AccountId: 011433970860
ContactId: 76b1d2ea-845e-4bc5-adf2-3c71c66efd86
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 401660 ms
Total Talk Time (AGENT): 144594 ms
Total Talk Time (CUSTOMER): 207657 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/16/76b1d2ea-845e-4bc5-adf2-3c71c66efd86_20250616T12:46_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] For contacting ATL, my name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I'm calling to verify coverage and benefits for a patient of ours.
[AGENT][NEUTRAL] I can help with eligibility and benefits, with whom am I speaking, please?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] [PII], thank you. What is that policy number that we're looking at today?
[CUSTOMER][NEUTRAL] I'm showing 9800 00 hold on I'm sorry I was on the wrong one.
[CUSTOMER][NEUTRAL] Alright, that would be 02.
[CUSTOMER][NEUTRAL] 29
[CUSTOMER][NEUTRAL] 2668.
[AGENT][NEUTRAL] Thank you. And the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] I'm showing [PII] Busy. Uh, date of birth is [PII].
[AGENT][NEUTRAL] Thank you. Is there a callback number I can have in the event that we're disconnected?
[CUSTOMER][NEUTRAL] That would be [PII]. It's not a direct line to me. The front desk has to uh forward calls to me. I'm remote.
[AGENT][NEUTRAL] Oh, OK, OK, certainly. Thank you. Um, [PII], the policy went into effect on [PII]. It is active.
[AGENT][NEUTRAL] This is a secondary or gap insurance and it's meant to pick up the deductible.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Co-payment or co-insurance for in and out of hospital settings. Is there anything in particular that I can tell you about the secondary or gap insurance?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I just have to, uh, this patient comes for, to us for regular injections every month.
[CUSTOMER][NEUTRAL] And I have to make sure they have active insurance to do the injections. I know that this is a secondary plan and what we've previously shown from you is that they don't have any office visit benefits. They, you only cover for covered services and you pay up to $500 per day, is that correct?
[AGENT][NEUTRAL] Well, what we will do for this, um, you're, you're talking about uh an office visit setting, is that correct? That you're doing it within your physician's office. So treatments, um, or procedures within the physician's office are covered. So, um, uh.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] If you needed to draw blood, do labs.
[AGENT][NEGATIVE] Shots, whatever it is, that's covered up to $500 per calendar day, which of course is just a verification, not a guarantee your payment. It's just the office visit co-pay that's not covered.
[AGENT][NEUTRAL] So treatments or procedures within the physician's office is covered, the office visit co-pay is not.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] No, uh, but you do know how where to send. Is there anything else I can help with? You know where to send your claims, um.
[CUSTOMER][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] Let me just look at something real quick while I have you on the phone.
[AGENT][POSITIVE] Sure, absolutely.
[CUSTOMER][NEUTRAL] Because I'm not sure.
[CUSTOMER][NEUTRAL] What APL has been paying for it.
[CUSTOMER][NEUTRAL] Let me just check.
[CUSTOMER][NEUTRAL] I'm typically just tasked with verifying the coverage, but I do occasionally um dip into the billing side of it a little.
[AGENT][NEUTRAL] we are showing a, we are showing a reoccurring charge um for um
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, administration of patient-focused health risk assessment instruments.
[AGENT][NEUTRAL] Is that uh um 961-60. Does that sound right?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 96,160. OK. Yeah, that's, that's what we, um, an assessment that we do to determine whether or not these injections are helping them.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Right
[CUSTOMER][NEUTRAL] So that's not the injection co-pay, I mean the uh code itself. Um.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm showing that.
[CUSTOMER][NEUTRAL] It's been filed through EBMS, but I'm not showing where they've actually been filing it through APL.
[AGENT][NEUTRAL] We have another CTP code is 96372, a therapeutic.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yes, that's the injection.
[AGENT][NEUTRAL] OK, yes, it does look like that has been covered in the past.
[CUSTOMER][NEUTRAL] OK. I do see something here from May. Shows that you paid $2.94 for his last injection.
[AGENT][NEUTRAL] Well, yes, but this, whatever the deductible, co-payment or co-insurance is when you make your medical, yeah.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, cause it was, uh, let's see.
[CUSTOMER][NEUTRAL] That was an office visit, yeah.
[CUSTOMER][NEUTRAL] So, it looks like you did pay towards that assessment that you were talking about the 96,160 on that visit. Let me pull up an injection appointment actually.
[CUSTOMER][NEUTRAL] Yeah, here's an injection appointment.
[CUSTOMER][NEUTRAL] OK, um, do you show a claim for [PII]?
[AGENT][NEUTRAL] We do. Um, there was a CPT code of 99214, which was not covered, and 96,160, which was.
[CUSTOMER][NEUTRAL] For [PII].
[AGENT][NEUTRAL] This is [PII].
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] Uh let me just check and see if.
[CUSTOMER][NEUTRAL] Yeah, I'm showing uh an [PII] claim for an injection.
[CUSTOMER][NEUTRAL] And we've shown a payment from
[AGENT][NEUTRAL] OK, doesn't look like you.
[CUSTOMER][NEUTRAL] Primary, but nothing as of yet from APL.
[AGENT][NEUTRAL] For
[AGENT][NEUTRAL] Oh, I would, I would submit it then, um, because it's, uh, we just showed the other two CPT codes, so, um, I would certainly submit that because it's.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That way we can, we can uh see that uh that uh processing.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is it possible that you have to submitted.
[CUSTOMER][POSITIVE] That's interesting, cause that one.
[CUSTOMER][NEUTRAL] All right, let me look at the one from March.
[CUSTOMER][NEUTRAL] OK, that one.
[CUSTOMER][NEUTRAL] Yeah, it looks like that one was just filed to their primary Cigna. Yeah, I'll have to see if I can get somebody to look at that and see whether they're being processed through the secondary for injections cause I'm not showing that it may be going through you, so.
[CUSTOMER][NEGATIVE] A couple of them have been sent but have not been.
[CUSTOMER][NEUTRAL] Paid as of yet, looks like but.
[CUSTOMER][NEUTRAL] One of them hasn't
[CUSTOMER][NEUTRAL] Been submitted OK alright well I'll have them take a look at that but.
[CUSTOMER][POSITIVE] I appreciate you helping me.
[AGENT][POSITIVE] OK, if there's nothing else I can help with, um, thank you for contacting APR a very good morning.