AccountId: 011433970860
ContactId: b7c5794f-2ecc-4a19-8073-397c3840b913
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 414959 ms
Total Talk Time (AGENT): 234228 ms
Total Talk Time (CUSTOMER): 205971 ms
Interruptions: 7
Overall Sentiment: AGENT=0.9, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/26/b7c5794f-2ecc-4a19-8073-397c3840b913_20250626T15:35_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, good morning. This is [PII] calling from Dolphin Pediatrics to verify patient eligibility and benefits, please.
[AGENT][NEUTRAL] Yeah, sure. I can assist you with the eligibility and benefits. And you say you're calling from Mary's Pediatrics or what is the name? I'm sorry. Oh.
[CUSTOMER][NEUTRAL] Dolphin Dolphin pediatrics. [PII]'s my name.
[AGENT][POSITIVE] I'm so sorry.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] No worries.
[AGENT][NEUTRAL] OK. And may I have a callback number just in case we get disconnected, Ms. [PII]?
[CUSTOMER][NEUTRAL] Sure it's gonna be [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] OK, policy number it's going to be there's like two there's one it's 02497634 M as in Mary, L as in Larry, then there's one with is number 7 and 8 so I guess this is a PCP office, so it will be the outer network I think.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, yes, outpatient, outpatient. All right, thank you. Yes.
[CUSTOMER][NEUTRAL] Outpatient, OK.
[AGENT][NEUTRAL] Alright, and may I have the name and date of birth of the patient.
[CUSTOMER][NEUTRAL] Sure, it's gonna be [PII] and her date of birth is [PII].
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Perfect. Thank you. All right, and you said he was in office, so let me go ahead and get that benefits for you and this is not a guarantee of payment, just a verification of coverage and that's just a disclaimer. We have an effective date of [PII]. It is active at the moment and this is one of our secondary supplemental plan to the major medical.
[AGENT][NEUTRAL] And with this one, it looks like we covered the office procedures and office uh treatment and let's see, and we.
[CUSTOMER][NEUTRAL] Do you guys cover wellness?
[AGENT][NEGATIVE] No, we do not cover wellness. No, we do not cover wellness. We shouldn't.
[CUSTOMER][NEUTRAL] For the child.
[CUSTOMER][NEGATIVE] Yeah, because the insurance denied it and that because he ran out of benefits last year and um the dad is like, no, just build my secondary. I'm like, I have to ask because I don't think they cover wellness.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] Mm mm. No, we do not. We do not cover wellness and it's the major medical, don't pay, we do not pay. Um, she does have office visit benefits as well as office treatment, but yeah, it looks like she's, uh, they started on [PII] and this is for sickness or illness or accidents, but it's not for wellness or preventative.
[CUSTOMER][NEUTRAL] So, accidents and sickness. Whatever, so let's say Aetna doesn't cover the sickness visit. Do you guys cover it?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] If they apply, yeah, if they apply the benefits towards the deductible, co-payment, and co-insurance, then we'll go ahead and pick it up from there. Now, if they say um this member does not qualify because uh let's say it's out of network and we don't deal with that with that company or that place, then um if they deny completely, we will deny as well.
[CUSTOMER][NEUTRAL] Something like that?
[CUSTOMER][NEUTRAL] Uh huh
[CUSTOMER][NEUTRAL] Uh huh
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Do you guys cover copays, co-insurance, or deductibles, or the parent is responsible for that?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, we are the ones that cover the deductibles, co-payment, and co-insurance from the major medical.
[AGENT][POSITIVE] And let me give you the maximum benefit. Mhm.
[CUSTOMER][NEUTRAL] OK, because usually he has a $10 copay, so he usually pays for it.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Oh no, we pay for that.
[CUSTOMER][NEUTRAL] OK, so you guys do cover the copayments. I know some of them, some plans that you guys have don't because I have a mom with the same plan with the American public and they're like, no, we only cover hospital and accidents.
[AGENT][NEUTRAL] Mhm. Yeah.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] Mm, yeah.
[CUSTOMER][NEUTRAL] So OK, so you guys cover coba deductibles.
[AGENT][NEUTRAL] Yeah, for this one we do for this group, mhm.
[CUSTOMER][NEUTRAL] And co-insurance, OK, but that's only for 6 visits.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] For sickness or accident, office visit. Mhm, yes.
[CUSTOMER][NEGATIVE] Sick visits like office visits or accidents. OK, it's office visits, yeah, like if it's a follow up you guys will cover the copay, right? $10.
[AGENT][NEUTRAL] Correct, yes. Any office visit, it will be covered. Any office procedures will be covered as long as it's, um, um, you know, like sickness or accident, and it's not related to preventativeone wellness. And that is subject to the outpatient maximum, and there is an outpatient maximum of 7900 per cover person per calendar year on this one.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] How much do they have remaining?
[AGENT][NEUTRAL] Um, I can check. Let's see.
[CUSTOMER][NEUTRAL] Please.
[CUSTOMER][NEUTRAL] 01.
[CUSTOMER][NEUTRAL] moment.
[AGENT][NEUTRAL] OK, so they have not used their benefits for [PII] as of today, so the full amount is still available.
[CUSTOMER][NEUTRAL] OK, so is this like a deductible or is it like a an out of pocket?
[AGENT][POSITIVE] The amount that I'm giving you is a total benefit amount.
[CUSTOMER][POSITIVE] Total benefit.
[CUSTOMER][NEUTRAL] Amount, OK, and then you guys cover corporate deductible co-insurance for office visits and.
[AGENT][POSITIVE] So it's a maximum benefit.
[AGENT][NEUTRAL] For office visit and office procedures. Mhm. Correct.
[CUSTOMER][NEUTRAL] An office procedures procedures. OK, so no wellness. I have to make that very clear to that because no wellness. How about the vaccines? Do you guys cover vaccines for the child? like routine vaccines?
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] If it's part of the wellness or preventative, we do not.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] No, OK, no cover. OK, uh, may I please, so then for the outpatient since it's also the PCP, I have to put number 8, right, not number 7.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, yeah, you can do that or you can just leave the numbers. We don't really use that ML 8 or 7. That's just to let us know which one is it, but it's not really required. The first digits are enough.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, no, I just need to know because I have to input it in my system. So do I just put the [PII] 8?
[AGENT][NEUTRAL] I say that.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][POSITIVE] Yeah, you can, yes.
[CUSTOMER][NEUTRAL] Oh OK and then um.
[CUSTOMER][NEUTRAL] Because we do take American Public Life, so, um, can you check it for a network?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, you don't have to be.
[CUSTOMER][NEUTRAL] Can I give you the MPI of the box? No, OK.
[CUSTOMER][NEUTRAL] I don't have to be OK, um, so last thing, can I please get a reference number of the call and that's it.
[AGENT][NEUTRAL] Your medical. No.
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will, Miss [PII].
[CUSTOMER][NEUTRAL] OK, what is your name?
[AGENT][NEUTRAL] My name is [PII]. That's [PII]. Last initial [PII].
[CUSTOMER][POSITIVE] So oh that's cute and then today's date, right?
[AGENT][POSITIVE] Thank you. Yes, that's correct. Mhm.
[CUSTOMER][POSITIVE] OK, thank you so much have a good day bye bye.
[AGENT][POSITIVE] You're welcome, ma'am. Thank you for calling APR.