AccountId: 011433970860
ContactId: bf03453d-bbf9-4771-9097-1a0e7ceb092d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 246600 ms
Total Talk Time (AGENT): 151015 ms
Total Talk Time (CUSTOMER): 76490 ms
Interruptions: 3
Overall Sentiment: AGENT=0.2, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/26/bf03453d-bbf9-4771-9097-1a0e7ceb092d_20250226T14:33_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yeah, this is [PII] at Women's Health Specialist. I have a patient that's having um outpatient surgery and she gave us this card, I guess this is her um.
[CUSTOMER][NEUTRAL] Another insurance that she has?
[AGENT][NEUTRAL] Mhm. What is your name?
[CUSTOMER][NEUTRAL] The APL, so I'm just calling.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Could you provide me with the spelling of your name, [PII], and a callback number?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you, [PII], and what is the policy number of the member that you're inquiring eligibility for today?
[CUSTOMER][NEUTRAL] OK, so do I have.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, do I go by the outpatient benefit number?
[AGENT][NEUTRAL] It doesn't matter which policy number you provide, it's gonna pull up the policy.
[CUSTOMER][NEUTRAL] 0302329
[CUSTOMER][NEUTRAL] 399 ML 8.
[AGENT][NEUTRAL] Thank you, [PII], could you verify that patient's name and date of birth, and I'll be able to provide you benefits.
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] You're calling to verify benefits and eligibility for outpatient, correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] This patient policy has been active since [PII] and is currently active. She has outpatient benefits of $2000 per calendar year, and this is not a guaranteed benefits, just a disclaimer of the policy's coverage. This policy is a gap insurance that assists with deductible, co-pay and co-insurance to the primary for services that's covered under the policy.
[CUSTOMER][NEUTRAL] OK, so it's for the doctor and the hospital or just the hospital?
[AGENT][NEUTRAL] It's for any medical services. It helps with any services that's covered under the policy, a gap insurance with the deductible, co-pay and co-insurance.
[CUSTOMER][NEUTRAL] OK, so she has a $2000 deductible.
[CUSTOMER][NEUTRAL] So, I just wouldn't collect that?
[AGENT][NEUTRAL] No, you will submit the claim to the primary insurance company then you're submitted here.
[CUSTOMER][NEUTRAL] And they'll pay the $2000.
[AGENT][NEUTRAL] We would cover whatever went goes towards deductible, co-pay and co-insurance because you may be a participant provider in her network. So once the primary make adjustments and whatever goes towards deductible copay and co-insurance, that's the patient responsibility, then we will cover that with her gap insurance.
[CUSTOMER][NEGATIVE] Hey this isn't make a lot of sense to me because we collect up front.
[CUSTOMER][NEUTRAL] The $2000 because we don't want to.
[AGENT][NEUTRAL] Well, [PII], I can't tell you how to bill unfortunately I can only verify the benefits that you called to verify and I did that and this is a gap insurance. I tried to explain it the best that I can without you being confused after the phone call, but this is a gap insurance and we.
[AGENT][NEUTRAL] Put whatever goes towards her deductible copay and co-insurance to whatever her primary insurance is, we submit the claim here after you received the ELB from the primary showing what went towards deductible copay and co-insurance, and then we will make payments on it.
[CUSTOMER][NEUTRAL] You make payments on or you pay it?
[AGENT][NEUTRAL] We will pay the claim for services that's covered under the policy.
[CUSTOMER][NEUTRAL] OK, I'm gonna have to check with my boss on this one, OK, because it's going to be the hospital and us both going for the same thing.
[AGENT][NEUTRAL] Right, I get that. So it's gonna be a facility charge, it's gonna be a facility charge, and it's gonna be a professional charge. However, if she has a $2000 deductible for her primary insurance, it's not, that does not mean that it's gonna be $2000 for you and $2000 for the facility.
[CUSTOMER][NEUTRAL] So it's whoever gets there first.
[AGENT][NEUTRAL] It wouldn't that's not possible if she has a $2000.
[CUSTOMER][NEUTRAL] No, it's just 12, it's 1 $2000 payment and then everything is covered at 80%.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So I've explained how we make payments. Is there anything else that I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] All right, let me talk to my boss.
[CUSTOMER][NEUTRAL] No, and your name again was?
[AGENT][NEUTRAL] [PII], and today's date of the reference.
[CUSTOMER][POSITIVE] OK, thank you, [PII].
[AGENT][POSITIVE] You're welcome, [PII]. Thanks for calling APL. Have a good day. Goodbye.
[CUSTOMER][NEUTRAL] You too