AccountId: 011433970860
ContactId: e54d4d4e-ef84-4269-b027-19d9cad54652
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 285500 ms
Total Talk Time (AGENT): 123729 ms
Total Talk Time (CUSTOMER): 96493 ms
Interruptions: 2
Overall Sentiment: AGENT=1.2, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/e54d4d4e-ef84-4269-b027-19d9cad54652_20250428T20:40_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi [PII], I am not even sure if I, uh, pressed the correct button. I'm trying to see if you guys cover a patient's, um, physical therapy benefits.
[AGENT][NEUTRAL] Sure, I can assist you. Could I have your name and a callback number?
[CUSTOMER][NEUTRAL] Yeah my name is [PII]. Callback number is [PII].
[AGENT][NEUTRAL] Oh, what is the policy number of the member?
[CUSTOMER][NEUTRAL] 02554747
[AGENT][NEUTRAL] Can you verify the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yes, patient's name is [PII] and her date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] This policy is a gap insurance that has been active since [PII] and it's currently active. You're calling to verify outpatient benefits. The member has outpatient benefits of $3500 per calendar year, and this is not a guarantee guarantee of benefits, just a disclaimer of the policy's coverage and physical therapy falls on her outpatient benefits.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, uh, you said it does fall underneath it?
[AGENT][NEUTRAL] Yes, our outpatient benefits. Physical therapy will be considered as outpatient. Could you provide me with the spelling of your name?
[CUSTOMER][NEUTRAL] Yeah, it's [PII]
[CUSTOMER][NEUTRAL] Do you all cover 100% after the primary up to $3500?
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] Has any been met towards that $3500?
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] It looks like she's utilized $173.69 of her benefits.
[CUSTOMER][NEUTRAL] You said 179 or 100, what was that? 100.
[AGENT][NEUTRAL] $173.69.
[CUSTOMER][NEUTRAL] 6. OK, so does all medical fall, like if the patient has surgery, does that also fall under this gap insurance?
[AGENT][NEUTRAL] It depends on the place of service because the policy doesn't cover some services like office visits are not covered.
[AGENT][NEUTRAL] So if it's outpatient services.
[CUSTOMER][NEUTRAL] OK, so offices, OK, so.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we are, we are outpatient physical therapy, but we, you know, we build off like billing code 11 which is office setting.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] Would it be physical therapy procedure codes with the GP as the modifier?
[CUSTOMER][NEUTRAL] No GP modifiers.
[AGENT][NEUTRAL] OK, so she has treatment in the office covered under her policy which falls on the outpatient benefits. Only the office visit itself is not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so, uh, I guess I'm kind of confused and so and up y'all cover the secondary uh secondary.
[AGENT][NEUTRAL] Um, what are you confused about?
[CUSTOMER][NEUTRAL] Because you said office visit isn't covered, you are you talking about like the office visit code?
[AGENT][NEUTRAL] Right, place of service like 9914, the office visit CPT code, anything considered as the office visit for the CPT code is not covered. However, the treatment received in the office, any CPT code that's not an office visit is covered under the policy.
[CUSTOMER][NEUTRAL] Is covered.
[CUSTOMER][NEUTRAL] OK, only up to that $3500. So is the patient aware of like her accumulation?
[AGENT][POSITIVE] Yes, that is correct.
[AGENT][NEUTRAL] I'm not sure, but we definitely when she, when a claim is submitted, then we definitely send out an EOB to the primary to the pro to the provider who submitted the claim, and we are allowed to um make sure that the insured is aware that someone has submitted a claim on their behalf and we've made payments towards the bill.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Um, may I have a call reference number?
[AGENT][NEGATIVE] We don't provide those, unfortunately.
[CUSTOMER][NEUTRAL] OK, so do I just use your name in today's date?
[AGENT][POSITIVE] In today's day, yes, that is correct.
[CUSTOMER][POSITIVE] OK, perfect. Thank you so much.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Have a great day, [PII]. Good bye.
[CUSTOMER][NEUTRAL] Alright, you too. Bye-bye.