AccountId: 011433970860
ContactId: 809f0d38-f804-4d11-a072-1cde8bb203d5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 628549 ms
Total Talk Time (AGENT): 294305 ms
Total Talk Time (CUSTOMER): 221392 ms
Interruptions: 6
Overall Sentiment: AGENT=0.8, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/12/809f0d38-f804-4d11-a072-1cde8bb203d5_20250312T20:13_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL this is.
[AGENT][NEUTRAL] [PII], how may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from Club Health Pediatric therapy. I am calling um because we have a um a patient who actually provided us with their secondary insurance which is APO.
[CUSTOMER][NEUTRAL] Um, but we've never worked with this plan, so I guess I wanna get some information on how we would bill to you guys.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, Ms. [PII], I can help you with that information. Can you first give me your callback number just in case our call gets disconnected?
[CUSTOMER][NEUTRAL] Yes ma'am, um, best callback number is [PII].
[AGENT][NEUTRAL] Thank you ma'am. And then what is the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Yes, ma'am. Um the first name is [PII], last name [PII] [PII]
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] IRE Z. Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] And the policy number for this insurance is 02013247.
[AGENT][NEUTRAL] OK let me look up that policy number real quick.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] You're very welcome.
[AGENT][NEUTRAL] OK, I do show that [PII] is covered under this policy. His effective date is
[AGENT][NEUTRAL] pulling in, uh, [PII].
[AGENT][NEUTRAL] So this is a supplemental insurance policy, and it's billed secondary to the primary.
[AGENT][POSITIVE] It, it helps with the deductible, co-pay, and co-insurance.
[AGENT][NEUTRAL] And this is just to verify benefits. It's not a guarantee of payment. So the insured has an inpatient um calendar year benefit amount of $7000.
[AGENT][NEUTRAL] And then they also have an outpatient benefit amount per calendar year of $7000 to help with the deductible co-pay or co-insurance. Um, in order to file the claims, I have a per uh payer ID number if you would like that so you can file them electronically.
[CUSTOMER][NEUTRAL] Payer ID number um to file claims yes, I will take that if you can provide it with provide it for me.
[AGENT][NEUTRAL] Yes, it's, it's 60801.
[AGENT][NEUTRAL] And then we also have a claims fax number and mailing address if you would like those also.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] OK, the fax number is [PII].
[AGENT][NEUTRAL] 365.
[AGENT][NEUTRAL] 942 3.
[AGENT][NEUTRAL] And then the mailing address is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that's [PII].
[AGENT][NEUTRAL] And that's in [PII].
[AGENT][NEUTRAL] And then the zip code is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII] OK.
[AGENT][NEUTRAL] So when you uh send in the claim we'll need the explanation of benefits from the primary insurance along with the claim.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So this is something we would send to you guys or is this something mom will submit to you guys?
[AGENT][NEUTRAL] We have providers submit to us all the time um now if you want mama to submit the claim she can do it also.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and since we've never like this is something really new to us, so what we, for example, this patient has Blue Cross Blue Shield Primary and they pay the full amount of the visit because they haven't met their deductible now the way mom explained it to us is.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] She explained it as in they don't have to pay anything anymore because we would automatically send it to you guys so my main question is, do I not charge mom anymore?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And just
[AGENT][NEUTRAL] What kind of facility are you? I know your clubhouse pediatrics that are, would it be an office visit?
[CUSTOMER][NEUTRAL] Yeah, it's an office visit. It's for therapy.
[CUSTOMER][NEUTRAL] They're receiving speech therapy.
[AGENT][NEUTRAL] OK, let me look and see if um speech therapy is.
[AGENT][NEUTRAL] On their policy it's gonna be just a moment so I can pull that up.
[CUSTOMER][POSITIVE] OK, no worries.
[AGENT][NEUTRAL] I'm gonna actually pull up their policy certificate and read it to see.
[AGENT][NEUTRAL] If speech therapy is covered in an office visit or if it's just the treatment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Like medical.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Just give me just a second because I have to wait for it to load and then scroll through it and read exactly what it says.
[CUSTOMER][POSITIVE] Oh yes ma'am, no worries.
[AGENT][NEUTRAL] OK, so this policy is for accident or sickness, so with the uh speech therapy fall under accident or sickness?
[CUSTOMER][NEUTRAL] Um, no, ma'am, so sickness would be considered like.
[AGENT][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Um, like them going to the doctor, right? Like the flu or sore throat or something like that?
[AGENT][NEUTRAL] Right, or in the event of an accident.
[AGENT][NEUTRAL] So unless it's accident or sickness, then it's not covered.
[CUSTOMER][NEUTRAL] OK, yeah, no.
[CUSTOMER][NEUTRAL] OK, so they most likely wouldn't be covered because this is for speech therapy. This patient is coming in, um, let me take a quick look.
[CUSTOMER][NEUTRAL] Yeah, so they're just coming in for malfunctional therapy, um, it's like.
[CUSTOMER][NEUTRAL] Treatment of swallowing, I guess for feeding, they're coming in for feeding. So not sickness and not an accident either.
[AGENT][NEUTRAL] Right. OK. So, yes. Um, this policy covers for accident or sickness, and also, it does not cover physician office visit fees.
[CUSTOMER][NEUTRAL] I'm just writing all this down sorry.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, so covered for accident and sickness, and what else did you say?
[AGENT][NEGATIVE] It does not cover the physician office fee.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Cover.
[CUSTOMER][NEUTRAL] OK, so what would it cover if it, if it doesn't cover the office physician fee just because I know my boss is gonna ask me this, so I'd rather just have it.
[AGENT][NEUTRAL] Right, right. OK, so physician covered charges.
[AGENT][NEUTRAL] And this is um incurred by a covered person because of an accident or sickness.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For necessary treatment services and supplies recommended by a physician incurred in a physician's office, incurred while insured under the certificate subject to any extension of benefits and not listed under the exclusion section. So this is not, this is what's not covered, um, durable medical equipment, cancer treatment, physical therapy, or physician's office visit fee.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right. Um, so just for future reference, is this only for this patient or does this insurance in general not cover for
[CUSTOMER][NEUTRAL] Like does this insurance only cover for sickness and.
[CUSTOMER][NEUTRAL] Accident or would it just vary by patient?
[AGENT][NEUTRAL] Only
[AGENT][NEUTRAL] It's only sickness and accident um per the insured's policy. So sickness is defined as any illness, disease, infection, or abnormal condition of the body, not caused by an accident, which is the direct cause of the loss.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, all right, I believe I have the answers I need. You were so helpful. If I need anything else, I'll call back.
[AGENT][POSITIVE] OK, awesome. Oh.
[AGENT][POSITIVE] OK, sounds perfect. And we'll be here to help you.
[CUSTOMER][POSITIVE] Thank you so much for your help. Thank you so much. You were so great. I was really nervous because I had no idea what to ask or if I would understand a single word, but thank you so much for your help. I will give this information to my boss.
[AGENT][POSITIVE] You're very welcome, Ms. [PII]. Oh.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Well
[AGENT][NEUTRAL] You
[AGENT][POSITIVE] You're very welcome and I enjoyed talking with you and I'm glad I was able to help you and put you at ease.
[CUSTOMER][POSITIVE] Oh thank you, thank you, thank you so much. Have a good day.
[AGENT][POSITIVE] OK. You're welcome.
[AGENT][NEUTRAL] You too, Ms. [PII] mhm bye bye.
[CUSTOMER][NEUTRAL] Bye bye.
[CUSTOMER][POSITIVE] Thank you bye bye.