AccountId: 011433970860
ContactId: 86173211-0246-4488-9258-14fa57681c4c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 696479 ms
Total Talk Time (AGENT): 264843 ms
Total Talk Time (CUSTOMER): 234199 ms
Interruptions: 4
Overall Sentiment: AGENT=0.9, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/12/86173211-0246-4488-9258-14fa57681c4c_20250512T19:56_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. I'm on a recorded line and I'm calling to verify benefits for a patient coming into the office for infusion therapy and I need to verify coverage for specific procedure codes.
[AGENT][NEUTRAL] OK [PII], you're needing to verify the eligibility and benefits on a member, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes ma'am, I can help you with that and what is a good call back number for you please, [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you and the member's policy number please.
[CUSTOMER][NEUTRAL] It is
[CUSTOMER][NEUTRAL] 02331798.
[AGENT][POSITIVE] OK, thank you. Give me a couple of moments please to get the member's information pulled up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] [PII], how did you spell your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You have a name like mine that everybody spells differently, so that's why I always try to ask.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and any information that I provide for you would be a verification of benefits and not a guarantee of payment. What is your patient's name please and their date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] So I show that on this policy number you gave me she had been the subscriber on the supplemental policy but this policy is no longer active um this policy was active from 5.
[AGENT][NEUTRAL] [PII] has a term date of [PII].
[AGENT][NEUTRAL] And let me see if she has another policy that picked up after that. Maybe, mhm. That's because you have an old policy number.
[CUSTOMER][NEUTRAL] Oh, it's been termed that long?
[AGENT][NEUTRAL] So let me get up, let me, yeah, you have an old policy number.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] So give me just a moment and I'll get the.
[CUSTOMER][NEUTRAL] OK, what is the uh.
[AGENT][NEUTRAL] Yeah, give me just.
[CUSTOMER][NEUTRAL] Policy number. OK.
[AGENT][NEUTRAL] Mhm. So bear with me just a.
[AGENT][NEUTRAL] OK, so the active policy that she has, [PII] is 262.
[AGENT][NEUTRAL] 0609.
[AGENT][NEUTRAL] And it has an effective date on here of [PII].
[CUSTOMER][NEUTRAL] OK. So,
[CUSTOMER][NEUTRAL] Um, what type of, um,
[AGENT][NEUTRAL] And this is a supplemental.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, it's a supplemental, but what time does it run from 5:1 to 4:[PII] or how does it run?
[AGENT][NEUTRAL] The calendar year. It's a calendar year. It's just this policy renewed effective date is [PII]. It's a calendar year policy.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK. And then, um,
[CUSTOMER][NEUTRAL] What is the benefit max on it?
[AGENT][NEUTRAL] OK, so she has an outpatient benefit maximum of $6750 per calendar year for covered outpatient services, and there is an outpatient deductible on the supplemental policy of $1500.
[CUSTOMER][NEUTRAL] Has she met anything towards the deductible?
[AGENT][POSITIVE] I can check that for you
[AGENT][NEUTRAL] As of now, no, ma'am, no benefits have been used or deductible amount on there's no claims for her.
[CUSTOMER][NEUTRAL] OK, and then she hasn't used any of her Benefit Max either?
[AGENT][NEUTRAL] She has not used any of her benefit maximum, no, ma'am.
[CUSTOMER][NEUTRAL] OK, so, um.
[AGENT][NEUTRAL] Now when the claim is
[CUSTOMER][NEUTRAL] Is this a fully funded or self-funded type?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] This is a supplement to her primary insurance.
[AGENT][NEUTRAL] We show her primary insurance to be Blue Choice Health plan.
[CUSTOMER][NEUTRAL] OK, 22.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Good choice.
[AGENT][NEUTRAL] Mm, that's what I show in the system.
[CUSTOMER][NEUTRAL] So you don't have, you're not fully funded or self-funded and
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] We're not a major medical carrier.
[CUSTOMER][NEGATIVE] No. OK.
[AGENT][NEUTRAL] So when you won't file any claims with us for her on this policy, you will also have to include a copy of her primary insurance company's explanation of benefits as well.
[CUSTOMER][NEUTRAL] OK. And then um is
[CUSTOMER][NEUTRAL] OK, do you guys have provider networks?
[AGENT][NEUTRAL] There is no network with the supplemental policy.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Network.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and then, uh, so not disclosed, so.
[CUSTOMER][NEGATIVE] It's not a health plan, it's, it doesn't follow any health plan guidelines.
[AGENT][NEUTRAL] This does not. No, ma'am. Again, we're not a major medical carrier.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The supplemental policy only helps with, no, ma'am.
[CUSTOMER][NEUTRAL] So does she have to have a referral to use you guys?
[AGENT][NEUTRAL] Again, it's a supplement that, sure, oh, OK. Well then I'm, OK, go ahead.
[CUSTOMER][NEUTRAL] OK, I just have questions I have to ask.
[CUSTOMER][NEUTRAL] Yeah, um, does it have a group name or group number?
[AGENT][NEUTRAL] The group number is 19344.
[AGENT][NEUTRAL] The name is Favor Upstate.
[CUSTOMER][NEUTRAL] Does it have a plan name or number associated with it?
[AGENT][NEUTRAL] This is a Medlink supplemental policy.
[CUSTOMER][NEUTRAL] OK, me link supplemental.
[CUSTOMER][NEUTRAL] OK, and is there a claims mailing address? So send EOB with claim to.
[AGENT][NEUTRAL] Mhm. And the address should be the same as on the card you had. [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] And do you guys have a payer number?
[AGENT][NEUTRAL] 60801.
[CUSTOMER][NEUTRAL] OK. And then, um,
[CUSTOMER][NEUTRAL] I know it's supplemental, but I'm gonna ask you some questions that I would normally ask for a regular policy. Yes or no is fine. Can we buy and bill with this policy, or do you guys even take codes?
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Do you guys even take codes like for, OK, so you don't take codes.
[AGENT][NEUTRAL] In advance? No, ma'am.
[CUSTOMER][NEUTRAL] OK, so no, um.
[CUSTOMER][NEUTRAL] Do you guys cover infusion therapy?
[AGENT][NEUTRAL] Again, we would have to receive the claim to review that for benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and do you guys need an authorization or anything?
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] Or just that you received the EOB with the claim, OK.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, OK. And
[CUSTOMER][NEGATIVE] All right, let me just put, oh, I can't put nothing in there. All right, so, uh, you gave me the new policy number 262-0609 cause there's one spot like there's a glitch right now. So if I put something in this one spot, it's gonna mess me all up and then I'm gonna be sitting here waiting for it to stop acting up. I know, so I'm like, no, I got, I went to go do it and I like I had to stop myself. I was like, no, we don't want to go there. OK, so, so, so this is just covered uh deductible of 1500 then.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEGATIVE] Oh no
[AGENT][NEGATIVE] Oh no.
[AGENT][NEUTRAL] Uh uh.
[AGENT][NEGATIVE] Uh, no.
[CUSTOMER][NEUTRAL] Up to the benefit max of 6750, which nothing has been met towards the deductible or the benefit max of 6750. So this is the secondary gap plan to Blue Choice Health plan, no network, um, effective date [PII] runs on a calendar year. There's no funding type, um, no following the health plan, no referrals from a primary care physician because it's a supplemental gap.
[AGENT][NEUTRAL] Right, that's what.
[CUSTOMER][NEUTRAL] So I put commercial gap saver upstate in the group name 19344 for the group number for the plan meddling supplemental policy and then for claims send EOB with claims to [PII] [PII] or [PII] and the payer number is 60801.
[AGENT][NEUTRAL] Yes, and then, um, that is correct. And when the claim is submitted to APL for review once it's been processed by us, um, [PII], we do have a portal in which you should be able to check claim status and the website for our portal is located at [PII].
[CUSTOMER][NEUTRAL] Is that correct?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, ma'am. Uh-huh.
[CUSTOMER][NEUTRAL] OK, and you gave me a portal [PII]. Can I get a reference number for our call?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] You would use my name that I gave you along with today's date.
[CUSTOMER][POSITIVE] Thank you. You have a good rest of your day.
[AGENT][POSITIVE] Well, you're certainly very welcome. It was my pleasure. Is there anything else that I could help you with today?
[CUSTOMER][NEUTRAL] No, thank you.
[AGENT][POSITIVE] OK, well thank you again for calling ATL and I hope you have a great afternoon also.
[CUSTOMER][NEUTRAL] You too bye