AccountId: 011433970860
ContactId: d8de1ae8-33fe-46a6-9d08-b04ff728c275
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 622229 ms
Total Talk Time (AGENT): 245127 ms
Total Talk Time (CUSTOMER): 267950 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/03/d8de1ae8-33fe-46a6-9d08-b04ff728c275_20250603T20:15_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. Yes, my name is [PII], first initial last S like [PII]. I am calling to check for pre-certification if required on this page.
[AGENT][NEUTRAL] OK, can I get a good callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure. [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you so much, [PII]. And what is the uh policy number?
[CUSTOMER][NEUTRAL] Policy number is 02455081.
[AGENT][NEUTRAL] OK, give me just a moment to look that up.
[AGENT][NEUTRAL] And can you verify the patient's name and date of birth for me, please?
[CUSTOMER][NEUTRAL] Yeah, patient is [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Thank you so much for verifying that for me.
[CUSTOMER][NEUTRAL] And tell me your name again, please.
[AGENT][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] I'm sorry to have you uh repeat yourself. My phone was breaking up. What was that again?
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII], OK, and the first initial last name [PII]?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] OK, that's a beautiful name, [PII]. They always teach you about [PII], huh?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, or, or the ballerina or the mouse.
[CUSTOMER][NEUTRAL] It's a pretty name.
[AGENT][NEUTRAL] Um, so I am showing that this policy is active but an effective date of [PII]. This is secondary gap insurance. Uh, so when filing a claim for this insurance, we'll need the primary insurance EOB within the claim document.
[CUSTOMER][NEUTRAL] Oh what?
[AGENT][NEUTRAL] Um, we don't require pre-authorization. Uh, I don't know about their major medical though.
[CUSTOMER][NEUTRAL] All right, so
[CUSTOMER][NEUTRAL] OK, so this is gap insurance, um, so with the gap insurance, um, the primary will just send it over to you guys, correct? Gap insurance.
[AGENT][NEUTRAL] I believe so, uh, go ahead.
[CUSTOMER][NEUTRAL] All right. Is this a
[CUSTOMER][NEUTRAL] It's just, it's not like [PII], is it?
[AGENT][NEUTRAL] It's not like what?
[CUSTOMER][NEUTRAL] A Mediga or Medicare gap or I'm not exactly sure.
[AGENT][NEUTRAL] No, this is, this is an APL policy American Public Life, um, it's a Medlink policy, it's just secondary gap insurance.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] That link. OK, now is there in a in and out of network benefits for this or not really?
[AGENT][POSITIVE] Uh, no, not for this one. As long as the primary insurance doesn't deny the claim, we should be able to help pay for that. Um, this insurance helps with co-pay, co-deductible, and co-insurance.
[CUSTOMER][NEUTRAL] Alright, so there's no in and.
[AGENT][NEUTRAL] So the primary does have to pay at least partial.
[CUSTOMER][NEUTRAL] OK, yeah, alright, so she has sickness.
[AGENT][NEUTRAL] Right, so no in and out of network for us.
[CUSTOMER][NEUTRAL] OK, no, in and out of the network and no authorization is required for any codes at all?
[AGENT][NEUTRAL] Uh, not for us. I don't know about their primary.
[CUSTOMER][NEUTRAL] Yeah, the primary, yeah, they do require all. I've already submitted, so I put in here, uh, no offer required for this insurance, OK, um, do, do you have like her benefits, uh, is there a referral required? I don't think so. Right.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Um, no, did you want me to go over some of the benefits they have?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yes, do you like an annual deductible out of pocket they have stuff like that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I can help you with that. Let me pull up their policy real quick.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And is it, do you have specific uh inpatient or outpatient?
[CUSTOMER][NEUTRAL] It's like a gap
[AGENT][NEUTRAL] That you'd like me to discuss?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Uh, let's just do inpatient. I don't, um.
[CUSTOMER][NEUTRAL] Inpatient since the first one since she doesn't have in and out of network benefits so the primary is inpatient. I mean, um.
[CUSTOMER][NEUTRAL] It is outpatient, so the primary will usually pay because it is uh Cigna. So is there a deductible so it's like in the specialist office? It's like surgery in a specialist office.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, um, and I do want to say that this is a verification of benefits, not a guarantee of coverage. I'm not showing that they have a deductible for this policy. I am showing that they have.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] An inpatient benefit of up to $3000 per covered person per calendar year.
[CUSTOMER][NEUTRAL] What about outpatient in the doc doctor's office?
[AGENT][NEUTRAL] I'm showing an outpatient benefit maximum of the same $3000 per calendar year and I am showing for outpatient percentage to be 100% it needs to be due to an illness or an accident.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Illness or an accident. Um, well, this is an illness, OK, outpatient 3000 and it could be, it could be covered in the doctor's office too.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Let me see if they have doctor's office. I know not a doctor's office visit typically, um, but let me double check.
[CUSTOMER][NEUTRAL] Yeah,
[CUSTOMER][NEUTRAL] Yeah, see if it covers, yeah, see if it covers like outpatient surgery done in the doctor's off[PII]. This could be a plan that is for inpatient and outpatient hospital and doesn't cover doctor's office maybe, but I don't know, I'm not familiar with this insurance at all.
[AGENT][NEUTRAL] Right, I am [PII]ng that it excludes um where'd it go? Physician office visit fees. Now, surgery should be covered.
[AGENT][NEUTRAL] Um, but it won't, it won't pay for the, the office visit fee.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It'll pay for some of the procedures done.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It won't pay for the office visit, but it may pay, may pay for the procedure.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, it just has to be billed out we don't know for sure, right?
[AGENT][NEUTRAL] Right, because I don't have the codes with me.
[CUSTOMER][NEUTRAL] OK, um, well, the code we're doing is 37242. Uh, would you be able to look that up maybe?
[AGENT][NEUTRAL] Um, I'm not able to see codes, um.
[AGENT][NEUTRAL] What is it for?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, it's for, um, this will be for, uh, arteriovenous malformation procedure that we're doing.
[AGENT][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And you said that is due to an illness that sounded like a cardiac event.
[CUSTOMER][NEUTRAL] I'm sorry, say that one more time.
[AGENT][NEUTRAL] Was it due to an illness? It sounded like it was something for.
[CUSTOMER][NEUTRAL] Pulmonary, yeah, pulmonary more so long, yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, yeah.
[CUSTOMER][NEUTRAL] So that what you think of a cover?
[AGENT][POSITIVE] Yes, it does show that that should be covered.
[CUSTOMER][NEUTRAL] OK, should be covered. Alright, um, any out of pocket.
[AGENT][NEUTRAL] Yes, I have.
[AGENT][NEUTRAL] Um, we don't do patient responsibility such as out of pocket for, um, our portion of the insurance, we don't have that, uh, it, it would be up to the primary, but we don't have that.
[CUSTOMER][NEUTRAL] Oops, go ahead, sorry.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Alright, is there a copay under hers for this?
[AGENT][NEUTRAL] Uh, not under this policy. This policy helps pay the copay, um, so some of the benefits might go towards the copay or the deductible.
[CUSTOMER][NEUTRAL] No co-pay, right?
[CUSTOMER][NEUTRAL] OK, I see.
[AGENT][NEUTRAL] But we don't have a copay.
[AGENT][NEUTRAL] Uh, for this policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alrighty, well I guess that's it is gap insurance it does cover no pre-existing conditions on this, is it?
[AGENT][NEUTRAL] Uh, I did not see any preexisting condition listed on there, no.
[CUSTOMER][NEUTRAL] OK, so this is in and out of network. Uh, she has in and out of network benefits and would you be able to tell if we're in network or not really?
[AGENT][NEUTRAL] Um, no, because we, we don't do networks, we just pay a set amount, um, based off of the procedure codes. It would be, it would be completely up to the primary, but we don't, we don't go in or out of network.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, no network. OK, very good, um, no network, it will pay if the primary pays.
[CUSTOMER][NEUTRAL] Alright, alrighty, a reference number, [PII], um.
[AGENT][POSITIVE] Correct. Mhm.
[CUSTOMER][NEUTRAL] Yes, may I get a call reference number?
[AGENT][NEUTRAL] So we don't have call reference numbers um but you can use my name and last initial in today's date.
[CUSTOMER][NEUTRAL] OK, his name.
[CUSTOMER][NEUTRAL] Date
[CUSTOMER][NEUTRAL] Uh, the date which is um [PII].
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] And the time.
[AGENT][NEUTRAL] Oh, we don't need the time for ours.
[CUSTOMER][NEUTRAL] OK, the time I have is.
[CUSTOMER][NEUTRAL] OK, alright, uh, I'm gonna document the time [PII] on our side.
[CUSTOMER][NEUTRAL] Uh, what time do you have? Do you go on?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] We're we're one hour behind you.
[CUSTOMER][NEUTRAL] You want
[CUSTOMER][NEUTRAL] OK, so you're on [PII], OK, alrighty.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] In [PII], OK, alright, well thank you very much. There's nothing we need to do. OK, step 5.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] Thank you for calling APL.
[CUSTOMER][POSITIVE] Alright, thank you very much I appreciate.
[CUSTOMER][POSITIVE] Take care. Bye bye.
[AGENT][POSITIVE] You have a great day bye.
[CUSTOMER][NEUTRAL] Did