Talk Time (CUSTOMER): 129757 ms
Interruptions: 1
Overall Sentiment: AGENT=1.9, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/13/54aee03f-618d-4b23-a652-a89041a34505_20250113T21:31_UTC.wav
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[AGENT][NEUTRAL] Hi, thanks for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi [PII], I'm calling from Eye Care Associates of South Tulsa. I'm needing to check benefits for a patient, um, and to see if you guys pay or if there's a deductible that needs to be satisfied first before you cover, um, what would you need for that?
[AGENT][POSITIVE] Yeah, absolutely. Can I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, 01457121.
[AGENT][POSITIVE] Wonderful, thank you. And while I'm pulling up that policy, do you mind if I get your first name and a good call back number?
[CUSTOMER][NEUTRAL] Yes, my name is [PII]
[CUSTOMER][NEUTRAL] And my direct line is [PII].
[AGENT][POSITIVE] Wonderful, thank you. And.
[AGENT][NEUTRAL] One more second and could you verify for me please your patient's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] Yes, [PII], [PII].
[AGENT][POSITIVE] Perfect. Thank you so much. And your patient is current and active with us and let me look at some of those benefits for you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, I do wanna let you know any benefit information I give you over the phone is going to be um a verification of coverage and not a guarantee of payment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] this way.
[AGENT][NEUTRAL] Mhm mhm.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Sorry, thanks for your patience while I was getting that all loaded. Um, so we are your insured secondary insurance, um, and so there's no copay on our part and it does not look like he has a deductible, but he does have an outpatient calendar year benefit of $2500.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So 2500. How does that work? So should we build community care that is first and then we send the claim to you guys and you will pay up to 2500.
[AGENT][NEUTRAL] Um, yes, so that, that's the like the max benefit amount in their calendar year. Um, what we do is we try to pick up and pay on anything that's applied to the copay, co-insurance or deductible for major medical as long as it's within the purview of their policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And so technically on our end as providers, we should build a community care in you first and then if it reaches the max, then the patient will be responsible.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] Is that correct?
[AGENT][NEUTRAL] I we at APL we can't determine patient responsibility because we're not their primary insurance um we're just a supplemental policy um so unfortunately we can't like make any call on patient responsibility but yes if you build their major medical and then you'll put the claim in with us and send us the EOB for major medical, anything we're able to pay on that claim we'll pay and then I guess from there.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's kind of out of our hands.
[CUSTOMER][NEUTRAL] OK, well, that's what I wanted to clarify because this is unusual like usually a secondary will have like a deductible amount the patient has to pay and then after that there's coverage for the remaining but in your case it's backwards, which I understand, um, so we're just gonna have to wait and see I guess what is the uh do you have a reference number from today?
[AGENT][NEUTRAL] Yes, we do. Well, it's my name [PII] and then today's date for the reference.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] You are expecting the provider to send the bill, right? Not the patient, just making sure.
[AGENT][NEUTRAL] Um, yes, well, we accept it from both. If you send us the claim, we will pay you and if the, um, insured sends us the claim, um, we'll pay the insured, but it's typically a lot easier um as providers because you have all of the itemized billings, um, to receive it from you all because you'll have all the right information.
[CUSTOMER][NEUTRAL] I understand
[CUSTOMER][NEUTRAL] If you get like the regular uh you bill for or the for the other one CMS uh form um that would be all right is that like just as a regular claim?
[AGENT][NEUTRAL] It just needs to have their diagnosis code, their, um, procedure codes, and then the total charge for each procedure code.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And then the explanation of benefits for major medical so we can look at how it's applied to their copay coinsurance and deductible, yep, yep.
[CUSTOMER][NEUTRAL] OK, yeah.
[CUSTOMER][POSITIVE] Right, right, exactly, OK, well that sounds good thank you so much [PII].
[AGENT][POSITIVE] Hey it's my pleasure. I'm really glad I could help today and if there's anything else you need, feel free to give us a call back OK?
[CUSTOMER][POSITIVE] Sounds good I will thanks.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][NEUTRAL] bye bye.