AccountId: 011433970860
ContactId: 0ac7b825-600e-424d-8948-73a2faa1fc9d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 371380 ms
Total Talk Time (AGENT): 236513 ms
Total Talk Time (CUSTOMER): 120066 ms
Interruptions: 6
Overall Sentiment: AGENT=1.1, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/18/0ac7b825-600e-424d-8948-73a2faa1fc9d_20250618T14:43_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APO. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yes, good morning. My name is [PII]. I'm calling from Florida Women's Care Coal patient policy is active and how does this policy actually work? I'm not really familiar with it.
[AGENT][POSITIVE] Sure, sure, I can assist you with that. Can I have a callback number for you and that policy number?
[CUSTOMER][NEUTRAL] Yes ma'am, the direct line is [PII].
[CUSTOMER][NEUTRAL] [PII] policy number is 980,760.
[AGENT][NEUTRAL] What's the member's name and date of birth that you're calling to verify benefits for today, [PII]?
[CUSTOMER][NEUTRAL] Oh [PII], and I'm gonna spell it. I'm to his name [PII]
[CUSTOMER][NEUTRAL] Uh last name is [PII] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] So [PII], this policy is a gap insurance with us which assists with the deductible, co-pay and co-insurance to the primary. This policy has been active since [PII] and it's currently active. And what is the place of service that you're calling for benefits?
[CUSTOMER][NEUTRAL] Um, OBGYN specialist office.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] You said deductible co-insurance, and you said co-pay?
[AGENT][NEUTRAL] For the members
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So the member's policy has outpatient benefits of $500 per calendar day.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The office visit itself is not covered under the policy. Let me see, hold on.
[CUSTOMER][NEUTRAL] So office visit is not covered.
[AGENT][NEUTRAL] $500.
[AGENT][NEUTRAL] Give me a moment. I'm looking through the policy if you don't mind.
[CUSTOMER][NEUTRAL] OK, OK honey.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] So there is an office so the office visit is covered under the outpatient benefits of $500 per calendar day, but there is a physician rider where the member gets 4 office visits per calendar year and will pay up to $25 per visit and this is not a guarantee of benefits, just a disclaimer of the policy's coverage.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so she has a $500 max is what you're saying?
[AGENT][NEUTRAL] Per calendar day for the treatment received in the office for outpatient services.
[CUSTOMER][NEUTRAL] And for account.
[CUSTOMER][NEUTRAL] OK, and then she has 4 of those.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] No, no. So, so she has $500. No, she, so she has $500 per calendar day for outpatient services, and her outpatient services include the visit. Whatever treatment received while at that visit falls under her outpatient benefits. However, the visit itself falls under the physician rider, which covers office visits, up to $25 per visit with 4 visits per calendar year.
[CUSTOMER][NEUTRAL] I'm just trying to understand kind of.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] Has she used any of those 4 visits?
[AGENT][NEGATIVE] No, she has not. She has not utilized any of her benefits for [PII].
[CUSTOMER][NEGATIVE] She's not, she not utilize any benefits.
[CUSTOMER][NEUTRAL] And she doesn't need the authorization.
[AGENT][NEUTRAL] No, this is the gap insurance. She knows me. She doesn't need the authorization for anything.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, and you did say it can effect of 21 to 14.
[AGENT][NEUTRAL] I don't want you to get off the phone.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Go ahead. I don't want you to get off the phone and be and be confused, so let me know if I need to explain it again.
[CUSTOMER][NEUTRAL] Oh, I'm confused, girl. You don't worry, I'm gonna.
[CUSTOMER][NEUTRAL] It uh yeah, I'm, I got the basic of it um I'm just gonna.
[CUSTOMER][POSITIVE] I got it, don't worry though.
[CUSTOMER][NEUTRAL] It'll click in probably later, but I know I got it.
[AGENT][NEUTRAL] It was active [PII].
[CUSTOMER][NEUTRAL] [PII]. OK, I put [PII].
[AGENT][NEUTRAL] I'm sorry, no, I'm sorry. I'm, I wanted to be active in [PII]. It's [PII].
[CUSTOMER][POSITIVE] It's all right.
[AGENT][NEUTRAL] And currently active.
[CUSTOMER][NEUTRAL] Oh, it is [PII]. I thought you said that the first time, OK, um.
[AGENT][NEUTRAL] That I know I'm just trying to give a whole another number.
[CUSTOMER][NEUTRAL] This
[CUSTOMER][POSITIVE] Alright my dear, uh I appreciate you. What's your name again?
[AGENT][NEUTRAL] [PII], today's date as a reference. So basically she has $500 per calendar day for outpatient services and she has $25 per office visit with 4 visits per calendar year.
[CUSTOMER][NEUTRAL] All right
[CUSTOMER][NEUTRAL] Now you say $25 does she pay the $25 or you guys pay $25?
[AGENT][NEUTRAL] We, the benefit, the amount that I gave is what we will pay up to.
[CUSTOMER][NEUTRAL] So who pays the $25 a patient?
[AGENT][NEUTRAL] No, we will pay it. So this is, so this is a gap insurance.
[CUSTOMER][NEUTRAL] But you only, but it only goes up to 500 is what you're saying.
[AGENT][NEUTRAL] No, so forget about the $25 right now, just forget about the $25. That does not matter with the $500 per calendar day. So the $500 per calendar day is her outpatient benefit. Her outpatient benefit consists of anything considered as outpatient and also she, the treatment rider, meaning there's any type of treatment received in the doctor's office.
[CUSTOMER][NEUTRAL] Right?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Falls under her outpatient benefits. So the treatment and the visit is completely different from the two. So the office visit itself saves, you know how we charge the, well, you know how the physician charged for the office visit plus the treatment, say, hey, so I went to the doctor and my blood pressure was high, so I wanted to go to the doctor, so the office visit itself is, is gonna be a bill by itself, then the treatment is gonna be a bill by itself.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so the patient doesn't pay anything when she come in, is that what you're saying?
[AGENT][NEUTRAL] Yes, because her, this is a gap insurance so you will submit the claim to the primary and then once you submit it to the primary, you'll submit it here to us with the along with the ELB because we're definitely gonna need the EOB to the primary insurance company.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, alright, I got you. Alright, [PII], I appreciate your, your, your help.
[AGENT][NEUTRAL] So we, you got, you got it now, we understand now.
[CUSTOMER][POSITIVE] Yeah, I got it, yes ma'am, I do.
[AGENT][POSITIVE] OK, well I think it was a pleasure speaking with you. Thanks for calling APL and you have a great day.
[CUSTOMER][POSITIVE] That's all I need to know. I appreciate it. You too, my dear. Have a great day. You too, bye bye.
[AGENT][POSITIVE] Thanks.