AccountId: 011433970860
ContactId: 56561a9f-3d12-4759-b80c-fb246c8f8feb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 598650 ms
Total Talk Time (AGENT): 275741 ms
Total Talk Time (CUSTOMER): 210816 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/14/56561a9f-3d12-4759-b80c-fb246c8f8feb_20250314T14:36_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, good morning, [PII]. My name is [PII]. I'm calling from a provider's office in regards of the patients to obtain eligibility and benefits for.
[AGENT][POSITIVE] Alright, [PII], I'm happy to check on eligibility and benefits.
[AGENT][NEUTRAL] Um, do you have the patient's policy number?
[CUSTOMER][NEUTRAL] Yes, one second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It is 02595548.
[AGENT][POSITIVE] All right, thank you so much. Let me take a look here one moment.
[AGENT][NEUTRAL] And if I can get the patient's name and date of birth?
[CUSTOMER][NEUTRAL] It is uh uh [PII] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Thank you. All right. The patient is active. The effective date is [PII].
[CUSTOMER][NEUTRAL] The [PII]. OK, um, I'm not too familiar with this insurance. Uh, would you guys be like connected with like multiplan or PHCS?
[AGENT][NEUTRAL] Let me pull, let me pull up the member's plan here and see if you guys need a fax back with a breakdown of benefit star we can also send that um let me see here.
[CUSTOMER][NEUTRAL] Or any of those?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] It looks like the members plan does participate in the Carrington PPO network. Um, it's not required for for usage.
[CUSTOMER][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] I'm sorry, can you just repeat that again? I'm sorry, the Carrington.
[AGENT][NEUTRAL] Yeah, no, that's yep, Carrington, so C A R E I N G T O N PPO network.
[CUSTOMER][NEUTRAL] Is OK, is that dental?
[AGENT][NEUTRAL] It's dental. Are you looking for medical?
[CUSTOMER][NEUTRAL] Yes, we are medical.
[AGENT][NEUTRAL] OK. Your medical. Well, that would make sense why you're confused. Let's see.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, cause I've never heard this insurance are called before, so I'm not even sure if we're in network out of network.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. What's the patient being seen for star?
[CUSTOMER][NEUTRAL] So we're a podiatrist. He's coming in for an ingrown.
[AGENT][NEUTRAL] OK, see here.
[AGENT][NEUTRAL] All right, that number you gave me is their dental policy. Do you want their medical policy card or number?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK. So the medical is going to be [PII].
[AGENT][NEUTRAL] 5546.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, um, is there a certain, a number that I called to get the eligibility and benefits or to know if we're in network?
[AGENT][NEUTRAL] So I can give you eligibility and benefits. The active date on this is the same as the dental. It's [PII]. The member has a limited benefit medical plan, so it's called a hospital indemnity plan.
[AGENT][NEUTRAL] It pays a set amount just depending upon what they're being seen for so there's no percentages, no network required for usage. So if the patient's coming in for a physician's office visit.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The plan's going to pay $50 for the visit, and they're allowed 4 visits in a year.
[CUSTOMER][NEUTRAL] OK, so the insurance bills the patient since they, we don't charge them nothing the or is that their co-pay $50?
[AGENT][NEUTRAL] So it's not a co-pay. Whatever that physician charges for the office visit, this plan is going to pay $50 towards that visit, whatever the cost is.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 50
[CUSTOMER][NEUTRAL] OK, because usually I think the office he's a new patient, so it's like $175 so you guys only pay $50 of that $175 basically.
[AGENT][NEUTRAL] Right, we pay $50 towards the visit. Now, if they're having surgery, or it's considered surgery in a physician's office.
[AGENT][NEUTRAL] It's gonna pay $250 towards that.
[AGENT][NEUTRAL] And they're allowed a maximum of 2 days in the calendar year for any surgery in a physician's office.
[CUSTOMER][NEUTRAL] OK. How about um any like DME or orthotics? Would you guys cover those or no?
[AGENT][NEUTRAL] Let me see if any medical equipment's covered here.
[AGENT][NEUTRAL] I don't see any sort of medical equipment listed on here. The only thing I see is diagnostic testing. If they had any sort of medical imaging, there is a benefit for that.
[CUSTOMER][NEUTRAL] OK, so DME not covered, um, and then as far as like being in network out of network, who would be the payer for, um, APL? Would it be like MagnaCare, Aetna, or?
[AGENT][NEUTRAL] So let's see.
[AGENT][NEUTRAL] So as far as submitting claims and all of that, I can give you that information as far as where they go to in the payer ID. Do you need that information?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So to submit claims they go to attention IMA.
[AGENT][NEUTRAL] And that's at [PII].
[AGENT][NEUTRAL] And that's in [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And then the payer ID is 64556.
[CUSTOMER][NEUTRAL] 645.
[CUSTOMER][POSITIVE] OK perfect um.
[CUSTOMER][NEUTRAL] And would APL be their primary insurance?
[AGENT][NEUTRAL] We don't have that information. Honestly, if the insured has another insurance, you would have to check with them.
[CUSTOMER][NEUTRAL] OK, so referred to member, no worries. Um, do they need any referral to see a specialist?
[AGENT][NEUTRAL] No, no referral or pre-op required.
[CUSTOMER][NEUTRAL] OK, no referral, no offs and OK, perfect. And would we be out of network?
[AGENT][NEUTRAL] Well, so there is no network required for the plan. It's just a limited benefit plan. It's not a major medical like where there's in network out network. It just pays a set amount.
[CUSTOMER][NEUTRAL] OK, perfect. Um, and if I'm able to still, uh, get the fax back?
[AGENT][NEUTRAL] Oh, yeah, I, you know what, I apologize, sir. I misunderstood in the beginning of the call. I thought you were calling for dental. We only have a breakdown of benefits for dental, so I apologize. That was my mistake.
[CUSTOMER][NEUTRAL] Oh OK.
[CUSTOMER][POSITIVE] OK, no worries, I know.
[CUSTOMER][NEUTRAL] It's OK, um, OK, so, mm mm mm.
[CUSTOMER][NEUTRAL] OK, so you pay up to 50 and then you guys pay up to, I'm just making sure I got my notes right so when I write it for the patient, um.
[AGENT][POSITIVE] No, no worries. Yeah.
[CUSTOMER][NEUTRAL] OK, so surgery is a 250 and then they have a max basically two surgeries per calendar year. Oh, thank you, yeah, um, and then it's a hospital indemnity.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, OK.
[CUSTOMER][NEUTRAL] OK, so, um, I just wanna confirm, so when you say it pays $50 towards the visit, um, would the patient be billed the rest or would we charge them?
[AGENT][NEUTRAL] Yeah, I mean that's up to the facility or their provider if they're gonna bill you know any sort of remaining we're not able to advise on the patient responsibility.
[CUSTOMER][NEUTRAL] OK, no, no, no, that's fine, that's fine. OK, no worries, um, I think and it runs on a calendar year, correct?
[AGENT][NEUTRAL] Mhm, yes, ma'am.
[CUSTOMER][POSITIVE] Alright, perfect. I believe I have everything I need. Is there any, um, you said no deductible, no out of pocket, no copay, OK, no.
[AGENT][POSITIVE] Right, correct.
[CUSTOMER][NEUTRAL] No, out of pocket, you know, copay.
[CUSTOMER][NEUTRAL] Don't be is covered. OK, perfect. I believe I have everything I need. May I have your name again, please, with the initials of your last name?
[AGENT][NEUTRAL] Absolutely. My name again is [PII], that's [PII] My last initial is [PII], and that is the call reference with today's date, which is [PII].
[CUSTOMER][POSITIVE] [PII] perfect thank you so much, [PII], for your help.
[AGENT][POSITIVE] You're welcome. Have a good day, sir.
[CUSTOMER][NEUTRAL] You as well bye bye.
[AGENT][NEUTRAL] Bye bye.