AccountId: 011433970860
ContactId: ee89764d-e4a7-4f7f-b1ce-f1f6e191873e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 539669 ms
Total Talk Time (AGENT): 241930 ms
Total Talk Time (CUSTOMER): 213614 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/30/ee89764d-e4a7-4f7f-b1ce-f1f6e191873e_20250430T17:25_UTC.wav
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[AGENT][NEUTRAL] Afternoon thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, hi, I'm calling to verify some benefit about a medication that is needed for the baby.
[AGENT][NEUTRAL] OK, you're trying to verify medication benefits, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Yeah, that is correct.
[AGENT][NEUTRAL] OK, yes, ma'am. Are you the, calling from a provider's office or are you the insured?
[CUSTOMER][NEUTRAL] I'm calling from on behalf of the provider, on behalf of the patient and the manufacturing company or the medication the baby is gonna be on.
[AGENT][NEUTRAL] OK, and who am I speaking with please?
[CUSTOMER][NEUTRAL] My name is [PII], and I'm the case manager for So of Fijian design.
[AGENT][NEUTRAL] OK, and [PII], what is your callback number?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you and the member's policy number?
[CUSTOMER][NEUTRAL] The members that I have for the certification number.
[CUSTOMER][NEUTRAL] I have here for the outpatient benefit is 02440192, the letter ML and number 8.
[AGENT][NEUTRAL] Thank you one moment while I get the member's information pulled up please.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK, and any information that I provide for you today, [PII] would be a verification of benefits and not a guarantee of payment. What is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, the patient's name is [PII], and the last name [PII]
[CUSTOMER][NEUTRAL] UN and the date of birth that I have here is [PII].
[AGENT][NEUTRAL] OK, thank you. So first off, um, uh, and again any information provided would be a verification of benefits and not a guarantee of payment. The policy number that you gave me, [PII], is an old number that's no longer active. Well, I have a different policy number that I need to give you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, I have 2 numbers here. One is the, one is say that is the in hospitals, which is the same number that I gave you.
[AGENT][NEUTRAL] The current
[AGENT][NEUTRAL] No, ma'am.
[AGENT][NEUTRAL] Right, but all of that number is invalid. It's no, it's not the active policy. So the correct policy number that you should have is 02451595.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that policy is active as of.
[CUSTOMER][NEUTRAL] OK, so let me put it here, policy active uh.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, ma'am, that is correct.
[AGENT][NEUTRAL] The policy has
[CUSTOMER][NEUTRAL] And when does this policy start?
[AGENT][NEUTRAL] The policy went into effect on [PII].
[CUSTOMER][NEUTRAL] [PII] or [PII]. OK.
[AGENT][NEUTRAL] Yes, ma'am. Now, this is a supplemental medical policy.
[AGENT][NEUTRAL] That helps with co-pays, deductibles and co-insurance amounts of coverage services. It does not cover pharmacy.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, it doesn't cover pharmacy. OK.
[AGENT][POSITIVE] Correct. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK. So then I will not ask them the question because this is about a medication that needs to be infused. So probably it's not gonna be covered. Do you want to still verify just in case, or does it still?
[CUSTOMER][NEUTRAL] It's not something that needs to be checked.
[AGENT][NEUTRAL] With APL again, medications or not, um, give me just a moment to look at one thing.
[AGENT][NEUTRAL] As far as anything related to a medication question, yes, ma'am.
[CUSTOMER][NEUTRAL] Because this is a medication that is infused.
[AGENT][NEUTRAL] Yeah, I, but the medication itself.
[AGENT][NEGATIVE] That is not something that's covered by this policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What about infusion?
[AGENT][NEUTRAL] Let me check that for you.
[AGENT][NEUTRAL] So I can provide you the outpatient benefit maximum is this gonna be performed in an office setting?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It, will this be performed in an office setting?
[CUSTOMER][NEUTRAL] It will depend because um I think probably it can be done in an office setting if the pediatric office offer those services, but it's not, it's gonna be in hospital setting because this is a baby. And probably they wanna be sure they can do some observation while they are doing the infusion.
[AGENT][NEUTRAL] So it will be outpatient at the hospital. Is that correct?
[CUSTOMER][NEUTRAL] Probably it's gonna be outpatient at the hospital, but sometimes, yeah, I would say outpatient at the hospital for infusion, yes.
[AGENT][NEUTRAL] OK, so the outpatient benefit maximum.
[AGENT][NEUTRAL] For covered outpatient services per calendar day is $500.
[AGENT][NEUTRAL] And there is no outpatient deductible per covered person per calendar day.
[CUSTOMER][NEGATIVE] No patient deductible.
[AGENT][NEUTRAL] Because
[AGENT][NEUTRAL] Yes ma'am, and because it is a supplemental policy, Dana, to the primary insurance, we will have to have a copy of the primary insurance company's explanation of benefits.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Showing the amounts applied to co-pays, deductibles and co-insurance amounts when reviewing the claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then once we have processed any claim here at APO we do have a portal that you all should be able to check our claim status in and that website for the portal is located at secured.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and then, you say this is a co-insurance, right?
[AGENT][NEUTRAL] This is a supplemental.
[CUSTOMER][NEUTRAL] Oh, it's not.
[AGENT][NEUTRAL] This is a supplemental plan.
[AGENT][NEUTRAL] To their primary health care insurance.
[AGENT][NEUTRAL] That helps with co-pays, deductibles, and co-insurance amounts of covered services.
[CUSTOMER][NEUTRAL] You talk to.
[CUSTOMER][NEUTRAL] In car insurance.
[CUSTOMER][NEUTRAL] Amount.
[AGENT][NEUTRAL] He covered services.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] For coverage services. OK. So, I'm gonna provide the information to the parents of the baby so they can then call the primary insurance and they, if they need to submit any claim, they can submit the claim there.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Sorry about that.
[AGENT][NEUTRAL] So any claim would have to be filed with their primary first and then with APL since we have to have a copy of the primary insurance EOB along with the claim for our review.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] OK, I will do that. I will do that then.
[AGENT][NEUTRAL] OK. Well, is there anything else that I can help you with today, [PII]?
[CUSTOMER][NEUTRAL] No, if you can give me a reference call number so I can put it on my, on my notes.
[AGENT][NEUTRAL] Yes, ma'am. You would use my name that I gave you along with today's date.
[CUSTOMER][POSITIVE] OK. I will do that. Thank you so much.
[AGENT][POSITIVE] Oh, you're very welcome. And again, is there anything else that I can help you with today?
[CUSTOMER][POSITIVE] No, thank you so much, you've been really helpful. I'm gonna be calling the parents of the patient and then I'm gonna be uh letting them know everything that you have explained to me, so they have that information.
[AGENT][NEUTRAL] Well
[AGENT][POSITIVE] OK, that will be fine, ma'am. Well, if that's all I can help you with, thank you again for calling APL and I hope you have a very nice afternoon.
[CUSTOMER][NEUTRAL] And before you hang up, can you repeat your name for me?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] [PII], OK, thank you, [PII], have a good day.
[AGENT][NEUTRAL] Yes, ma'am. OK, you too.
[AGENT][NEUTRAL] Bye-bye.