AccountId: 011433970860
ContactId: 0593f38d-fd5d-489a-bdfd-88e9e19bae91
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 340670 ms
Total Talk Time (AGENT): 197673 ms
Total Talk Time (CUSTOMER): 95252 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/0593f38d-fd5d-489a-bdfd-88e9e19bae91_20250121T17:24_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How may I help you?
[CUSTOMER][NEUTRAL] My name is [PII]. I'm calling from Doctor [PII]'s office. I need to verify benefits and see a research required for a patient to have outpatient surgery.
[AGENT][POSITIVE] Sure, I'd be happy to help you with eligibility and benefits, [PII].
[AGENT][NEUTRAL] Uh, can I please have a callback number in case we should get disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] I'm sorry, what was the last four digits? My apologies.
[CUSTOMER][NEUTRAL] That's fine. [PII].
[AGENT][NEUTRAL] My apologies. Thank you. My pen stopped writing. Go ahead and provide me the policy certificate or member ID.
[CUSTOMER][NEUTRAL] You're fine.
[CUSTOMER][NEUTRAL] Uh, policy number 02576453.
[AGENT][NEUTRAL] Thank you. And can you spell the doctor's name for me?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, just one moment please.
[CUSTOMER][NEUTRAL] And your name was [PII]?
[AGENT][POSITIVE] Yes, [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You're welcome and can I please have you verify patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And you said it was gonna be for outpatient surgery, is that right?
[CUSTOMER][NEUTRAL] Yes, at an outpatient hospital.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Outpatient hospital. OK, thank you.
[AGENT][NEUTRAL] Just give me one moment to pull up their policy information, just to let you know it is a verification of coverage, not a guarantee of payment. The policy is active. The effective date [PII].
[AGENT][NEUTRAL] Of [PII].
[AGENT][NEUTRAL] Um, now this, uh, policy is a limited medical hospital indemnity plan.
[AGENT][NEUTRAL] So it does have limited medical benefits.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And just bear with me for one moment while I pull up and can you tell me um so the outpatient uh.
[AGENT][NEUTRAL] Surgery, you said it's gonna be outpatient hospital and this is um for this uh.
[AGENT][NEUTRAL] Surgeon or doctor fee?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Now again, this policy is limited medical hospital and then they do have a rider available for surgical and anesthesia benefit. It is based on the surgical procedure. The fee itself is based on that surgical procedure, um, and their benefit, um, again, it goes by the schedule of benefits based on the procedure. Um, they do have a $2000 benefit. However, again, it is based on that surgical fee.
[AGENT][NEUTRAL] And then the anesthesia would be 25% of the surgical benefit amount. So whatever amount is allowed for that typical or for that particular procedure, we would pay a 25% um anesthesia benefit of that surgical benefit amount.
[CUSTOMER][NEUTRAL] And then the $2000 if that would be what I would pay for the for everything else.
[AGENT][NEUTRAL] No, that $2000 benefit again is the surgical benefit itself, so they have up to $2000. Well, again, this policy is not a major medical plan. It is limited medical hospital indemnity. So that again that surgical procedure is based on a schedule of benefits in their policy.
[CUSTOMER][NEUTRAL] What's that mean?
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Um, it is up to a $2000 benefit again, but it is based on the surgical fee itself. So in other words, the CPT code that is billed, it would be that reimbursement would be based on that surgical procedure and then that anesthesia would be 25% of the allowed amount for that surgery.
[CUSTOMER][NEUTRAL] Up to $2000.
[AGENT][NEUTRAL] Correct. But again, it is based on that surgical, again, it's not major medical coverage, it is limited, uh, coverage. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, right, right, I knew I told the patient it would be, it was limited, he would have a good bit of out of pocket potentially, so I'll pay up to $2000 and 25% of the allowable for anesthesia and up to $2000 would be the facility and the surgeon.
[AGENT][NEUTRAL] Right, and again that
[AGENT][NEUTRAL] Right. Well, usually it's based on that surgical, right, surgical CPT that's used. So the surgical operation is equal to a percentage of the set opposite amount of the procedure listed in their schedule of operations.
[CUSTOMER][NEUTRAL] Based on the CPT code.
[CUSTOMER][NEUTRAL] OK, is pre-cert going to be required for this?
[AGENT][NEUTRAL] Pre-cert is not required.
[CUSTOMER][NEUTRAL] OK, and it's Roxy L and could I get a call reference number?
[AGENT][NEUTRAL] Certainly the call reference number, [PII] you would use my name and today's date.
[AGENT][NEUTRAL] Again it's R O X Y last [PII]
[AGENT][NEUTRAL] And today's date.
[CUSTOMER][POSITIVE] [PII] great thank you so much for your help.
[AGENT][POSITIVE] You're welcome, [PII]. Thank you for calling APL. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] Thanks you too bye bye.
[AGENT][POSITIVE] Thank you. Bye bye.