AccountId: 011433970860
ContactId: a212f117-eeb1-4755-8b07-9d0aacd30faf
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 374299 ms
Total Talk Time (AGENT): 209861 ms
Total Talk Time (CUSTOMER): 112132 ms
Interruptions: 1
Overall Sentiment: AGENT=1.1, CUSTOMER=1.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/06/a212f117-eeb1-4755-8b07-9d0aacd30faf_20250606T15:48_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, how are you? I just wanted to call about a member's benefits.
[AGENT][NEUTRAL] OK, you're needing to get benefit information for a member, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, I can help you with that. Do you also need eligibility or only benefits?
[CUSTOMER][NEUTRAL] Uh, both.
[AGENT][POSITIVE] OK, yes, I can help you with both. And who am I speaking with?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] Can you spell your name for me, please?
[CUSTOMER][NEUTRAL] Sure, [PII]
[AGENT][NEUTRAL] And can you pronounce it again, please?
[CUSTOMER][POSITIVE] You got it.
[AGENT][NEUTRAL] You get me?
[CUSTOMER][NEUTRAL] You have [PII], you have [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] [PII]? Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you and if again, what is your callback number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you and the member's policy number, please.
[CUSTOMER][NEUTRAL] Uh, one moment, it is.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So it's a there's a group number is that what what you're talking about?
[AGENT][NEUTRAL] No, so there should be an in-hospital or an outpatient or a policy certificate. OK.
[CUSTOMER][NEUTRAL] Oh yeah, yeah, yeah, outpatient, sorry, yep, yeah, this would be outpatient um uh 023.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 71753.
[CUSTOMER][NEUTRAL] M like Michael. L like Larry 8.
[AGENT][NEUTRAL] OK, thank you, give me one moment while I get the member's information pulled up.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And any information that I do provide for you today will be a verification of benefits and not a guarantee of payment, so one moment.
[AGENT][NEUTRAL] OK. And what is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] Date of birth is [PII], and the name is [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, if any, do you need for him inpatient, outpatient or office?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] outpatient physical therapy benefits.
[AGENT][NEUTRAL] OK, so on this supplemental policy, the outpatient benefit maximum per calendar day for covered outpatient services is $500 and there is no outpatient deductible per covered person per calendar day.
[AGENT][NEUTRAL] Because this is a supplemental policy to the primary insurance when you all file your claim with APL, we will have to have a copy also of the primary insurance company's explanation of benefits.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Along with that claim for review and then once we process the claim here ifcan we do have a portal in which you should be able to check our claim status and the website for our portal is located at secured.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah, I got it. um, got it. So you, so because here's the thing, he's got, um, he's got a plan that I'm not participating with, so he was just curious like how that works if I don't participate with this plan, um, then, then what it it defaults to you guys.
[AGENT][NEUTRAL] OK, so with APL we, there's no network affiliated with APL and if the primary insurance does not cover, APL would not provide any benefits either.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Oh, I see, so it's only in network so it's only with in network benefits, got it.
[AGENT][NEUTRAL] Well, it's, again, anything whether it's regardless of the reason, if it's not a covered benefit, if it's not covered by the primary insurance.
[AGENT][NEUTRAL] A service or because it's out of network, if it's not covered by the primary, it would also not be covered by APL.
[CUSTOMER][NEUTRAL] OK, so just so I could kind of.
[CUSTOMER][NEGATIVE] Repeat what you're where you're telling me from based on what I'm understanding if he is out of network with his primary insurer, right, they don't cover the services in network it is out of network benefit you guys don't cover that as well. You only cover what his insurance covers in network, whatever the in work benefit is that they're denying or not covering you guys are covering the secondary part of it, right?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] This policy only helps with co-pays, deductibles, and co-insurance amounts of covered services up to that benefit maximum per calendar day of $500.
[CUSTOMER][NEUTRAL] OK, so he has a $75 copayment, right? In network, so then what he submitted to you guys?
[AGENT][NEGATIVE] Now, an office visit is not covered under this policy. This was, I was giving physical therapy for the treatment, but office visits are not covered. Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] Oh for the treatment.
[CUSTOMER][POSITIVE] Got you. OK, perfect, thank you so much I appreciate it.
[AGENT][NEUTRAL] OK, well, you're very welcome. So what I would recommend is that once the claim has been filed, if you all are filing the claim for him, um, most providers do file the supplemental. If you all don't, then he can, but it would have to be filed with his primary first and then with [PII] since we have to have a copy of their explanation of benefits showing those three categories.
[AGENT][NEUTRAL] But the co-pay deductible or co-insurance amounts. OK, well, you're very welcome. So is there anything else I can help you with today?
[CUSTOMER][POSITIVE] Got you. OK, thank you so much.
[CUSTOMER][POSITIVE] Perfect, thank you.
[CUSTOMER][POSITIVE] That's it thank you so much bye bye.
[AGENT][POSITIVE] Well, you're welcome have a great day and thank you again.