AccountId: 011433970860
ContactId: 0479cbda-61b8-479e-8475-82f186180d6b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 865859 ms
Total Talk Time (AGENT): 400177 ms
Total Talk Time (CUSTOMER): 208804 ms
Interruptions: 1
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/27/0479cbda-61b8-479e-8475-82f186180d6b_20250327T22:50_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I'm just trying to get a hold of someone who can help me um I was scheduled, I'm scheduled for an ultrasound uh next week and they called me and said that the.
[CUSTOMER][NEUTRAL] Uh, insurance authorization.
[CUSTOMER][NEUTRAL] Denied or that they only cover $100 or something so I'm just trying to verify or see what I need to do to get that authorization verified.
[AGENT][NEUTRAL] OK, yeah, let's take a look. Do you have your policy number?
[CUSTOMER][NEUTRAL] Yeah, give me 11 sec.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] It is 025.
[CUSTOMER][NEUTRAL] 956.
[CUSTOMER][NEUTRAL] 00.
[AGENT][NEUTRAL] All right, thank you. Let me pull this up here. Give me one moment.
[AGENT][NEUTRAL] And then what is your first and last name, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] All right. Thank you, Mr. [PII]. And then I need to get your date of birth, please, and address.
[CUSTOMER][NEUTRAL] Yeah, uh, [PII] and then the address is [PII].
[AGENT][POSITIVE] All right, thank you.
[CUSTOMER][NEUTRAL] Alright
[AGENT][NEUTRAL] OK, I don't, so, in looking at your policy, like I don't see.
[AGENT][NEUTRAL] Any sort of pre-authorization or anything on file.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] The provider said that they sent a pre-authorization to us.
[CUSTOMER][NEUTRAL] Uh, I believe so, yeah, they, when they reached out to me today, they basically said that it was unclear whether or not it would be covered, uh, and I think they reached out to the customer service, uh, line.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And they called, they ended up calling twice and got two different answers, so they said that I had to call you guys and try to get it sorted out.
[CUSTOMER][NEGATIVE] The service is an ultrasound uh for next Thursday and one person had told them uh it wasn't covered or like.
[CUSTOMER][NEUTRAL] It's something about the week to week pay, uh, and then another person had said only $100 per day is covered and the rest is out of pocket.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I mean I guess now that I have your guys' number as well because the only number I have on my card is the customer service.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] I mean I could maybe have them call you guys I guess I'm not really sure what to do honestly.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, so the type of plan that you have with us, uh, [PII] is what they call a limited benefit hospital indemnity plan. So it's not a major medical where you, if you've had something like that in the past, um, it covers a percentage and then you just pay, you know, the remaining cost.
[AGENT][NEUTRAL] With limited benefit hospital indemnity plans, they do pay just a set amount depending upon what you're being seen for.
[AGENT][NEUTRAL] So, on the schedule of benefits, when you look at that, it does show that like outpatient treatment benefit in a physician's office would be $50 a day. So that means that it would pay $50 towards the physician's office visit.
[AGENT][NEUTRAL] Um, under the medical imaging and test, it doesn't list any sort of ultrasound on there. That benefit is $100.
[AGENT][NEUTRAL] Um, uh, looks like it has CAT scans, PET scans, [PII].
[AGENT][NEGATIVE] But I don't see anything for like an ultrasound, unfortunately.
[CUSTOMER][NEUTRAL] By chance, do you see anything for like an endoscopy or like a colonoscopy?
[AGENT][NEUTRAL] Um, most of that would be considered like,
[AGENT][NEUTRAL] Preventative, I feel like.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Cause then I, I'm
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] My company has switched insurance, so now I'm like all confused as well. Like I think I had also opted into like a MEC like.
[CUSTOMER][NEUTRAL] Uh, preventative benefits or something like it was like an additional charge, but I guess that could have been with the old insurance. I'm not exactly sure.
[AGENT][NEUTRAL] Yeah, I mean, it looks like you had some added things on here for like
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Looks like there was some like coverage, if there was any sort of like cancer.
[AGENT][NEUTRAL] Anything like that, it looks like, um, and then they had for like heart attacks, stroke, critical illness, stuff like that.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So, so how do I get authorization for something like that then because I, I'm under the impression that I'm completely covered. That's, that's what I was told by my employer and I, I'm scheduled to do this ultrasound. I have the endoscopy, the colonoscopy, and.
[CUSTOMER][NEUTRAL] I guess I'm not really sure what to do.
[AGENT][NEUTRAL] Um, so, yeah, I mean, you do have coverage. Your coverage is active, so that's definitely accurate and correct. Um, the provider that you're seeing, um, you know, if they, like I said, I don't see, usually we'll see on our side like a form for like pre-treat.
[AGENT][NEUTRAL] Or pre-authorization and then it'll kinda give like a breakdown, but I don't see any of that even like in our records. So you can use the policy to go see the physician to have the endoscopy and the colonoscopy, um.
[AGENT][NEUTRAL] I just don't know that I don't see on the scheduled benefits that the endoscopy or colonoscopy are covered under medical testing.
[AGENT][NEUTRAL] So, from what I can see, the only benefit payment at this point would just be for the physician and the office visit fee.
[CUSTOMER][NEUTRAL] So how, how do I verify my coverage for those things then?
[AGENT][NEUTRAL] For the endoscopy and colonoscopy?
[CUSTOMER][NEUTRAL] Yeah, and the ultrasound.
[AGENT][NEGATIVE] So based off of what I'm looking at on the policy certificate, it's not covered.
[CUSTOMER][POSITIVE] My gosh.
[AGENT][NEUTRAL] Because it would be medical testing or medical imaging, and it lists all the medical imaging and testing that are like allowed.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] And there's those are not on there?
[AGENT][POSITIVE] Correct. It has MRI, CAT scan, um, radioactive thyroid test, CT scan, and a PET scan.
[AGENT][NEUTRAL] Uh, allowed follow-up test would be nuclear stress test, sleep studies.
[AGENT][NEUTRAL] Uh, barrier swallow upper GI series, but not, I don't see anything that states ultrasound, colonoscopy or endoscopy, so.
[AGENT][NEGATIVE] I would say they're not covered.
[CUSTOMER][NEUTRAL] OK, I mean, how do, how do I verify that though because I'm being told a million different things right now.
[AGENT][NEUTRAL] Um, do you have your policy at all?
[CUSTOMER][NEUTRAL] I mean, I have my, I just have my, my insurance card, that that's just, that's it.
[AGENT][NEUTRAL] OK
[CUSTOMER][POSITIVE] My gosh
[AGENT][NEUTRAL] Um, is the email on your policy still a good one? It looks like it's a Gmail account, [PII], is that still a valid email for you?
[CUSTOMER][NEUTRAL] Is it [PII] or [PII]?
[AGENT][NEUTRAL] Yeah, it looks like it's [PII].
[CUSTOMER][POSITIVE] Yeah, that works.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I, I guess I just don't understand because like I went through.
[CUSTOMER][NEUTRAL] My network because I wasn't.
[CUSTOMER][NEGATIVE] You know, to get a referral where my insurance was accepted and like, why would my insurance be accepted and then just nothing at all is covered, it doesn't make sense. Why would I go through a place that is in network that like it doesn't.
[AGENT][NEUTRAL] Well, the plan that you have with us is not a major medical, so I think that's like the confusion. It's a limited benefit plan.
[AGENT][NEUTRAL] So there's a difference between a limited benefit plan and like a major medical. Major medical, uh, generally like PPOs, HMOs, those things, uh, pay percentages, and then you have a co-pay, co-insurance, whatever that may be that you're responsible for. Limited benefit plans.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Just pay the set amount irregardless of who you see because you don't even have to stay in network with these plans you can see anybody because regardless of.
[AGENT][NEGATIVE] You know, if they're in network or out, it's paying that set amount, it's not gonna pay anything additional.
[CUSTOMER][NEUTRAL] And what's the set amount, the $50 per day?
[AGENT][NEUTRAL] I don't know.
[AGENT][NEUTRAL] It's for the office visit, it's $50 per day, a maximum of 4 visits per calendar year.
[AGENT][NEUTRAL] And then the uh
[AGENT][NEUTRAL] Diagnostic testing was $100 per day, and you're allowed one per calendar year.
[CUSTOMER][NEGATIVE] Oh my gosh, what, what, why am I paying for I mean.
[CUSTOMER][NEUTRAL] Oh my gosh, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I did email you the policy itself so you can look at it um if you want to, the scheduled benefits page, which is like page 17.
[AGENT][NEUTRAL] It breaks it down as far as exactly what the benefit is and what the benefit amount is and what the coverage is, so maybe that'll help you as far as looking at it. um, there is a spot in there for exclusions as well, what's not covered, and it breaks it down under the testing too if you wanna look at that, it'll show you exactly which ones are covered.
[CUSTOMER][NEUTRAL] OK, I'll take a look at it.
[AGENT][NEUTRAL] All right, [PII]. I'm sorry for the confusion on this. Do you have any other questions or concerns?
[CUSTOMER][NEUTRAL] No, I've been lost in the system for 6 months now, so I'm, I'm.
[CUSTOMER][POSITIVE] It's, it's all I got. I'm, I, I can't do it anymore, so I appreciate, I appreciate your help though.
[AGENT][NEUTRAL] Do you have this, do you have this through your room?
[AGENT][POSITIVE] Yeah, you're welcome.
[CUSTOMER][POSITIVE] Yeah, thanks.
[AGENT][NEUTRAL] Mhm. Bye-bye.