AccountId: 011433970860
ContactId: e5328427-5dcf-4f83-8540-bf28f31621be
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 535070 ms
Total Talk Time (AGENT): 219380 ms
Total Talk Time (CUSTOMER): 206214 ms
Interruptions: 0
Overall Sentiment: AGENT=1.8, CUSTOMER=1.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/26/e5328427-5dcf-4f83-8540-bf28f31621be_20250226T21:19_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi there. My name is [PII]. I'm calling from Tandem Diabetes Care. How are you, [PII]?
[AGENT][POSITIVE] I'm doing well, thank you for asking, [PII]. How are you today?
[CUSTOMER][POSITIVE] Doing pretty good thank you.
[AGENT][POSITIVE] Good, what is a good callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] All right, that is [PII].
[AGENT][POSITIVE] Thank you, [PII].
[AGENT][POSITIVE] And how can I help you today?
[CUSTOMER][NEUTRAL] Yeah, I am just looking to get some benefit information for a single member um and also to verify if we would be considered in network or out of network or if there's a network we could use and.
[CUSTOMER][POSITIVE] Got some DME benefits hopefully that I write a lot of stuff off. Hopefully we can go over it.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] You just want alcohol, don't you? I'm just kidding.
[CUSTOMER][POSITIVE] That's right.
[AGENT][POSITIVE] And it would be my pleasure to assist you. What is the patient's policy number?
[CUSTOMER][NEUTRAL] All right, that is 02566560.
[AGENT][NEUTRAL] Thank you, [PII]. And what is the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] [PII] and [PII].
[AGENT][NEUTRAL] All right, thank you. Now for eligibility, [PII]'s policy is active.
[AGENT][NEUTRAL] Effective date is [PII].
[AGENT][NEUTRAL] And this is a secondary policy to his primary insurance.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We don't participate in the network. We do follow the guidelines of the major medical.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And were you needing specific benefits or just eligibility?
[CUSTOMER][NEUTRAL] Yeah, um, benefits for durable medical equipment we're looking to send out an insulin pump and supplies.
[AGENT][NEUTRAL] OK, let me check to see if they have durable medical equipment benefit.
[AGENT][NEUTRAL] Bear with me just one second. I'm checking on that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Is that a kid or a cat?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] I thought it was a cat. I like cats. Yeah, no, I like cats. I got one too.
[CUSTOMER][NEUTRAL] I'm surprised you can hear.
[AGENT][NEUTRAL] Let's see. Just checking for that durable medical equipment.
[AGENT][NEUTRAL] I don't think it's covered, but I did want to verify that. Well,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It looks like they do have durable medical equipment benefit, that's why I wanted to verify. Now, it does have to um meet the our definition of durable medical equipment for covered benefits. If it can withstand if it can withstand repeated use, is not disposable or refillable.
[AGENT][NEUTRAL] I used to serve a medical purpose.
[AGENT][NEGATIVE] It is not useful to a person in the absence of a sickness or injury.
[AGENT][POSITIVE] Is appropriate for use and primarily used within the home.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's not implantable and is covered by the major medical.
[CUSTOMER][NEUTRAL] Got you, yeah, so I, I do show that their, their primary is Blue Cross, Oklahoma, and I know we are contacted directly with them. Is that the major medical that you're referring to?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][POSITIVE] Just the primary. OK, perfect.
[CUSTOMER][POSITIVE] Good, so as long as we're contracted with them, then um then we should be good to go with you guys too, correct?
[AGENT][NEUTRAL] Yes, sir, as long as they apply something to the deductible, co-pay, or co-insurance of the major medical.
[AGENT][NEUTRAL] And as long as it meets the definition of durable medical equipment.
[CUSTOMER][NEUTRAL] OK, got you. I think we checked all those boxes. I'm trying to pull up that other verifications what it looks like, um.
[CUSTOMER][NEUTRAL] OK, yeah, OK, so looks like, looks like on there on the other one it looks like 100% after deductible, um, is that gonna be the, uh, the same coverage for, for you guys or do you guys have, um, additional, additional coverage?
[AGENT][NEUTRAL] Mhm. This policy pays up to $3000 per calendar year toward the deductible co-pay or co-insurance of the major medical. That is a verification of coverage and not a guarantee of payment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got you, so they got that $3000 deductible, and do you show anything being met towards that already?
[AGENT][NEUTRAL] As of right now, [PII] has not met any of those benefits for [PII].
[CUSTOMER][POSITIVE] OK, sounds good so then um.
[CUSTOMER][NEUTRAL] Nothing's been met so far and after their 3000 deductible they are covered at 1100%, was that right? Um, looks like that's the exact same coverages there.
[AGENT][NEUTRAL] So we
[CUSTOMER][NEUTRAL] Major medical as well is that how it usually is.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So we paid for the deductible copay or co-insurance of the major medical up to $3000 per calendar year.
[CUSTOMER][NEUTRAL] Oh, OK, got you. OK, so you guys are paying.
[AGENT][NEUTRAL] It's like a
[CUSTOMER][NEUTRAL] You guys are paying up to that $3000 amount and then.
[CUSTOMER][NEUTRAL] And then the and then the co-insurance and everything kicks in for for the other.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yeah, OK, I think, I think I understand they're covered up 100%.
[AGENT][POSITIVE] Yeah, good.
[AGENT][NEUTRAL] Yeah, it depends on
[AGENT][NEUTRAL] It depends on what Blue Cross applies to their deductible co-pay or co-insurance. And then so the patient doesn't have to pay that out of the pocket, we can pay up to $3000 toward that for the covered services on the plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So your father claim with Blue Cross.
[CUSTOMER][NEUTRAL] I think I'm, I think I'm under.
[AGENT][NEUTRAL] And then when you get that Blue Cross COP then file a claim with APL.
[CUSTOMER][POSITIVE] Got you.
[AGENT][NEUTRAL] Does that help?
[CUSTOMER][POSITIVE] Perfect yeah yeah and then where would um do we have a good claims address that we can send it to?
[AGENT][NEUTRAL] Absolutely, it's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] [PII], OK.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Alright. And then is this a, would this be because they're like a a PPO plan or uh or like an HMO or anything like that or is this a different kind of plan?
[AGENT][NEUTRAL] It's a different kind of plan. It's just a supplemental plan to help cover their deductibles, co-pays, or co-insurance of the major medical.
[CUSTOMER][NEUTRAL] Got you. Sorry, we don't deal with many supplemental plans.
[AGENT][POSITIVE] Not a problem.
[AGENT][POSITIVE] I'm here to help you any way I can.
[CUSTOMER][NEUTRAL] I appreciate it and OK and then another question here for you um for authorization um the major medical does require authorization for the pump but not for the supplies is do we need additional authorization directly through you guys?
[AGENT][NEUTRAL] No authorization is required on the secondary gap policy.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] And then I think that should do it for me. I I appreciate your help. Could I get a reference number?
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Reference number is my name and today's date, and I spell my name [PII].
[AGENT][POSITIVE] And [PII], it was a pleasure to assist you with the eligibility and benefits. Anything else I can?
[AGENT][NEUTRAL] Help you with today?
[CUSTOMER][POSITIVE] No, I think you answered everything, thank you.
[AGENT][POSITIVE] Thank you for calling APO. You have a wonderful day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye-bye.