AccountId: 011433970860
ContactId: 0bf668ed-98f8-4f4d-a1b0-b880771a7ce3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 626809 ms
Total Talk Time (AGENT): 310371 ms
Total Talk Time (CUSTOMER): 126795 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/24/0bf668ed-98f8-4f4d-a1b0-b880771a7ce3_20250324T19:57_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah, hello [PII]. Yes, my name is [PII]. I'm calling for Total MD Primary Care Physicians Group calling for patient eligibility and benefits.
[AGENT][NEUTRAL] OK, [PII], you're needing eligibility and benefits from them, is that correct?
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][POSITIVE] Yes, I can help you with those things. And [PII], what is your callback number, please?
[CUSTOMER][NEUTRAL] Yes, that would be [PII], no extension.
[AGENT][POSITIVE] Mhm thank you I'm the member
[AGENT][NEUTRAL] Policy number please.
[CUSTOMER][NEUTRAL] Uh yes, um, uh there was.
[CUSTOMER][NEUTRAL] I guess that would be 024.
[CUSTOMER][NEUTRAL] 11054.
[CUSTOMER][NEUTRAL] Yeah, first name is [PII], and last name is [PII]. Uh date of birth is uh [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so I do show that he is a subscriber on this limited benefit plan, [PII], and this policy is active with an effective date of [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what type of benefit information are you needing for him, inpatient, outpatient or office?
[CUSTOMER][NEUTRAL] Uh, this would be for office.
[CUSTOMER][NEUTRAL] Um, uh, first one would be for an office visit and this would be for PCP.
[AGENT][NEUTRAL] Office
[CUSTOMER][POSITIVE] Uh yes, that's right.
[AGENT][NEUTRAL] OK. One moment.
[CUSTOMER][NEUTRAL] And then after that is diagnostic labs also will be done in office.
[CUSTOMER][NEUTRAL] And then um injections for a specialty drug.
[CUSTOMER][NEUTRAL] And then after that next would be for a routine physical.
[CUSTOMER][NEUTRAL] And the last and final benefit after that is for a telehealth uh for behavioral health benefits.
[AGENT][NEUTRAL] OK, so on this limited benefit plan, we'll just start at the beginning, um.
[AGENT][NEUTRAL] So for a physician's office visit, the benefit is $75 per day, maximum of 6 days per calendar year per cover person, and that's for accident or sickness treatment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Of the routine health screening benefits.
[AGENT][NEUTRAL] That has multiple tiers. Uh, let's see.
[AGENT][NEUTRAL] Give me just a moment.
[AGENT][NEUTRAL] You did say for a routine health screening, is that correct?
[CUSTOMER][NEUTRAL] Oh sure.
[CUSTOMER][POSITIVE] That's correct, yes.
[AGENT][NEUTRAL] OK, so for an annual fiscal that would be $75 the benefit amount on this plan is $75.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Per day.
[CUSTOMER][POSITIVE] OK, good.
[AGENT][NEUTRAL] And that is a
[AGENT][NEUTRAL] I have, I'm having a go, give me just a moment, and that's one day per calendar year.
[CUSTOMER][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Then there are certain procedures that fall under a routine health screening tier 2 benefit.
[AGENT][NEUTRAL] That's either and this is also one.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Exam or preventative test.
[AGENT][NEUTRAL] That's a blood test for triglycerides, the CA 199, blood test for pancreatic cancer, a CEA fasting blood glucose, Pap smear, which wouldn't be applicable for him on a routine skin check for cancer.
[AGENT][NEUTRAL] ACA 15-3 test, CA 125, chest X-ray, hemacult stool analysis, PSA or serum cholesterol test to determine the levels of HDL and LDL.
[AGENT][NEUTRAL] And a serum protein electrophoresis.
[CUSTOMER][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] And then also he has a tier 3 health screening benefit.
[AGENT][NEUTRAL] It's also a one per day or one at
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Per day and then one per year. And that would be for such things as a breast mammography, colonoscopy.
[AGENT][NEUTRAL] This could be electrocardio echocardiogram rather size or pharmacologic stress test, uh, thermography, I couldn't speak Doppler ultrasound and EK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] AG, a flex, sigmoidoscopy, or tisso.
[CUSTOMER][POSITIVE] OK, great.
[CUSTOMER][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] Uh mhm.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Now, under
[AGENT][NEUTRAL] Now, for his out for the prescription drug benefit on this limited benefit plan, we will pay the outpatient prescription drug benefits per day when a covered person has a written prescription filled or refilled, and this prescription must be ordered by a physician, be dispensed by a licensed pharmacist, and
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For the purpose of this benefit, it does not include therapeutics, experimental drugs, or drugs, medicines, or insulin used or administered to a person while he or she is confined to a hospital, rest home, extended care facility, convalescent home, nursing home, or similar institution.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Or immunization agents.
[AGENT][NEUTRAL] Biological serra, blood or blood plasma, or contraceptive materials, devices or medications or infertility medication except required by law.
[CUSTOMER][NEUTRAL] Thank you, so just to confirm it's uh not covered correct for this patient's plan.
[AGENT][POSITIVE] Correct.
[CUSTOMER][MIXED] Ok great got it on missing notes, uh.
[CUSTOMER][POSITIVE] OK, great, got it.
[AGENT][NEUTRAL] And is there any other information?
[CUSTOMER][NEUTRAL] Uh yes, uh, for the mental health and the diagnostic labs, by the way, um.
[CUSTOMER][NEUTRAL] What uh the coverage for that?
[AGENT][NEGATIVE] When you say diagnostic labs, he does not have benefits for lab work on this plan.
[CUSTOMER][NEGATIVE] Uh, sorry, the other is gonna, it's not covered correct for this plan.
[AGENT][NEUTRAL] Mental health, there's not a separate benefit that that would.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] And mental health would fall under the physician's office visit benefit that I gave you of the 75 per day max of 6 days per calendar year.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK, great. Alright um let me just put notes here, uh, yeah, so, um, but just also just to confirm, um, this patient plan doesn't have a deductible or out of pocket, correct?
[AGENT][NEUTRAL] No, this is not major medical insurance. This is a limited benefit plan that pays for, yeah, specific amounts for certain services.
[CUSTOMER][POSITIVE] OK great.
[CUSTOMER][NEUTRAL] OK, great. Also, can I ask for a uh payer ID and payer address for claim submission information?
[AGENT][NEUTRAL] KRID 60801.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] 68.
[AGENT][NEUTRAL] And the address for claims would be [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mailing address is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] OK, great, yes, so so far that's all the information, uh, I wanna say I just need the reference number for this call by the way.
[AGENT][NEUTRAL] Sure, you would use my name along with today's date and then one last thing, [PII], if you all do file a claim with APL once we have.
[AGENT][NEUTRAL] Process the claim. We do have a portal in which you should be able to claim status and the portal website is located at [PII].
[CUSTOMER][POSITIVE] OK great thank you so much again and you have a great day.
[AGENT][POSITIVE] OK. Well, I hope you have a great day too, if that's all I can help you with. Thank you again for calling ATL.
[CUSTOMER][POSITIVE] Thank you have a great day bye bye.
[AGENT][NEUTRAL] Mm. You too. Bye-bye.