AccountId: 011433970860
ContactId: 13a5b575-6eb3-4ef1-af75-977bc5e8f4e7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 465750 ms
Total Talk Time (AGENT): 191410 ms
Total Talk Time (CUSTOMER): 168740 ms
Interruptions: 2
Overall Sentiment: AGENT=0.6, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/13a5b575-6eb3-4ef1-af75-977bc5e8f4e7_20250429T15:56_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, hello [PII]. Yes, my name is [PII]. I'm calling in for Total MD Primary Care Physicians Group. I'm calling in for patient eligibility and benefits.
[AGENT][POSITIVE] All right. Happy to check on eligibility and benefits today, [PII]. Can I get the patient's policy number?
[CUSTOMER][NEUTRAL] Uh, yes, uh, policy number is D for Delta 43,733,130.
[AGENT][NEUTRAL] All right. Unfortunately, [PII], I can't pull them with that number. Do you see, do you have their card? Do you see anything that says certificate number?
[CUSTOMER][NEUTRAL] Uh, yes, the, uh, the policy's last certificate number, is that is that it?
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, uh, that would be 02608322.
[AGENT][POSITIVE] All right, thank you so much. And then do you have a good callback number?
[CUSTOMER][NEUTRAL] Uh, yes, that would be [PII], no extension.
[AGENT][NEUTRAL] Thank you. What's the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh, yes, first name is [PII]. Last name is [PII]. Uh, date of birth is [PII].
[AGENT][POSITIVE] Thank you so much. So patient is active. Effective date on here is [PII].
[CUSTOMER][NEUTRAL] OK, great, thank you. Um, also I just need to confirm, um, certain benefits if they're covered for the patient's plan. Um, first one would be for a sick office visit and this would be for a PCP.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Let me just pull the member's plan here, go ahead.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Uh, sure, and after the, uh, office visit, uh, next would be for the agnostic labs also will be done in office.
[CUSTOMER][NEUTRAL] And then, um, 3 would be for injections. Uh, do you need the CPT code or just the description of the, um, the injection?
[AGENT][NEUTRAL] Yeah, just injections will work. Let me take a look and see.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, great, yeah, and that's, uh, that's for a specialty drug, um, for the injection as well.
[AGENT][NEUTRAL] So the patient has a hospital indemnity plan with us. This is a limited benefit.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, plan, it's gonna pay a set amount depending upon what the patient is being seen or treated for. So the patient does, it looks like, have um outpatient office visits. They're allowed a total of 5 for the calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the plane is going to pay $75 towards the cost of the visit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And it's 5 visits um per year correct calendar year.
[AGENT][NEUTRAL] Per calendar year. Uh-huh. Correct.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Uh, patient's plan does also have a diagnostic test benefits. Uh, that benefit amount is $250 towards diagnostic testing.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, great. Um, is there any, uh, number of visits limited for the, uh, for the, uh, the agnostic class?
[AGENT][NEUTRAL] I don't show a limit as far as the diagnostic testing. No, there's not a restriction on that.
[CUSTOMER][POSITIVE] OK, great, thank you.
[AGENT][NEUTRAL] And it looks like that's pretty much the extent of the plan coverage aside from hospital, uh, confinement and intensive care and surgery. So as far as any sort of injections, I don't show that there would be any benefit on the member plan towards that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, great. um, also just, um, last two benefits I need to check if they're covered, um, if, if routine physical like preventative, uh, wellness or behavioral health is covered for telehealth.
[AGENT][NEUTRAL] A wellness visit would definitely be covered. Uh, telehealth, you're asking for, um, like mental health?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] That's, that's yes, that's correct.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] I don't see anything in the limitations or exclusions that speaks to telehealth being an exclusion, so that would be something that would just fall under their outpatient benefits.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, uh, you mean the, uh, office visit it, um, falls into that.
[AGENT][NEUTRAL] The office visits, yeah, yeah.
[CUSTOMER][NEUTRAL] OK, great, um, and also, um, one thing for the routine physical or preventative, uh, uh, preventive wellness if that's also covered.
[AGENT][NEUTRAL] Yes, it would be.
[CUSTOMER][NEUTRAL] OK, um, how much would that be? Is it, um,
[AGENT][NEUTRAL] Um, so for wellness, it looks like the benefit amount is $75.
[CUSTOMER][NEUTRAL] I guess it, uh, it's the same as uh the office is, um, but just only once per year correct?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] This is a once per year correct.
[CUSTOMER][POSITIVE] OK great one is it next for you?
[CUSTOMER][NEUTRAL] Um, yeah, so far that's all the information I need, um, for this patient, um, uh, can I also ask for a payer address and payer ID for claim submission information?
[AGENT][POSITIVE] Yeah, absolutely. Let me just verify that on here. Give me one moment.
[CUSTOMER][POSITIVE] OK great.
[AGENT][NEUTRAL] So for this patient's plan, it looks like all of the claims are going to IMA. So it's attention IMA that's I as in India, M as in [PII].
[CUSTOMER][NEUTRAL] She
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] And that's in [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][POSITIVE] OK, great.
[AGENT][NEUTRAL] Did you want the payer ID as well?
[CUSTOMER][NEUTRAL] And also the
[CUSTOMER][POSITIVE] Yes, thank you.
[AGENT][NEUTRAL] Uh huh, payer ID is gonna be 64556.
[CUSTOMER][NEUTRAL] 645-5. OK, great, um, yeah, just one last thing, um, all I need is the reference number, um, for this phone that we're good to go.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, Call reference is my name with my last initial in today's date. My name again is [PII], that is [PII] Last initial is [PII] and then today's date.
[CUSTOMER][POSITIVE] OK, great, thank you so much again sir for the assistance. You've been a great help and you have a great rest of your day.
[AGENT][NEUTRAL] You too, [PII]. Bye bye.