AccountId: 011433970860
ContactId: bdcd3175-e35c-4132-a84c-b51a2f86f365
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 416019 ms
Total Talk Time (AGENT): 199061 ms
Total Talk Time (CUSTOMER): 143109 ms
Interruptions: 3
Overall Sentiment: AGENT=1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/22/bdcd3175-e35c-4132-a84c-b51a2f86f365_20250422T12:50_UTC.wav
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[AGENT][NEUTRAL] Good morning thank you for calling APL. This is [PII].
[AGENT][NEUTRAL] How can I help you?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Oh yes, hi, good morning. I am calling for benefits for a patient that's coming in for a specialist office visit as well as an ultrasound being done in the office.
[AGENT][NEUTRAL] OK, so you're needing, do you also need eligibility or only benefits?
[CUSTOMER][POSITIVE] Eligibility would be great too, yeah.
[AGENT][POSITIVE] Sure, yes ma'am. I can help you with all of that and who am I speaking with please?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][POSITIVE] Thank you. And [PII], what is a good callback number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and the member's policy number please, [PII]?
[CUSTOMER][NEUTRAL] Is 02216511 ML8.
[AGENT][POSITIVE] OK, thank you one moment please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then the information that I provide for you today, [PII] would be a verification.
[AGENT][NEUTRAL] Payment. What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] It's [PII] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so I do show she is the spouse of the subscriber on this uh excuse me, the supplemental policy, [PII], and it is active.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And on this policy, office visits are not covered. However, they do have an office treatment rider in which we could review.
[AGENT][NEUTRAL] Office and the outpatient benefit maximum per calendar day for covered outpatient services is $200 and there is no outpatient deductible per covered person per calendar day.
[CUSTOMER][NEUTRAL] OK, the phone keeps going in and out for some reason, but um, so from what I took from that was the office visit is not covered and then I kinda lost you when you said about a writer.
[AGENT][NEUTRAL] They do have an office treatment writer in which the test could be reviewed under.
[AGENT][NEUTRAL] And their outpatient benefit maximum per calendar day for covered outpatient services is $200.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so would you say that ultrasound being done in the office falls under that 200?
[AGENT][NEUTRAL] And there is no outpatient deductible?
[AGENT][NEUTRAL] That is something we could review. Yes, ma'am.
[AGENT][NEUTRAL] We could review that under her $200 per calendar day for covered outpatient services.
[CUSTOMER][NEUTRAL] OK, um.
[AGENT][NEUTRAL] And because it is a supplemental policy, [PII], when the primary, excuse me, when the claim is submitted to APL for review, we will also have to have a copy of her primary insurance company's explanation of benefits as well.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then once we have processed our claim, we have a portal that you should be able to check our claim status in by going to [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, um, just because I need like a little more clarification when you say it has to be reviewed, um, is there anything that I can give you, um, over this phone call, possibly a CPT code or anything like that in order to narrow down if it'll be covered or not?
[AGENT][POSITIVE] That is correct.
[AGENT][NEGATIVE] No, ma'am, it is not.
[AGENT][NEUTRAL] Because again, this is a supplement to the primary that helps with co-pays, deductibles and co-insurance amounts of coverage services. So we cannot guarantee payment over the phone, we will have to receive the claim along with the primary EOB for review.
[CUSTOMER][NEUTRAL] OK, so supplement not gap, right?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Is that right? Is this considered a supplement insurance or a gap insurance?
[AGENT][NEUTRAL] Some people call it a, some people call it a, yes, but it is a supplement to the primary healthcare insurance.
[CUSTOMER][NEUTRAL] OK, because there is there's.
[AGENT][NEUTRAL] We are not a major medical insurance company.
[CUSTOMER][NEUTRAL] No, I understand that it's just there's a difference with the gap insurance with the classification of gap how they cover as well as there's a difference for supplement. So supplement typically it's gonna pick up the remainder of the deductible and co-insurance from the primary and.
[CUSTOMER][NEGATIVE] For this insurance American Public Life, it doesn't seem like it's working that way. From my experience, this is a gap insurance, so.
[CUSTOMER][NEUTRAL] The problem I'm having is that we need to advise the patient whether her ultrasound is gonna be covered or not. I don't want her to have to pay for the ultrasound, sorry?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Yes, ma'am, and we can't guarantee that.
[AGENT][NEUTRAL] Right, and we can't guar yes ma'am, and we cannot guarantee payments. I can only provide you with the benefit information is on the supplemental policy.
[CUSTOMER][NEUTRAL] OK, alright, um.
[CUSTOMER][NEUTRAL] Alright, so this $200 how is it classified again outpatient?
[CUSTOMER][NEUTRAL] Benefits
[AGENT][NEUTRAL] That's the outpatient benefit maximum.
[AGENT][NEUTRAL] Benefits per calendar day. Mhm.
[CUSTOMER][NEUTRAL] Per day, right?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Got it. Alrighty, I'll go with it and let's see what happens. um, what was your name again? I'm sorry.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] My name is [PII] and you would use my name along with today's date if you need a call reference number today, [PII].
[CUSTOMER][POSITIVE] All right will do thank you for your help.
[AGENT][POSITIVE] OK. Well, you're welcome. So again, is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No.
[AGENT][POSITIVE] OK, well, thank you so much then for calling APL and I hope you have a very nice day.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Bye bye.