AccountId: 011433970860
ContactId: 775e99e2-67fe-4376-bd32-d807c467cbcd
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 351910 ms
Total Talk Time (AGENT): 181817 ms
Total Talk Time (CUSTOMER): 123192 ms
Interruptions: 2
Overall Sentiment: AGENT=1.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/29/775e99e2-67fe-4376-bd32-d807c467cbcd_20250129T16:25_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], I'm calling from a doctor's office, and we have a patient who's scheduled for surgery. I need to check his benefits secondary to his Blue Shield of Florida.
[AGENT][NEUTRAL] OK, so you're needing to verify eligibility and outpatient benefits for a member, is that correct?
[CUSTOMER][NEUTRAL] Um, yes.
[CUSTOMER][NEUTRAL] It's for hospital for surgery.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, but is it an inpatient admission or is it for an outpatient surgery?
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Outpatient mhm outpatient.
[AGENT][POSITIVE] Yes, I can help you with that. And who am I speaking with, please?
[CUSTOMER][POSITIVE] Thank.
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][POSITIVE] Thank you and [PII], what is a good callback number for you?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Thank you. And the member's policy number please, [PII]?
[CUSTOMER][NEUTRAL] 02552102
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so any information that I do provide for you today, [PII] will be a verification of benefits and not a guarantee of payment. If you need a call reference number for our call, you will use my name that I gave you along with today's date.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is your patient's name, please, and their date of birth?
[CUSTOMER][NEUTRAL] Um, his name is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you. So I do show he is the subscriber on the supplemental policy and it is active with an effective date of [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Uh one moment on the benefits.
[CUSTOMER][POSITIVE] Thank you, thank you.
[AGENT][POSITIVE] Mm. You're welcome.
[AGENT][NEUTRAL] So he has an
[AGENT][NEGATIVE] Oh goodness, one second, my screen went too far on me. Just one moment.
[AGENT][NEUTRAL] So he has an outpatient benefit maximum of $7350 per calendar year per covered person for covered outpatient services, and there is no outpatient deductible per covered person per calendar year.
[CUSTOMER][NEUTRAL] So wait a minute, his his benefits.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Maximum.
[CUSTOMER][NEUTRAL] Is up to 7300.
[AGENT][NEUTRAL] $7350.
[CUSTOMER][NEUTRAL] But that's all you'll pay.
[AGENT][NEUTRAL] Per calendar year for covered outpatient services. This is his supplemental policy, not his primary insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, right, mhm.
[CUSTOMER][NEUTRAL] OK, so you'll cover that amount he has no deductible at all?
[AGENT][NEUTRAL] Not on the supplemental policy.
[CUSTOMER][NEUTRAL] Right, well I'm calling his.
[CUSTOMER][NEUTRAL] I show Blue Blue Cross Blue Shield as his primary.
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] Yes, on this supplemental coverage, he does not have a deductible to meet.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, do you cover his primary insurance company's deductible?
[AGENT][NEUTRAL] This policy is designed to help them with their co-pays, deductibles, and co-insurance amounts of coverage services, [PII], up to that outpatient benefit max that I gave you.
[AGENT][NEUTRAL] So when the claim is submitted to APO for review, you will also have to send us a copy of his primary insurance company's explanation of benefits as well.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] Correct, mhm.
[CUSTOMER][NEUTRAL] So let's just say that Blue Cross Blue Shield processed the claim. He has a high deductible. They allowed $1500 let's just say from Blue Shield they paid $0. You guys will cover the $1500.
[AGENT][NEUTRAL] Again, I cannot guarantee payment. We will have to re
[CUSTOMER][NEUTRAL] But is that how it works?
[AGENT][NEUTRAL] Yes, and that's
[AGENT][NEUTRAL] Again, this policy is designed to help them.
[CUSTOMER][NEUTRAL] I understand that I'm trying to find out if he owes us any money if the plan.
[AGENT][POSITIVE] Up to that benefit.
[AGENT][NEUTRAL] And I can't give you a definitive answer on that because I can't say that for sure that we will pay on this claim.
[AGENT][NEUTRAL] Again, I can only
[CUSTOMER][NEUTRAL] Why would you not plan the claim I guess is my question.
[AGENT][NEUTRAL] Again, we do not pay, we do not pay claims over the phone, so we'll have to receive the claim and his primary and his primary.
[CUSTOMER][NEUTRAL] I under I understand how it works and how it works. I'm just trying to understand if the patient is fully covered, if everything is processed correctly, or does he owe us money that we need to collect that.
[AGENT][NEUTRAL] I can't answer. Yes, ma'am, I can't answer that for you.
[CUSTOMER][NEGATIVE] OK, I'm gonna, I'll call someone else because you're not answering my questions.
[AGENT][NEUTRAL] That's, you are, I am answering your question, [PII]. I mean, I don't, you're asking, you're wanting me to tell you if we will pay this claim.
[CUSTOMER][NEGATIVE] No, you're not.
[CUSTOMER][NEUTRAL] No, I understand there's no guarantee of payment. I'm trying to ask you if Blue Cross Blue Shield puts everything to his deductible, which looks like it's going to be, do you guys pick up the deductible that Blue Cross Blue Shield didn't cover?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] The maximum benefit per calendar year that this plan will cover is $7350 and claims are processed as they are received.
[CUSTOMER][NEUTRAL] I got that.
[CUSTOMER][POSITIVE] OK, thank you so much I appreciate your time.
[AGENT][POSITIVE] You are very welcome. Is there anything else I can help you with?