AccountId: 011433970860
ContactId: dd1a1cfc-a657-4e0e-b8b3-4e274a5c7e95
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 354049 ms
Total Talk Time (AGENT): 172124 ms
Total Talk Time (CUSTOMER): 121519 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/13/dd1a1cfc-a657-4e0e-b8b3-4e274a5c7e95_20250313T12:36_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 [PII], my name is [PII]. Last initial is [PII] I'm calling on a recorded line for Doctor [PII], and I just need to get some eligibility information for our patient, [PII].
[AGENT][NEUTRAL] OK, [PII], so you're only needing eligibility. You do not need benefits, is that correct?
[CUSTOMER][NEUTRAL] Um, I'll need both, but if we could do eligibility first.
[AGENT][NEUTRAL] Yes, I can help you with that, [PII]. And what is your callback number?
[CUSTOMER][NEUTRAL] [PII] and that's a direct line.
[AGENT][NEUTRAL] Thank you and the member's policy number please, [PII]?
[CUSTOMER][NEUTRAL] 02542049
[AGENT][POSITIVE] Thank you, one moment please.
[AGENT][NEUTRAL] And [PII], any information that I do provide for you today would be a verification of benefits and not a guarantee of payment. What is your patient's name again and their date of birth?
[CUSTOMER][NEUTRAL] [PII], date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] So I do show that he is the subscriber on the supplemental policy, [PII], and it is active with an effective date of [PII]. And what type of benefit information do you need for him inpatient, outpatient or office?
[CUSTOMER][NEUTRAL] Um, well, it's gonna be, uh, for, um, CPT code S 1091 for Propel, um, it'll be done outpatient in the specialist office.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I don't know if you need the diagnosis code.
[AGENT][NEUTRAL] Uh, no, ma'am, not now, because this policy is a supplemental policy to the primary insurance that helps with co-pays, deductibles and co-insurance amounts of coverage services, and he does have an office treatment writer on this policy. So the outpatient, uh, benefit maximum.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Her calendar year for covered outpatient services is $6000.
[AGENT][NEUTRAL] And there is no outpatient deductible per covered person per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and has any of that benefit max been met this year?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I can check one moment.
[AGENT][NEUTRAL] And while this information is pulling up, when the claim is submitted to APO for review, we will have to have a copy of the primary insurance company's explanation of benefits along with the claim for review.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] OK, and give me just one moment.
[AGENT][NEUTRAL] OK, so as of now he has used $5,477.78.
[CUSTOMER][NEUTRAL] All right, OK.
[AGENT][NEUTRAL] And then also if you all end up filing a claim with us for him in addition to sending the explanation of benefits from the primary insurance once we've processed our claim, we do have a portal that you should be able to check claim status in [PII] and the website for our portal is secured. [PII].
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right and um.
[CUSTOMER][NEUTRAL] OK, so, um, as long as the provider is in network with the primary payer, um, and who are you showing as the primary payer for this?
[AGENT][NEUTRAL] One
[AGENT][NEUTRAL] We show the primary, it's this shows as uh United Healthcare.
[CUSTOMER][NEUTRAL] OK, alright, that's, yeah, that's what I have as well, um, and the group number for billing for this policy I have um 18514. Does that match what you have, [PII]?
[AGENT][NEUTRAL] QHC.
[AGENT][NEUTRAL] That is correct. 18514.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um, alright, and no deductible, just that benefit max, um, so it looks like he has like $522 and some odd cents left, um.
[CUSTOMER][NEUTRAL] And um is there a prior author required if there's no prior author required from the primary?
[AGENT][NEUTRAL] No, and there is no network with APO It would follow the primary.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right, excellent um.
[CUSTOMER][NEUTRAL] OK, and the patients responsible for any out of pocket that's left after that benefit max is met, correct?
[AGENT][NEUTRAL] Well, we are not a major medical insurance company, so we do not determine patient responsibility. That would be up to the provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it. OK, got it. OK, [PII], that is all that I needed. Can I get the initial to your last name and a reference number for the call?
[AGENT][NEUTRAL] Sure. My, yes, ma'am. The first initial of my last name is [PII] You will use my name along with today's daycare as your call reference number.
[AGENT][NEUTRAL] So again, there is nothing else I can help you with today?
[CUSTOMER][POSITIVE] Excellent
[CUSTOMER][POSITIVE] Uh, no, that is it. Thank you so much, [PII]. I appreciate it. I hope you have a great day.
[AGENT][POSITIVE] Well you, oh you, yes, ma'am. I hope you do too, and thank you again for calling APL.
[CUSTOMER][POSITIVE] Thank you, bye bye.
[AGENT][NEUTRAL] All right, bye bye.