AccountId: 011433970860
ContactId: 05895f64-52ae-4c9d-b23f-4b442e6b1527
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 448070 ms
Total Talk Time (AGENT): 175275 ms
Total Talk Time (CUSTOMER): 164918 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/14/05895f64-52ae-4c9d-b23f-4b442e6b1527_20250414T19:15_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi. My name is [PII] calling from Urology specialist group. I just wanna check uh benefits for one member.
[AGENT][NEUTRAL] OK, I can help you with benefits. And did you say [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, thank you. And you have a good callback number, [PII]?
[CUSTOMER][NEUTRAL] Sure. It's [PII].
[CUSTOMER][NEUTRAL] [PII]. That is a direct line.
[AGENT][NEUTRAL] OK, thank you. And you have the policy number of the patient?
[CUSTOMER][NEUTRAL] Uh, sure. Let me just a second. Let me pull that out.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] See that.
[CUSTOMER][NEUTRAL] Um, will be 023.
[CUSTOMER][NEUTRAL] 10,780 M as in Mary, L as in Larry, 8.
[AGENT][NEUTRAL] OK, thank you. And do you have the uh patient name and date of birth?
[CUSTOMER][NEUTRAL] Sure. He is um [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Um, this is not a guarantee of payment. It's a basic outline of the policy. Policy is effective [PII], currently active. And is this for outpatient hospital?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] All
[CUSTOMER][NEUTRAL] Outpatient.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me pull that up.
[CUSTOMER][NEUTRAL] I have uh codes.
[AGENT][NEUTRAL] Um, I can't look up codes. Is it for like surgery or just outpatient services or?
[CUSTOMER][NEUTRAL] Um, I have here, um, one that is diagnosis testing and the other one is an ultrasound.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And so they do have a diagnostic testing, uh, benefit, but let me see if it defines diagnostic testing. Sometimes it does. It'll only allow certain types of tests.
[AGENT][NEUTRAL] And their benefit pays out a max of 5000 per calendar year.
[AGENT][NEUTRAL] Um, let me see.
[AGENT][NEUTRAL] OK. Uh, and that would be for any kind of diagnostic testing and, and outpatient hospital setting, so there's no specification.
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] Um, there's no specification on what diagnostic testing is, so it's just, it's a benefit of 5000 per calendar year, and this is a secondary policy, so that would be after primary pays or processes the claim. It'll pick up the deductible, co-pay or co-insurance up to 5000.
[CUSTOMER][NEUTRAL] OK, and he has something metals, those 5000?
[AGENT][NEUTRAL] Um, let me see.
[AGENT][NEUTRAL] I don't show he's used any of that 5000 this year, so all of it's available.
[CUSTOMER][POSITIVE] OK, perfect. And for the ultrasound, is that something?
[AGENT][NEUTRAL] It's under the same, same information, yeah.
[CUSTOMER][NEUTRAL] Oh it's the same information.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][POSITIVE] Perfect, perfect, perfect. Um, can I get your, your name again?
[AGENT][NEUTRAL] Uh, my name is [PII], and then first initial to last name, [PII].
[CUSTOMER][NEUTRAL] [PII]. Let me ask you something, [PII]. Um, the past year, [PII], I called for the same benefits, exactly the same.
[CUSTOMER][NEUTRAL] And the answer of one of your colleagues, um, I don't have the name here, I think it's [PII].
[CUSTOMER][NEGATIVE] Um, said that for diagnostic testing, um, there is no coverage, like you guys don't cover this kind of costs.
[CUSTOMER][NEUTRAL] No procedures.
[CUSTOMER][NEUTRAL] You know, if that changed this year?
[AGENT][NEUTRAL] Some of our
[AGENT][NEUTRAL] So, it depends on the plan. Some of our plans do specify what is diagnostic testing. Um, so like, for instance, some will only pay for CAT scans, MRIs.
[AGENT][NEUTRAL] Um, PET scans, but then some will, they just have a blanket benefit. So it depends on the plan.
[CUSTOMER][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] There's different, there's different plans.
[CUSTOMER][NEUTRAL] Well, let me just a second, let me see if I can get um any specific uh you uh well, you said that you can see any type of diagnostic testing, right?
[AGENT][NEUTRAL] Well, I just looked up the definition of diagnostic testing under the plan, and it didn't specify those specific things I just mentioned.
[CUSTOMER][NEUTRAL] Hm, OK.
[AGENT][NEUTRAL] So we have, we have a lot of different gap plans for, so patients have a, they get to pick which gap plan they want.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And some of them only cover certain diagnostic tests.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] This one, however, I don't see that specified, so.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] OK, but that mean that will be cover everything or will not cover anything? Nothing. Sorry.
[AGENT][NEUTRAL] So the benefit, it's just a blanket benefit, and this, like I said, this is a secondary policy.
[AGENT][NEUTRAL] So it pays up to 5000 per calendar year for diagnostic testing in an outpatient hospital facility.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] After primary processes the claim.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] Mm, OK, well, this is a specialist office. I don't know if you have a different answer for that.
[AGENT][NEUTRAL] OK, so it's not a hospital. Is that correct?
[CUSTOMER][NEGATIVE] No, ma'am. No, no, no.
[AGENT][NEUTRAL] OK, OK, I didn't catch that.
[CUSTOMER][NEUTRAL] It's enough, especially
[AGENT][NEUTRAL] OK. Um.
[AGENT][NEUTRAL] OK, um, so that is
[CUSTOMER][NEUTRAL] 041
[AGENT][NEUTRAL] OK, so the diagnostic testing has to be in a hospital. It can't be in the doctor's office. So.
[CUSTOMER][NEUTRAL] OK, so for doctor's office will be, will be no cover, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Perfect. Exactly what I needed. Um, OK, uh, no problem, [PII]. Um, do you have a, do you have a reference number?
[AGENT][NEUTRAL] Um, it's just my name and today's date.
[CUSTOMER][POSITIVE] It's a nice day. OK, [PII], thank you so much for the help. Have a great day.
[AGENT][POSITIVE] OK, thank you for calling APL. You as well.