AccountId: 011433970860
ContactId: 5a316d67-21bd-4067-9fab-e88d6e162025
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 509640 ms
Total Talk Time (AGENT): 233276 ms
Total Talk Time (CUSTOMER): 142422 ms
Interruptions: 1
Overall Sentiment: AGENT=1.4, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/30/5a316d67-21bd-4067-9fab-e88d6e162025_20250430T17:10_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] Hi [PII].
[CUSTOMER][NEUTRAL] Sorry, good afternoon. I'm calling for physical therapy benefits. I'm a provider. Is this the right department?
[AGENT][NEUTRAL] OK, you're needing to get benefit information for a member, you said for physical therapy?
[CUSTOMER][POSITIVE] Yeah, yeah, correct.
[AGENT][POSITIVE] Yes, ma'am. I can help you with that. And who am I speaking with?
[CUSTOMER][NEUTRAL] Yeah, you're speaking with [PII] is my last initial.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Alright now thank you and what is your callback number, please?
[CUSTOMER][NEUTRAL] Yeah, that will be [PII].
[AGENT][POSITIVE] Thank you and the member's policy number please ma'am.
[CUSTOMER][NEUTRAL] I have 02478737, the letter M for Mary, L for Lima, the number 8.
[AGENT][NEUTRAL] OK, thank you. One moment please.
[AGENT][NEUTRAL] And any information now that I do provide for you will be a verification of benefits and not a guarantee of payment. What is your patient's name please and their date of birth?
[CUSTOMER][NEUTRAL] Yeah, this is for [PII]. The date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so I do show that she is the spouse, I'm sorry, he is the spouse of the subscriber on the supplemental policy.
[CUSTOMER][NEUTRAL] like
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Is this going to be done at an outpatient or physical therapy facility?
[CUSTOMER][NEUTRAL] Um, yeah, it will be, um, in, in an office setting rendered by a specialist.
[AGENT][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] OK, so it's, it's not a physical therapy facility. You did say it was an office setting, is that correct, ma'am?
[CUSTOMER][NEUTRAL] Oh, it should be, it should be under physical therapy, but the place of service is office setting rendered by a specialist. Yeah, that, that's what I meant.
[AGENT][NEUTRAL] OK, so on this, OK, on this supplemental policy, office visits and treatment within an office setting are not covered.
[CUSTOMER][NEUTRAL] Oh, but what about the
[CUSTOMER][NEUTRAL] Physical therapy itself.
[AGENT][NEUTRAL] On this policy, it shows that the place of service would be a physical therapy facility.
[AGENT][NEUTRAL] That would be a covered benefit, but an office setting is not covered. Office visits and treatment rendered within an office setting is not covered.
[CUSTOMER][NEUTRAL] Oh, I see. hm, um, this is actually my first time hearing this one, but thank you for telling me that. But, but what if, what if, um, I, I, because this is what you always needing, the one that I said which is physical therapy in an office setting rendered by a specialist. So is that mean I, there's no benefit for this patient for that?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] That is correct. On this supplemental policy and all of these supplemental policies are different and have different types of benefit information, but this specific policy.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] If it were being rendered in a physical therapy facility, that is something that could be reviewed, but office visits and treatment done in an office setting is not covered.
[AGENT][NEUTRAL] Any form of treatment in an office setting is not.
[CUSTOMER][NEUTRAL] Oh, I see, because this is.
[AGENT][NEUTRAL] Except for cancer.
[CUSTOMER][NEUTRAL] Oh, even, even the evaluation, right?
[AGENT][POSITIVE] No, that is correct.
[AGENT][NEUTRAL] Office visits and office-related treatment or treatment rendered in an office setting is not covered.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] But physical therapy facility is the one that is covered.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] That would be able to be considered under the outpatient benefit.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yeah, can I have that benefit just in case?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The physical, uh I mean physical therapy facility outpatient.
[AGENT][POSITIVE] Sure, yes ma'am.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK, so on the supplemental policy, the outpatient benefit maximum of covered outpatient services per calendar day is $300 and there is no outpatient deductible per covered person per calendar day.
[AGENT][NEUTRAL] Now if you all do end up submitting a claim for review mail for these services, we will also have to have a copy of his primary insurance company's explanation of benefits as well.
[AGENT][NEUTRAL] And then once we have processed our claim here at APL we do have a portal in which you should be able to check the claim status for us by going to [PII].
[CUSTOMER][NEUTRAL] Sorry, um, thank you for that, and, OK, just to make sure if I got you correctly, you need the explanation of benefits.
[AGENT][NEUTRAL] Along with the claim for review, since this is a supplemental policy to the primary insurance, yes ma'am.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Can we submit this through fax?
[AGENT][NEUTRAL] Yes, ma'am, and the fax number is [PII].
[AGENT][NEUTRAL] 365.
[AGENT][NEUTRAL] 942 3.
[AGENT][NEUTRAL] Attention claims departments.
[CUSTOMER][NEUTRAL] OK, thank you and can I still call the same number to check if you have received this request?
[AGENT][NEUTRAL] Yes, ma'am, if you're going to fax a claim to us, uh, allow at least 24 hours for it to be received to be put in line for processing.
[AGENT][NEUTRAL] To verify if it was received or not because it does take a little time to get on their profile.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah, I agree. Thank you so much and will do. um, may I have your name again and reference number?
[AGENT][POSITIVE] Well, you're welcome.
[AGENT][NEUTRAL] Again, my name is [PII]. The first initial to my last name is [PII], and my name in today's date would be your call reference number.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] OK, alright, well again if that is all now that I can help you with, thank you for calling APO and I hope you have a wonderful afternoon.
[CUSTOMER][POSITIVE] Thanks bye bye.
[AGENT][POSITIVE] Yes, ma'am. Thank you. Bye bye.
[CUSTOMER][NEUTRAL] Bye-bye.