AccountId: 011433970860
ContactId: 002a8fe9-e9c1-4da0-9e7a-c8bcd6131b3c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 445910 ms
Total Talk Time (AGENT): 124918 ms
Total Talk Time (CUSTOMER): 134240 ms
Interruptions: 0
Overall Sentiment: AGENT=1.6, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/26/002a8fe9-e9c1-4da0-9e7a-c8bcd6131b3c_20250326T16:29_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. I'm calling from the business office for um.
[CUSTOMER][NEUTRAL] for Berkeley Hospital, I have a patient scheduled for an outpatient colonoscopy. I'd like to get his benefits eligibility and check for pre-cert requirements.
[AGENT][POSITIVE] OK. Well, I'll be more than happy to assist you with the member's coverage and eligibility. And [PII], may I have a good contact number in case we're disconnected and then the policy number?
[CUSTOMER][NEUTRAL] Sure, [PII].
[CUSTOMER][NEUTRAL] And um
[CUSTOMER][NEUTRAL] His ID number.
[CUSTOMER][NEUTRAL] Policy er number, is that the 02491802?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, ma'am. Hold on one moment. That sounds right.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, and can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Uh, [PII] and it's [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So I am showing the policy is active. It's been effective since [PII].
[AGENT][NEUTRAL] Um, the APL as a whole doesn't require any prior authorization or pre-cert because we're not a major medical insurance company.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then you said you needed the coverage for out, you said it was an outpatient procedure?
[CUSTOMER][NEUTRAL] Yes, colonoscopy. Mhm.
[AGENT][NEUTRAL] OK. Colonoscopy, let me see.
[AGENT][NEUTRAL] And do you mind if I place you on just a brief hold? I'm just pulling up the benefits to look through them.
[CUSTOMER][NEUTRAL] All right. OK.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yeah, I'm here.
[AGENT][NEUTRAL] All right, thank you so much for holding. I apologize for that wait. So the policy um does have coverage for a colonoscopy. It's gonna be under the diagnostic testing. So for that benefit, um, we would pay up to $250 per test.
[CUSTOMER][NEUTRAL] So it goes under diagnostic testing and the, and the maximum payable is up to 250 per test and it considering the colonoscopy a test.
[AGENT][NEUTRAL] Yes, colonoscopy was under there.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Under there, OK, and that's maximum.
[CUSTOMER][NEUTRAL] Max payable.
[AGENT][NEUTRAL] Well, that's what it will pay per test. The max for diagnostic testing is 500, so I guess 2.
[AGENT][NEUTRAL] Per calendar year.
[CUSTOMER][NEUTRAL] OK, so 250 per calendar year time they can get two of these per calendar year?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, it's 250 per test, but the max for the benefit is 500, so that would be 2 tests.
[CUSTOMER][NEUTRAL] 22.
[CUSTOMER][NEUTRAL] OK, OK, so, OK, so they can have two tests per calendar year. Each one is 250, so the.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] But for one, it's 250.
[AGENT][NEUTRAL] Mhm. One test is 250.
[CUSTOMER][NEUTRAL] 2
[CUSTOMER][NEUTRAL] For calendar year allowed.
[CUSTOMER][NEUTRAL] At 250 each.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Mhm. Yes, ma'am.
[CUSTOMER][NEUTRAL] Two per calendar year allowed at 250 each. OK, so this occurrence is one of the two, so it would be 250 max.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And let me check the um benefits just to make sure it hasn't been nothing's been used.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] That'll help too.
[AGENT][NEUTRAL] Oh no, they haven't used any of the 25, yes, OK, so they haven't used any of the diagnostic testing benefits, so you still have those too.
[CUSTOMER][NEUTRAL] 9 news to date. OK. All right. And [PII], can I get the initial of your last name and?
[CUSTOMER][NEUTRAL] A call reference number.
[AGENT][NEUTRAL] Um, so there's no call reference number, but you can use my name. The first initial to my last name is [PII], and then today's date.
[CUSTOMER][POSITIVE] And today's date [PII] awesome thank you so much for your help. I appreciate it. No precer required because it's not a major med. So is this considered like a limited plan?
[AGENT][NEUTRAL] Yeah
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Hospital indemnity, yes, ma'am.
[CUSTOMER][NEUTRAL] Hospital indemnity.
[CUSTOMER][POSITIVE] OK. All right, great. Thank you so much.
[AGENT][POSITIVE] You're very welcome, Ms. [PII]. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] Yep, I mean, no, that's good.
[AGENT][POSITIVE] Alright, well, thanks for calling API. I hope you have a great day.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] All right, you too. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye-bye.