AccountId: 011433970860
ContactId: 0cc0f3cf-6c06-496c-9a85-d9a983ac7c5c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 389540 ms
Total Talk Time (AGENT): 144671 ms
Total Talk Time (CUSTOMER): 119870 ms
Interruptions: 0
Overall Sentiment: AGENT=1.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/06/0cc0f3cf-6c06-496c-9a85-d9a983ac7c5c_20250306T15:42_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], this is [PII] calling from Mental Health Specialty Group PA. Please be advised that this call is recorded for quality and training purposes. I am calling to check for eligibility and benefits for outpatient telehealth visit under mental health.
[AGENT][POSITIVE] All right, [PII], I'm happy to help and check benefits today. Do you have the patient's policy number?
[CUSTOMER][NEUTRAL] Yeah, it is 025.
[CUSTOMER][NEUTRAL] 362-54
[AGENT][NEUTRAL] All right, one moment.
[AGENT][NEUTRAL] And then if I could please have the patient name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, it is [PII] and the date of birth is [PII].
[AGENT][POSITIVE] All right, thank you so much. So, patient plan is active. The effective date on this is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see what their benefits are for outpatient here, one moment.
[AGENT][NEUTRAL] OK, so the patient plan has an outpatient physician office visit.
[AGENT][NEUTRAL] Of 5 a year per calendar year, they're allowed 5 visits.
[AGENT][NEUTRAL] It looks like there's a benefit payment of $50 per visit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And no deductible applies?
[AGENT][NEUTRAL] Yeah, there's no deductible, correct.
[CUSTOMER][NEUTRAL] OK. Can I have the out of pocket?
[AGENT][NEUTRAL] So this is a limited benefit plan, meaning that it's only gonna pay the set amount towards what the patient's actually being seen for. So it's only gonna pay that set amount of the $50 towards an outpatient physician office visit fee. Anything else would not be covered.
[CUSTOMER][NEUTRAL] OK, so no out of pocket.
[AGENT][NEUTRAL] Yeah, there's no, there's no limit or anything like that, correct.
[CUSTOMER][NEUTRAL] Limited plan.
[AGENT][NEUTRAL] Mhm, it's a limited benefit plan.
[CUSTOMER][NEUTRAL] OK, hold on, I'll just put it.
[CUSTOMER][NEUTRAL] Limited benefit plan and then uh no out of pocket max.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And no visit limit as well?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Uh, there is a visit limit. The patient is allowed 5 visits in a calendar year.
[CUSTOMER][NEUTRAL] OK, and the marriage and family counseling, is it covered?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] So, I don't see anything specifically that speaks to counseling itself. Uh, it may fall under the office visit and would be allowed 5 times a year.
[CUSTOMER][NEUTRAL] So it's still covered. Got it. How about the authorization or referral?
[AGENT][NEUTRAL] Uh, there's no prior authorization or referral required.
[CUSTOMER][NEUTRAL] OK, can you give me the claim's address?
[AGENT][POSITIVE] Yes, absolutely. Give me just one second, let me grab that for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, so it looks like for this member's plan all claims are gonna go to web TPA.
[AGENT][NEUTRAL] And that's at and that's at [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And that's in [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] And the payer ID?
[AGENT][NEUTRAL] It's 752-61.
[CUSTOMER][NEUTRAL] I'll just do a quick recap, [PII], and can I have the initial of your last name?
[AGENT][NEUTRAL] Absolutely. That's [PII].
[CUSTOMER][NEUTRAL] Thank you. OK. Uh, insurance effective date, [PII]. Uh just to confirm, there's no termination date.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] And yeah no termination date.
[CUSTOMER][NEUTRAL] Co-payment of $50. This is a limited benefit plan, no out of pocket max, and the visit limit is 5 visits per calendar year. Marriage and family counseling is covered. Authorization or referral is not required. Claims address will be [PII] with the payer ID of 75261.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK, uh, one last thing before we end this call, can I have the reference number?
[AGENT][NEUTRAL] Uh, call reference is my name with my last initial than today's date. My name again is [PII], last initial [PII] and today's date is [PII].
[CUSTOMER][POSITIVE] Thank you so much, [PII].
[AGENT][POSITIVE] You're very welcome.
[CUSTOMER][POSITIVE] Uh, I truly appreciate, yeah, I truly appreciate your help. Have a great day ahead of you and keep safe always.
[AGENT][NEUTRAL] You too. Bye-bye, [PII].
[CUSTOMER][NEUTRAL] Bye