AccountId: 011433970860
ContactId: 04c7c077-1ed4-464d-92b9-d827aec0b9f0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 378119 ms
Total Talk Time (AGENT): 193436 ms
Total Talk Time (CUSTOMER): 145360 ms
Interruptions: 1
Overall Sentiment: AGENT=0.9, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/21/04c7c077-1ed4-464d-92b9-d827aec0b9f0_20250521T18:40_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]. My name is [PII]. I'm calling from Sharre Cly Medical Group. I'm just trying to verify um if a patient's plan is just hospital only or if he has medical on this as well, like outpatient office visits.
[AGENT][NEUTRAL] Oh, office visits. OK, I can get that policy pulled up and see if office visits are covered. Um, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[AGENT][NEUTRAL] Thank you and do you have that policy number?
[CUSTOMER][NEUTRAL] And the policy is 02495893.
[AGENT][NEUTRAL] OK and then what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] On the insurance it says um I don't know on the card it says [PII], we have [PII] and [PII].
[AGENT][NEUTRAL] OK, um, yeah, I don't have it as [PII]. I do have it as, uh, [PII], but that's OK. All righty. Uh, so this policy, of course, is active, uh, effective date was [PII]. So this is a hos or limited indemnity medical plan. Um, if you'll bear with me just a moment, I will see if office visits are a covered benefit.
[CUSTOMER][NEUTRAL] He's probably name yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Vision specifically is what we're looking for.
[AGENT][NEUTRAL] I'm sorry, you said vision?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, give me just a moment.
[AGENT][NEUTRAL] OK, um, when you say vision, do you mean just like a a routine, um, exam?
[CUSTOMER][NEUTRAL] Yeah, routine eye exam. I mean, I guess it would be helpful to know because we are a large medical group, so I need to really know if he has medical coverage. Um, the department that reached out to business stuff was for routine vision, but I don't want to load it if he doesn't have, if he only has hospital, he's not gonna be able to, yeah.
[AGENT][NEUTRAL] I see. OK.
[AGENT][NEUTRAL] So.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, absolutely. OK, um, so of course I will let you know verification of coverage is not a guarantee of payment for claims. Uh, so this this policy does offer more than, uh, just hospital benefits. Vision is not going to be a covered benefit under this policy. However, they do have, um, wellness and diagnostic benefits, um, and then of course office visits pertaining to uh sickness.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let's see. Intensive care, coronary care, surgical.
[AGENT][NEUTRAL] And hospital confinement. That's uh the extent of
[AGENT][NEUTRAL] The benefits for this policy.
[CUSTOMER][NEUTRAL] OK, so I see that it's through the multi plan, um, which we are contracted with, so that would be the network, I guess we would use in the multi plan. So what is this benefit then overall? So is it deductible, co-insurance, limited, yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] No, not for this one, so the multiples can be a bit um confusing as you know, uh, he most likely has coverage uh or different policies through different, um, carriers. Um, however, this particular one he does have with us, as it's a limited indemnity, it does not have any uh co-pays or anything like that. It pays a set dollar amount per covered procedure or office visit.
[CUSTOMER][NEUTRAL] Anything.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So does it need authorization for that or how would we know what those amounts are?
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] No, no authorization is required, um, again, as it's pretty limited, um, the benefits I listed are the extent of the benefits provided, um, I think the only thing really would be.
[AGENT][NEUTRAL] The diagnostic testing benefit?
[CUSTOMER][NEUTRAL] So he's allowed
[AGENT][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] So he's allowed office visits with primary like um diagnostic-driven office visits. Is there a limit to office visits per year or how does it, I mean like how does the plan work?
[AGENT][NEUTRAL] Yeah. Sure. OK, so there, it is a separate benefit. So there's a wellness, so you know, like a routine wellness exam is covered, um, and that benefit pays up to $75. Diagnostic testing is going to be a separate benefit that would pay up to $250 per test. And then, um, any office visits regarding a sickness is also covered at $75 per visit, and that is limited to, let's see.
[AGENT][NEUTRAL] 5, visits per calendar year.
[CUSTOMER][NEUTRAL] OK, 5 visits per year.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And then um
[CUSTOMER][NEUTRAL] We would be
[CUSTOMER][NEUTRAL] Writing off the difference, I guess, with the multi-plan discount or is that patient to be billed for the difference?
[AGENT][NEUTRAL] So that honestly I would ask a multi plan I'm not familiar with how they do that I know we don't say what is patient responsibility that's up to the provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because yours would be coming from them. OK, so they get 5 office visits a year, um.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And it pays $75 a visit. OK. And they are effective, you said since um 527 $24. And then can I just get a reference number for this call? Mhm.
[AGENT][NEUTRAL] Mhm. Yes.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yeah, that would just be my first name, last initial, and today's date and so my name is spelled [PII] and then was there anything else I could help you with, [PII]?
[CUSTOMER][NEUTRAL] No, you said it was uh your name and the date of birth, um date of service date of birth.
[AGENT][NEGATIVE] Oh, no, no
[CUSTOMER][NEUTRAL] Um, today's date.
[AGENT][NEUTRAL] Yes, my first name, last initial, and today's date. There's a lot of dates.
[CUSTOMER][NEUTRAL] And your last initial was, there's a lot of A's in there, right? So your last initial is [PII] as well.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] OK, thank you. Um, I think I got it also, we got wellness, diagnosis testing, and 5 offices a year basically for um sickness and that's it. OK. Thank you very much for your help. Uh-huh. Bye-bye.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] Absolutely.
[AGENT][POSITIVE] Of course, thanks for calling APL bye bye.
[CUSTOMER][NEUTRAL] Bye.