AccountId: 011433970860
ContactId: fac3d1af-d14d-4ace-a40a-87b332af6d65
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 531140 ms
Total Talk Time (AGENT): 216885 ms
Total Talk Time (CUSTOMER): 176587 ms
Interruptions: 2
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/27/fac3d1af-d14d-4ace-a40a-87b332af6d65_20250227T17:03_UTC.wav
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[AGENT][POSITIVE] Good Morning, thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] This is [PII] speaking. How are you doing?
[AGENT][POSITIVE] I'm good, thank you. How about you, Mister [PII]?
[CUSTOMER][POSITIVE] I'm great thank you so much and I'm really sorry uh um if I'm just having thought for so I'm sorry for that for the for the phone. I'm sorry. So I'm looking for the benefits and eligibility. I'm calling on behalf of a provider.
[AGENT][NEUTRAL] Mm
[AGENT][POSITIVE] OK, sure, I can assist you with benefits and eligibility and may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure it's gonna be [PII] direct line no extension.
[AGENT][NEUTRAL] OK, what's the name of the facility you're calling from?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Holy Cross Orthopedics.
[AGENT][NEUTRAL] OK. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] It's gonna be 02573476.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII]. Date of birth is [PII].
[AGENT][POSITIVE] OK. Thank you.
[AGENT][NEUTRAL] And you need um eligibility and benefits for office specialists?
[CUSTOMER][NEUTRAL] Yes, it's going to be services will be done inside the specialist office and it's for the arthritis of the knee.
[AGENT][NEUTRAL] OK, so I say proceed, all right.
[CUSTOMER][NEUTRAL] I have the codes if you need them.
[AGENT][NEUTRAL] Before I give you any.
[AGENT][NEUTRAL] Mm, it's OK. Um, before I give you any benefit information, I need to let you know that this is not a guarantee of payment, just a verification of coverage, and that's just a disclaimer. We have an effective date of [PII]. It is active at the moment and this is one of our secondary supplemental plans to the major medical.
[AGENT][NEUTRAL] And with this one, let's see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Bear with me.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Alright, so
[CUSTOMER][NEUTRAL] Can I have the plan full name?
[AGENT][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] It is secondary to what's secondary to Medicare.
[AGENT][NEUTRAL] Secondary to major medical to primary insurance.
[CUSTOMER][NEUTRAL] And who is the major medical? Can you see that?
[AGENT][NEUTRAL] Uh, I'll have to search for that. Bear with me.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, one moment, let me see if I can find this information.
[AGENT][NEUTRAL] OK, one moment, I have to pull the.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, so this one is with [PII].
[AGENT][NEUTRAL] The [PII] is the primary.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and we are the secondary to [PII].
[AGENT][NEUTRAL] And let me check and see because it looks like there's a deductible on this one, bear with me.
[CUSTOMER][NEUTRAL] You can I, can I place you on hold for just 30 seconds, please? Just 30 seconds.
[AGENT][NEUTRAL] Sure. Mhm.
[CUSTOMER][NEUTRAL] Yes, I'm here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Thank you. All right, so this one has an outpatient maximum benefit of 1000, and this includes office treatment.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] No, um,
[CUSTOMER][NEGATIVE] So you, there's no percentage coverage of the $1000 coverage.
[AGENT][NEUTRAL] No, what we do is we help with the deductibles, co-payment, and co-insurance from a major medical.
[CUSTOMER][NEUTRAL] So you cover the remaining, so you cover the remaining Part B deductible and co-insurance.
[AGENT][NEUTRAL] Not Part B is, is the primary insurance which is Florida Blue. So it's gonna be deductibles.
[CUSTOMER][NEUTRAL] OK, so do you have your own
[CUSTOMER][NEUTRAL] So do you have your own deductible and out of pocket?
[AGENT][NEUTRAL] Yes, um, the deductible amount is 1500 per covered person per calendar year.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And after that, we pay $1000 per covered person per calendar year for any outpatient service.
[CUSTOMER][NEUTRAL] OK, so after meeting the deductible you pay up to $1000.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, so there's nothing like for the coverage percentage. I mean, every anything comes from the primary you cover all the 100%. You you will cover up to the $1000.
[AGENT][NEUTRAL] Up to $1000 correct, of the amount applied towards the deductible.
[CUSTOMER][NEUTRAL] OK, so is there any specific name for the plan? I mean, supplemental plan NFKL?
[AGENT][NEUTRAL] No, it's just a second.
[CUSTOMER][NEUTRAL] Or is it nonstand?
[AGENT][NEUTRAL] Non-standard.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Wonderful. And it's same coverage for everything, I mean, whatever the claims come to you after the primary, you will cover up to $100,000 not $100,000 I mean, uh, a total of $1000.
[AGENT][NEUTRAL] We will pay the amounts applied towards the deductible co-payment and coinsurance up to 1000 after the $1500 deductible is met.
[CUSTOMER][NEUTRAL] And how much is uh deductible out of 1500 me so far?
[AGENT][NEUTRAL] Oh, let me check and see. One moment.
[AGENT][NEGATIVE] As of today, she has not used her benefits at all, so she has not met any deductible or used any benefits. Mhm.
[CUSTOMER][NEUTRAL] 00. Alright, and what about the out of pocket? Is there any?
[AGENT][NEUTRAL] Oh no, there's not an out pocket because this is a secondary policy.
[CUSTOMER][NEUTRAL] OK, just give me one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And other than that, what guidelines you guys follow?
[AGENT][NEUTRAL] Primary.
[CUSTOMER][NEUTRAL] Primary skyline.
[AGENT][POSITIVE] Correc[PII]
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] And also if you can check for me any pre-certifications, any medical notes, or any referrals needed.
[AGENT][NEUTRAL] No, because we're just a secondary.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] And it's a commercial policy, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, and do you see?
[CUSTOMER][NEUTRAL] Any specialty pharmacy also listed under members plan or not?
[AGENT][NEGATIVE] No, this one doesn't cover pharmacy.
[CUSTOMER][NEUTRAL] And do you see the doctors in network?
[AGENT][NEUTRAL] We don't have a network we follow primary.
[CUSTOMER][POSITIVE] Wonderful. That's fine. Can I have your name one more time?
[AGENT][NEUTRAL] My name is [PII]. That's [PII].
[CUSTOMER][NEUTRAL] And the claims mailing address or will it be automatic crossover?
[AGENT][NEUTRAL] No, it will not cross over. You need to send the claim. The address is [PII].
[AGENT][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and the timely filing deadline to submit the claims?
[AGENT][NEUTRAL] No, there's no time to find the limit.
[CUSTOMER][NEUTRAL] There's no limit, so shall we write it as for the contract?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] There's no timely filing limits with us.
[CUSTOMER][NEUTRAL] OK, you have the reference number for this conversation?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today if you would like, Mr. [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So in [PII].
[CUSTOMER][NEUTRAL] Is that it?
[AGENT][NEUTRAL] Yes, it's, um, my name is [PII] last initial [PII], and today's date.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][POSITIVE] Great, thank you. And what is the time, uh, by your system if you can see there, what is the time at the moment?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] [PII] Great, thanks so much for the help you have a wonderful day. I appreciate it bye bye.
[AGENT][POSITIVE] You're welcome you as well and thank you for calling APL.