AccountId: 011433970860
ContactId: 84c8e45e-6476-43e5-817a-8c20447cfbe5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 381260 ms
Total Talk Time (AGENT): 198672 ms
Total Talk Time (CUSTOMER): 110803 ms
Interruptions: 4
Overall Sentiment: AGENT=1.4, CUSTOMER=1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/84c8e45e-6476-43e5-817a-8c20447cfbe5_20250207T14:57_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] Hi, good morning, ma'am. I'm just calling from an ophthalmologist, uh, on the front desk here, a candlelight specialist, and I just want to see if a patient, uh, they just gave me their APO plan, and I wanna see if this covers your co-payment on their primary insurance for a specialist visit.
[AGENT][NEUTRAL] OK, so you're wanting to verify eligibility and benefit information for a specialist office visit, is that correct? Yes, ma'am, I can help you with that. And who am I speaking with, please?
[CUSTOMER][NEUTRAL] Yes, yes, ma'am.
[CUSTOMER][NEUTRAL] My name is uh [PII]
[AGENT][NEUTRAL] Thank you. And [PII], what is your callback number?
[CUSTOMER][NEUTRAL] It's this number [PII].
[AGENT][NEUTRAL] Thank you. And what is the member's policy number, please, [PII]?
[CUSTOMER][NEUTRAL] The member ID the payer ID it's the payer ID, right?
[AGENT][NEUTRAL] No, ma'am. It would have another, that's our electronic payer ID. There should be another number on the front of her card or his card.
[CUSTOMER][NEUTRAL] The group number?
[AGENT][NEUTRAL] No, ma'am, there still should be another number and they say in-house, outpatient policy.
[CUSTOMER][NEUTRAL] Oh, I
[CUSTOMER][NEUTRAL] Oh, in hospital, yes, yes, I found, I'm sorry, yes, I found it.
[AGENT][NEUTRAL] That's OK. Uh-huh.
[CUSTOMER][NEUTRAL] OK, so it's 024.
[CUSTOMER][NEUTRAL] 657.
[CUSTOMER][NEUTRAL] 99.
[CUSTOMER][NEUTRAL] M as in Mary.
[CUSTOMER][NEUTRAL] L as in Louis number 7.
[AGENT][NEUTRAL] OK, thank you. One moment, please.
[CUSTOMER][POSITIVE] You're welcome thank you.
[AGENT][NEUTRAL] OK, and [PII], any information that I do provide for you today would be a verification of benefits and not a guarantee of payment. What is the patient's name, please, and date of birth?
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] The patient's name is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] OK, thank you. So let me see because this policy kind of was actually never active. Let me find you the correct policy number because it has an effective date and a term date of the same, so just one moment.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the correct policy number that you should have for this number is going to be 01982179.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] With an effective date of [PII].
[AGENT][NEUTRAL] And give me just one moment please to get all of his information pulled up, [PII] for this policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, so on this, this is a supplemental policy, Cassie, to his primary insurance that is designed to help him with his co-pay, deductibles and co-insurance amounts of covered services. So he does have um office visits or something that we can review under this policy. His outpatient benefit [PII]
[CUSTOMER][NEUTRAL] Yeah if you have.
[CUSTOMER][NEUTRAL] Um-hum.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Yeah, they'll call you in a minute.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Per calendar year for covered outpatient services is $7900 and there is no outpatient deductible per covered person per calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so is basically what you're saying this covers is co-payment, correct?
[AGENT][NEUTRAL] I can't guarantee payment. I can only provide benefits. This is something that that we can review under that outpatient benefit [PII] that I just gave you. Now because it is a supplemental policy, Cassie, to his primary insurance, we will also have to have a copy of his primary insurance company's explanation of benefits along with the claim for review.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then once we have processed our claim, we do have a portal in which you should be able to check claim status and have access to our explanation of benefits, and our portal website is [PII].
[CUSTOMER][NEUTRAL] D
[CUSTOMER][NEUTRAL] OK, just to confirm, so what would you think, what do you, I'm sorry, I've never heard of a supplemental plan like this. So what would you say? So his, his primary medical insurance, I'm sorry, is [PII], OK, and he has a $60 copay for specialists. Would you say I just bill the insurance like let the company bill the insurance and let them deal with it, or should I charge the $60 co-pay?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Well, that, I mean, we can't tell you how to handle the billing part. I, I, yes, so all I can tell you is that he does have benefits, outpatient benefits.
[CUSTOMER][NEUTRAL] No, no, no, I know, but like.
[CUSTOMER][NEUTRAL] Mhm he has.
[AGENT][NEUTRAL] In which office visits is a covered benefit under his outpatient, so that is something that we can review for and the maximum calendar year benefit that we would pay.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] On covered services is $7900.
[CUSTOMER][POSITIVE] OK, OK, I see, I understand now. OK, thank you so much.
[AGENT][POSITIVE] OK. Well, you, you are certainly very welcome. And is there anything else that I can help you with?
[CUSTOMER][POSITIVE] No, that's all you've been a great help thank you.
[AGENT][POSITIVE] OK, well, you're certainly very welcome and thank you again, [PII], for calling APL and I hope that you have a very nice weekend.
[CUSTOMER][POSITIVE] Thank you you too ma'am bye bye.
[AGENT][POSITIVE] Yes, ma'am. Thank you. Bye bye.