AccountId: 011433970860
ContactId: 0cc2f354-8997-49f4-8e1d-2f357d094929
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 392160 ms
Total Talk Time (AGENT): 213672 ms
Total Talk Time (CUSTOMER): 124563 ms
Interruptions: 0
Overall Sentiment: AGENT=1.1, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/03/0cc2f354-8997-49f4-8e1d-2f357d094929_20250303T20:24_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], I have a HR call. They, they need benefits on.
[AGENT][NEUTRAL] OK. All right. And who is on they need benefits on an HR policy, [PII], is that right?
[CUSTOMER][NEUTRAL] Uh, yes.
[AGENT][POSITIVE] OK, yes, I can help him and mhm.
[CUSTOMER][NEUTRAL] Her name is, her name is [PII].
[AGENT][POSITIVE] Thank you and her callback number?
[CUSTOMER][NEUTRAL] Her call back [PII].
[AGENT][NEUTRAL] Mhm. And the policy number?
[CUSTOMER][NEUTRAL] 023-39072. Now, I gave her the office visit benefit.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] But now she's asking about uh diagnostic X-rays done in the doctor's office and I'm not sure about that benefit.
[AGENT][NEUTRAL] Alright, so give me just a second, [PII].
[AGENT][NEUTRAL] Let me get that policy information pulled up.
[AGENT][NEUTRAL] Just for [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And I verified the birthday and everything.
[AGENT][POSITIVE] Oh but he's taking his time.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, so I'll be happy to speak to her.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] All right. Thank you. Bye.
[CUSTOMER][NEUTRAL] Mhm bye bye.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Hi [PII].
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Hi, [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hi, this is [PII]. How are you today?
[CUSTOMER][NEUTRAL] Just fine.
[AGENT][NEUTRAL] Good. So [PII] was telling me that you're trying to get benefit information for diagnostic testing. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. So yes, ma'am, I can help you with this, and [PII], any information that I provide for you would be a verification of benefits and not a guarantee of payment. So this is not a major medical plan that Mr. [PII] has with APL. This is a limited benefit plan. It's a hospital indemnity limited benefit plan.
[AGENT][NEUTRAL] So what type of testing?
[CUSTOMER][NEUTRAL] Um, do you want CPT codes or do you see them?
[AGENT][NEUTRAL] You can tell me the name of the test. There's only certain medical tests that have benefits on this plan.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] We're a heart doctor, so, um, this is echocardiograms.
[CUSTOMER][NEUTRAL] Um, carotid ultrasound.
[AGENT][NEUTRAL] OK. And I don't believe they're, so give me just a moment.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so on this, on this limited benefit plan.
[AGENT][NEUTRAL] The only types of tests that are approved that are, excuse me, that are covered under this policy, [PII] are, would be an MRI, a CAT scan, an RAIU, a CT, or a PET scan.
[AGENT][NEUTRAL] Under his medical imaging. And then there are follow-up tests, event follow-up tests, which would include an angiogram.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] Hibariium enema, lower GI series, myelogram, nuclear stress test, arteriogram, barium swallow, upper GI series sleep study, and a TEE.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Those are the only tests that are covered.
[CUSTOMER][NEUTRAL] So like for the nuclear stress test.
[CUSTOMER][NEUTRAL] PET scan, CTs, how much of those, what it is it just a flat amount towards those?
[AGENT][NEUTRAL] Yes, ma'am, it would be. So on this, uh, on those first tests that I listed, that's a benefit amount of $200 per day, maximum of 1 day per calendar year.
[AGENT][NEUTRAL] And for the advanced follow-up studies, that is $100 per day, maximum of 1 day per calendar year.
[CUSTOMER][NEUTRAL] So each of these tests can only be done once a year?
[AGENT][NEUTRAL] That well
[CUSTOMER][NEUTRAL] $200 a day per year.
[AGENT][NEUTRAL] Just
[AGENT][NEUTRAL] One test.
[AGENT][NEUTRAL] Per day, I mean 1 test per calendar year and the benefit amount would be 200 or 100 if it falls under the advanced test.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEGATIVE] So it didn't make a difference if they do a CT or a PET scan. It only pays $200 per year and only limit one per year. So if they want to do another one of those tests, they won't pay for it that year.
[AGENT][NEUTRAL] So
[AGENT][NEGATIVE] That would not be covered. I, no, ma'am, not because the benefit Max would have been met.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][POSITIVE] Got it OK.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] They said for a.
[AGENT][NEUTRAL] And then I don't
[AGENT][NEUTRAL] Uh-huh. I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] For a specialty office visit it'll pay $75.
[AGENT][NEUTRAL] Yes, and that is the benefit on here for an office visit. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, did any of these tests need authorization?
[AGENT][NEUTRAL] No, ma'am. None of this would require prior authorization since this is not major medical insurance.
[CUSTOMER][NEUTRAL] OK, and is it under um a PHCS or or some kind of.
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] No, OK, just a plain commercial and limited benefit plan calendar year contract.
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] Calendar
[CUSTOMER][NEUTRAL] Calendar, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it, uh, [PII], do we have any kind of a reference number?
[AGENT][NEUTRAL] You would use my name and today's date, [PII], and then one last thing if you all do file a claim on this policy for him, once the claim has been processed, we do have a portal that you should be able to check the claim status in and our website for our portal is secured. [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Great thank you so much.
[AGENT][POSITIVE] All right. Well, you are certainly very welcome. So is there anything else I can help you with?
[CUSTOMER][POSITIVE] No ma'am we're good.
[AGENT][POSITIVE] OK, well, thank you again for calling APL and I hope you have a great afternoon.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][POSITIVE] Thank you bye.
[AGENT][NEUTRAL] Yes ma'am, bye bye.