AccountId: 011433970860
ContactId: 9f091d93-09e8-47b7-b95b-3b3a31216af3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 377549 ms
Total Talk Time (AGENT): 182052 ms
Total Talk Time (CUSTOMER): 92289 ms
Interruptions: 0
Overall Sentiment: AGENT=1.3, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/17/9f091d93-09e8-47b7-b95b-3b3a31216af3_20250617T18:38_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Um, hi, good afternoon. My name is [PII]. Um, I'm calling from a provider's office. I would just like to get benefit information for one of our patients.
[AGENT][NEUTRAL] OK, do you also need eligibility or only benefits?
[CUSTOMER][NEUTRAL] Both actually.
[AGENT][POSITIVE] OK. Yes, ma'am. I can help you with both, and I'm sorry, what was your first name again, please?
[CUSTOMER][NEUTRAL] Uh [PII], is my initial. Can I also have again your name?
[AGENT][NEUTRAL] Again, my name is [PII] and the first initial to my last name is [PII].
[AGENT][POSITIVE] And [PII], what is a good, yeah, you're welcome. What is a good callback number for you please?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and the member's policy number?
[CUSTOMER][NEUTRAL] 02275891
[CUSTOMER][NEUTRAL] Mama Lima 8.
[AGENT][POSITIVE] OK, thank you one moment.
[AGENT][NEUTRAL] And any information that is provided will be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK, thank you. 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 what type of benefit information do you need inpatient, outpatient or office?
[CUSTOMER][NEUTRAL] Um, uh, I have a question. Is there a group number?
[AGENT][NEUTRAL] There he is.
[AGENT][NEUTRAL] The group number is 24091.
[CUSTOMER][NEUTRAL] Gonna have
[CUSTOMER][NEUTRAL] And is this an HMO PPO?
[AGENT][NEUTRAL] None of the above. This is not, we are not a major medical insurance. This is a supplemental plan only to his primary insurance.
[CUSTOMER][NEUTRAL] Got it. All right. So I'm looking for a specialist office visit. Is it covered and what would be the outpatient benefit maximum in the accumulation?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] OK, on the supplemental policy read that office visits are not covered.
[AGENT][NEUTRAL] If he, he does have an office treatment writer, so if he were to receive some form of treatment in the office that could be reviewed under his outpatient benefit and he has an outpatient benefit maximum of $7350 per calendar year per covered person for covered services.
[AGENT][NEUTRAL] With no deductibles.
[CUSTOMER][NEUTRAL] And what has been used as of the moment?
[AGENT][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] For this calendar year, he has used $4,705.07.
[CUSTOMER][NEUTRAL] Sorry, 4705.07.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Uh, all right. Can I just have, so in order for me to get the remaining, I have to subtract 735024705.07. Am I correct?
[AGENT][NEUTRAL] Yes, as of now he has used that $4,705.07 of his outpatient calendar year benefit maximum, and his outpatient benefit maximum is $7350. If you all do file a claim with us for review reason, you will also need to include a copy of his primary insurance company's explanation of benefits.
[AGENT][NEUTRAL] Because we must have that as well for review.
[AGENT][NEUTRAL] And then once we have processed our claims here at APL we do have a portal that you should be able to check our claim status in.
[AGENT][NEUTRAL] And the website that you would go to for our portal is located at [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Just wanna be sure that you are not providing me the, the remaining balance. I have to subtract it. Am I correct?
[AGENT][NEUTRAL] I provided you the accumulation.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Oh, OK, got it.
[CUSTOMER][NEUTRAL] That's the remaining balance already 4705.07.
[AGENT][NEUTRAL] No, no, no, no, that's what he's used.
[AGENT][NEUTRAL] So yes, you would need to deduct what he has used for.
[CUSTOMER][POSITIVE] Yeah, that's why I need, I still need.
[AGENT][NEUTRAL] Yes, ma'am. From here, you would deduct that 47 from his maximum benefit amount for the remaining available.
[CUSTOMER][NEUTRAL] Yeah, I still
[CUSTOMER][NEUTRAL] Got it. Can I have address? Mhm.
[CUSTOMER][NEUTRAL] Can I have a reference number?
[AGENT][POSITIVE] Yes ma'am, you would reduce my name along with today's date.
[CUSTOMER][POSITIVE] All right. That's all for today, [PII]. Thank you so much.
[AGENT][POSITIVE] OK. Well, you're welcome, [PII]. So that is all I can help you with. Thank you again for calling APL and I hope you have a, a great rest of your day.
[CUSTOMER][POSITIVE] You too. Take care. Bye-bye.
[AGENT][POSITIVE] Thank you. You too. Bye bye.