AccountId: 011433970860
ContactId: 7eff62b8-ac11-4d67-b7a9-bae8ec61beb8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 384519 ms
Total Talk Time (AGENT): 192098 ms
Total Talk Time (CUSTOMER): 135584 ms
Interruptions: 1
Overall Sentiment: AGENT=1.5, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/7eff62b8-ac11-4d67-b7a9-bae8ec61beb8_20250103T20:48_UTC.wav
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[AGENT][NEUTRAL] Hi, thanks for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from the product's office checking on eligibility and benefits.
[AGENT][POSITIVE] OK, I'd love to help you with eligibility and benefits today, [PII], and may I have that policy number, please?
[CUSTOMER][NEUTRAL] Yes, it is 02465471.
[AGENT][POSITIVE] Thank you and while I'm getting that policy pulled up, can I also get a good call back number?
[CUSTOMER][POSITIVE] Thank you
[CUSTOMER][NEUTRAL] Yes, it is [PII] and it is a direct line no extension.
[AGENT][POSITIVE] Perfect, thank you. And your patient's first and last name and date of birth, please?
[CUSTOMER][NEUTRAL] Yes, the member's name is [PII], and the date of birth is [PII].
[AGENT][POSITIVE] Perfect thank you so much. Your patient is current and active with us. It looks like they've been effective since [PII] and for benefits are you looking for inpatient or outpatient?
[CUSTOMER][NEUTRAL] It is for outpatient. Before getting to the benefits, may I have the plan name, please?
[AGENT][NEUTRAL] Yeah, the the plan la. No, I cannot talk. I'm sorry. It is [PII]
[CUSTOMER][NEUTRAL] Medlink, right? Medilink or Melink?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Medlink
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Uh, could you please check whether this is commercial or Medicare or not?
[AGENT][POSITIVE] I'm so sorry, can I check what?
[CUSTOMER][NEUTRAL] Is it commercial or Medicare Advantage plan?
[AGENT][NEUTRAL] I am really sorry. I'm not quite sure I understand your question.
[CUSTOMER][NEUTRAL] Yes, I'm asking whether it is a commercial plan or it is a Medicare plan.
[AGENT][NEUTRAL] Oh, it's commercial. It's not Medicare.
[CUSTOMER][NEUTRAL] OK, could you please check for the plan type whether it is?
[AGENT][NEUTRAL] I'm sorry, I've never had that question.
[CUSTOMER][NEUTRAL] OK, sorry.
[AGENT][NEGATIVE] No, no, sorry.
[CUSTOMER][NEUTRAL] Oh OK.
[CUSTOMER][NEUTRAL] OK, um, could you please check for the plan type is HMO or PPO.
[AGENT][NEUTRAL] Oh, so were there supplemental insurance or their gap plan?
[AGENT][NEUTRAL] So we're secondary. Mhm.
[CUSTOMER][NEUTRAL] So it is a gap plan, right?
[CUSTOMER][POSITIVE] Thank you, I got it. Do you have any group number for this plan?
[AGENT][NEUTRAL] Yeah, the group number is going to be 21499.
[CUSTOMER][NEUTRAL] Thank you. Does the policy run on your calendar year or on your plan year?
[AGENT][NEUTRAL] And I'm so sorry, the policy what?
[CUSTOMER][NEUTRAL] Does it run on your calendar year or on your plan year? Is it is on every January?
[AGENT][NEUTRAL] It runs on a calendar year.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Shall we get into the benefits? I need physical therapy benefits for the member.
[AGENT][POSITIVE] Yeah, absolutely.
[AGENT][POSITIVE] Yeah, so the physical therapy benefits are gonna fall under outpatient, um, and let me get this pulled up for you real fast.
[AGENT][NEGATIVE] Hang tight.
[CUSTOMER][NEUTRAL] OK. In the meantime, uh, shall I have your name, please? Could you please spell it for me?
[AGENT][NEUTRAL] Yes, it's [PII]
[AGENT][NEUTRAL] And then last initial is [PII].
[CUSTOMER][POSITIVE] Thank you. Thank you, [PII].
[AGENT][NEUTRAL] Um, this patient has a benefit, an outpatient benefit of $2000 per calendar year, um, and that is combined with their inpatient and outpatient. I do want to let you know that any benefit information we give over the phone is just a verification of coverage and not a guarantee of payment.
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] It looks like, I'm just going down. It does.
[CUSTOMER][NEUTRAL] Do you have any deductible?
[AGENT][NEGATIVE] Not with us, no.
[CUSTOMER][NEUTRAL] Do you have any out of pocket max?
[AGENT][NEUTRAL] No, because we're secondary, um.
[AGENT][NEUTRAL] We don't have those.
[CUSTOMER][NEUTRAL] Is there any co-payment or co-insurance?
[AGENT][NEUTRAL] No, our, our benefits help pay for the co-pay, co-insurance and deductible.
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] So it's a gap. I'm sorry, I misunderstood. Thank you. Do you have any visit limit?
[AGENT][POSITIVE] You're OK.
[AGENT][NEUTRAL] Do you have any what?
[CUSTOMER][NEUTRAL] Do you have any limitation in visits?
[AGENT][NEUTRAL] Um, no, the only limitation is the outpatient benefit maximum of $2000 combined with their inpatient benefit maximum.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It is a dollar limit, right?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Has the number used any dollars out of 2000 until now?
[AGENT][NEUTRAL] Um, for the [PII] calendar year, uh, we have not used any benefits.
[CUSTOMER][NEUTRAL] Thank you. OK, uh, I have the CPT codes. Can you please check with those CPT codes for the authorization is for physical therapy?
[AGENT][NEUTRAL] Uh, so unfortunately, we cannot, uh, determine coverage based off codes. Um, we have to have the claim and it's gonna be based off of how the claim form comes in and how major medical pays for it.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Do you follow any specific network?
[AGENT][NEUTRAL] We follow their major medical plan.
[CUSTOMER][NEUTRAL] So you you follow the primary guidelines, right?
[AGENT][NEUTRAL] Yeah, so we, we base all of our, our benefits off of the major medical. We need that explanation of benefits when you submit the claim with us.
[CUSTOMER][NEUTRAL] OK. Uh, took a we need to bill.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] To whom we need to bill for this number to whom we need to send the claim.
[AGENT][NEUTRAL] OK, yep, you're gonna wanna bill.
[AGENT][NEUTRAL] You're gonna want to bill to us um we have an electronic payer ID, a fax number, and a mailing address, whichever one you want I can give you.
[CUSTOMER][NEUTRAL] I need the mail, mailing address. Can you please set forward it to me.
[AGENT][NEUTRAL] Yes, mailing address is going to be [PII].
[AGENT][NEUTRAL] That's in [PII] City, [PII]. Our zip code here is [PII], and it can be made out to APL claims.
[CUSTOMER][NEUTRAL] So we need to send the claims to American public insurance, public life insurance, right?
[AGENT][NEUTRAL] Yes, and you'll want to do it once you receive the EOB for major medical because we'll need that on file with the claim to process anything.
[CUSTOMER][POSITIVE] OK, thank you. I got it.
[AGENT][POSITIVE] My pleasure.
[CUSTOMER][POSITIVE] Thank you. Um, thank you, [PII]. Thank you for your assistance. I hope I got all the details you need for this number. Shall I get the call reference number for this governor you already?
[AGENT][NEUTRAL] You bet you it's just gonna be my first name, last initial and today's date for your reference number, [PII].
[CUSTOMER][POSITIVE] Thank, thank you, [PII]. Thank you for your assistance. Have a great day and happy weekend. Bye-bye. Take care.
[AGENT][POSITIVE] Hey, my pleasure.
[AGENT][POSITIVE] You too bye bye. Thank you.
[CUSTOMER][NEUTRAL] Mhm