AccountId: 011433970860
ContactId: 64ce3628-d7f9-4312-ae14-f9b813f8a190
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 555820 ms
Total Talk Time (AGENT): 258804 ms
Total Talk Time (CUSTOMER): 184092 ms
Interruptions: 0
Overall Sentiment: AGENT=0, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/64ce3628-d7f9-4312-ae14-f9b813f8a190_20250213T15:25_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling from the provider's office. Um, I'm calling to get benefits and eligibility please on a patient.
[AGENT][NEUTRAL] Yeah, I can check eligibility and benefits for you. I'm sorry, you said your name was [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], OK, sorry about that. And then, uh, [PII], can I get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, my direct number is [PII].
[AGENT][NEUTRAL] Thank you. And then do you have the policy number?
[CUSTOMER][NEUTRAL] I do, um, it's 02265958.
[AGENT][NEUTRAL] Thank you. And what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] Uh, [PII]
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that [PII]. So this policy actually terminated [PII]. If you'll give me one moment, I'll see if uh they do have one that's active, might just be a different policy number.
[AGENT][NEUTRAL] OK, they do have one that is currently active. Uh, let me know when you're ready and I can give you that policy number.
[CUSTOMER][POSITIVE] I'm ready.
[AGENT][NEUTRAL] OK, it is 02.
[AGENT][NEUTRAL] 55.
[AGENT][NEUTRAL] 6241.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And so this policy's effective date was uh just picked up where that one left off, so [PII].
[CUSTOMER][NEUTRAL] I want
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then we're really need to look at the uh outpatient benefits.
[CUSTOMER][NEUTRAL] So I have this so yeah, so this is um infusion Services and in the provider's office.
[AGENT][NEUTRAL] OK, in a, a physician's office setting?
[CUSTOMER][NEUTRAL] Yes, we're doing this without an office visit.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, one moment.
[AGENT][NEUTRAL] OK, and of course I will let you know [PII] verification of coverage is not a guarantee of payment for claims. So for this policy office visits are not covered. However, treatment received in office could be and just so that you are aware, this is a secondary medical policy, so it is designed to help with co-pay, deductible and co-insurance after major medical pays. So their outpatient benefit is $8150 per calendar year.
[AGENT][NEUTRAL] If you'll give me one moment I'll see if any of that has been used.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Me too.
[AGENT][NEUTRAL] OK, so
[AGENT][NEUTRAL] Let's see, she has used $1,926.69 so far this year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that's her deductible?
[AGENT][NEUTRAL] No, that's the total benefit amount that this policy could pay after major medical does.
[CUSTOMER][NEUTRAL] OK, so once she allotted at 8150 then she anything after that she would be responsible on her own.
[AGENT][NEUTRAL] That's yeah that's the maximum amount um this policy could pay per calendar year and this plan does not have any deductibles.
[CUSTOMER][NEUTRAL] OK, I see what you're saying. You just get it for like a Skype net and then she could use that.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEGATIVE] Yeah, so once that um 8150 has been exhausted, then this policy simply couldn't pay anymore.
[CUSTOMER][NEUTRAL] So you don't
[AGENT][NEUTRAL] For the year.
[CUSTOMER][NEUTRAL] OK, so we know office visits are not covered, but you don't know, but what about infusion services in office setting?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] But the treatment received in office, they do have that benefit for treatment received in office so if it was something as simple as just like a consultation in an office setting that would not be covered. Does that make sense?
[CUSTOMER][NEUTRAL] Right. Yes, so like an injection could be covered treatments.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right, treatment in office, yes.
[CUSTOMER][NEUTRAL] OK, um.
[AGENT][NEUTRAL] Again, as long as her major medical is willing to pay this policy and it is very dependent on major medical.
[CUSTOMER][NEUTRAL] So for primary, do you guys have a primary insurance?
[AGENT][NEGATIVE] I do not, um, but if it, it's one of those like not like actual gap policy so she couldn't use this instead of major medical if they're not willing to pay. So if they can't then this policy can't.
[CUSTOMER][NEUTRAL] Oh, so they can't pay, then you, she'll pay as long as she's as long as she's with her liable.
[AGENT][NEUTRAL] Yeah, so if her primary does not pay or they can't this policy can't, it's very dependent on whoever she has as major medical.
[CUSTOMER][NEUTRAL] Oh, the oh, so they deny you would deny, basically.
[AGENT][POSITIVE] Right, exactly.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I just wanna make sure, so like, so I don't know if you're able to answer these questions because like do you do you are you able to look at the codes to make sure they're valid and billable or can I provide a buy and bill or this is just like a.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I don't, um,
[AGENT][NEUTRAL] Yeah, the only unfortunate way that uh we would have to file the have the claim filed um to see exactly if it would be covered or not. I don't have a way to look up uh codes.
[CUSTOMER][NEUTRAL] OK, is this so this is more like a HSA account I'm assuming?
[AGENT][NEUTRAL] This is, um, I mean, by definition, it's a secondary medical policy, but it is supplemental.
[CUSTOMER][NEUTRAL] And it's commercial Medicare.
[AGENT][NEUTRAL] I'm sorry, what was that?
[CUSTOMER][NEUTRAL] Is this like a Medicare supplement or a commercial?
[AGENT][NEUTRAL] No, no, it, it does follow major medical guidelines.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So it's not as well, I don't know why the I got it in as a sec as the Medicare.
[CUSTOMER][NEUTRAL] It's weird. That's why I asked.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] But they have it as a Medicare. It must have, it must have, I, I don't know. So I'm just gonna put this secondary as a medical, uh.
[CUSTOMER][NEUTRAL] I can't pronounce this a second there.
[AGENT][NEUTRAL] Oh man, yeah. Sorry.
[CUSTOMER][NEUTRAL] Medical
[CUSTOMER][NEUTRAL] This is a medical.
[CUSTOMER][NEUTRAL] Dang you just said it, um.
[AGENT][NEUTRAL] Uh, secondary medical policy, um, yes, depending on major medical, yes.
[CUSTOMER][NEUTRAL] It's not a major.
[CUSTOMER][NEUTRAL] Major, that's what it was.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, can you give me the set? Oh, you gave me to set the day you already did 101.
[AGENT][NEUTRAL] Yes, 101 of 24, yes.
[CUSTOMER][NEUTRAL] 242.
[CUSTOMER][NEUTRAL] Um, OK, so you basically follow the primary suit.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, so unfortunately you can't tell me the provider can buying bill or anything because you follow the primary suit.
[AGENT][NEUTRAL] Yes, so for claims to be filed for this kind of policy we would have to have the EOB from their major medical essentially showing what they did pay. If we don't have that we wouldn't be able to file claims.
[AGENT][NEUTRAL] Or process.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, I think I got it now.
[AGENT][NEUTRAL] OK and did you have any other questions for me?
[AGENT][NEGATIVE] I know it's a bit confusing.
[CUSTOMER][NEGATIVE] Uh, it is confusing, uh.
[CUSTOMER][NEUTRAL] So you wanna tell me if you need to like this plan doesn't require like a PCP referral or like limitations of car valves, OK, and they could get these infusions in the provider's office. So is there like any like carve outs or limitations or exclusions do you know?
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Just to that amount, just to the amount of the um outpay it just goes off of their outpatient benefit so that 8150 essentially once that's exhausted, then we wouldn't be able to pay anything additional.
[CUSTOMER][NEUTRAL] OK, I got it.
[CUSTOMER][NEUTRAL] And do you know if the providers and network with your um plan or does it?
[AGENT][NEUTRAL] This one, it does not follow a network again as long as the major medical it's within theirs um they can pay that's all that this plan really depends on.
[CUSTOMER][NEUTRAL] OK, so there's no, uh, in network or out of network. She could just go wherever she wants to go along with it. OK, got it.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] As long as it's covered by her major medical, yes.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] Thank you so much. May I just have a name and a reference number?
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Reference number would just be my first name, last initial, and today's date, uh so my name is spelled [PII] last initial is [PII]
[CUSTOMER][NEUTRAL] A lot of A's, huh?
[AGENT][NEUTRAL] I kiss me.
[CUSTOMER][POSITIVE] Perfect thank you so much for your help. I really appreciate your patience.
[AGENT][POSITIVE] Alright, yes ma'am, thank you for calling APL. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] You too.
[AGENT][NEUTRAL] Bye bye.