AccountId: 011433970860
ContactId: 8c5d5b08-a7bc-47ac-8847-3a520184cea6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 461200 ms
Total Talk Time (AGENT): 212664 ms
Total Talk Time (CUSTOMER): 155788 ms
Interruptions: 3
Overall Sentiment: AGENT=1.2, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/05/8c5d5b08-a7bc-47ac-8847-3a520184cea6_20250205T19:38_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] Good afternoon [PII]. My name is [PII]. I'm calling from the doctor's office, and I would like to check benefits for a member.
[AGENT][NEUTRAL] OK, did you say your name is [PII]?
[CUSTOMER][NEUTRAL] Yes, I I.
[AGENT][NEUTRAL] OK, thank you. And you're needing to check benefits for a member. Is that correct?
[CUSTOMER][NEUTRAL] Yes, exactly, because I called them the main insurance, the primary, and they told me that this member has an APL account, so I just wanna know if you guys cover anything done in the office.
[AGENT][NEUTRAL] OK, so yes, ma'am. I can help you with that. And I assist you also need eligibility in addition to benefits.
[CUSTOMER][NEUTRAL] Yeah, I mean the patient is not responsible for a co-payment, so I just wanna know if you guys cover the co-payment or the patient is responsible for that part.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I can help you. And what is your callback number, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you and the member's policy number, please.
[CUSTOMER][NEUTRAL] It is Dell patients uh benefits and uh certification number, right?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] 01849205 M [PII].
[AGENT][POSITIVE] OK, thank you. Give me a couple moments to get all the members' information pulled up please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And any information I just that I do provide for you today will be a verification of benefits and not a guarantee of payment. What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so I do show that he is the subscriber on the supplemental policy and it is active with an effective date of [PII].
[AGENT][NEUTRAL] And you were specifically wanting to know about treatment within the office and an office visit, is that correct?
[CUSTOMER][NEUTRAL] Yes, he's responsible. I mean, the, the insurance told me that he has a $60 co-payment and he's telling me that you guys cover that part, so I just wanna confirm that.
[AGENT][NEUTRAL] OK, and any information that I do provide for you again will be a verification of benefits and not a guarantee of payment. So he does have an office treatment writer and an office visit writer on this policy. His outpatient benefit maximum per calendar year for covered outpatient services is $7900 and there is no outpatient deductible per covered person per calendar year.
[AGENT][NEUTRAL] Because this is a supplemental policy, ISIS-2 is primary when you all file the claim with APO, you must also send us a copy of this primary insurance company's explanation of benefits.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] For our review.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then once our 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 EOB by going to secured.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Do you guys cover the co-payment then?
[AGENT][NEGATIVE] Again, I cannot guarantee payment.
[CUSTOMER][NEUTRAL] OK, because usually when I call you guys don't.
[AGENT][NEUTRAL] I can only provide you what his benefit information is, and he has an outpatient benefit maximum.
[AGENT][NEUTRAL] Of $7900.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] For cover person per calendar year.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Oh OK, yeah, because before he's, he used to be my patient like 2 years ago, and I remember when I called you guys told me that she had you guys cover like 3, specialist copayments in the year so you guys even told me like he he already met one, he has 2 left, so the 1st 2 visits we we pay $50 for each uh specialist visit, but now you're telling me a completely different benefits, so I'm assuming that the policy changed.
[AGENT][NEUTRAL] With no outpatient deductibles.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That is correct. Um, I provided you the benefit information on the policy that he currently has.
[CUSTOMER][NEUTRAL] Mm, got it. OK, um, [PII], can I get a reference number for the call please?
[AGENT][NEUTRAL] Yes ma'am, you would use my name along with today's date.
[CUSTOMER][POSITIVE] Beautiful, thank you very much.
[AGENT][POSITIVE] Well, you are certainly very welcome. So is there anything else I just that I can help you with now?
[CUSTOMER][POSITIVE] Just that honey thank you so much.
[AGENT][NEUTRAL] And give me, give me just one moment to look at something on on his policy information please before we hang up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so let's get back on something I said. He, the amount that I gave you as far as office treatment, any treatment would fall under that benefit. He does have his physicians, is this for a specialist or a primary?
[CUSTOMER][NEUTRAL] A specialist.
[AGENT][NEUTRAL] OK, so this is, this is a separate, it's up to $50 per visit at a maximum of 4 visits per calendar year.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, do you, does he have any visit cover this year already, or he has the 4 available?
[AGENT][NEUTRAL] Just one moment.
[AGENT][NEGATIVE] As of now he has not used any of the benefits for this calendar year.
[CUSTOMER][NEUTRAL] Mm, got it, OK.
[CUSTOMER][POSITIVE] Yeah, that's exactly what I was talking about because I remember for previous year.
[AGENT][NEUTRAL] Yes, he has
[AGENT][NEUTRAL] Yes, he has had some changes in his coverage, but with this one specific uh rider that's on this particular policy, yes, on the, on the visit fee. Mhm.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Yeah, so then he only have to pay $10 because for the primary insurance he has $60 and it's since you guys cover $50 he only have $10 co-payment to pay for today's visit. So yeah, that that was I was talking about because I remember he was, he and his wife were uh patients of of the doctor like 2-3 years ago and they have the same insurance but I know with years the policy changes that's why I always call to verify, you know.
[AGENT][NEUTRAL] It has. Sure, yes. But the, any treatment, if he receives treatment, it would fall under that outpatient benefit max that I gave you.
[CUSTOMER][POSITIVE] OK perfect thank you very much for your help, [PII].
[AGENT][POSITIVE] You are certainly very welcome. And again, is there anything else I can help you with today?
[CUSTOMER][POSITIVE] Just that honey thank you so much.
[AGENT][POSITIVE] Well, you're very welcome and thank you again for calling APL. I hope you have a wonderful evening.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Yes, ma'am. Thank you. Bye-bye.