AccountId: 011433970860
ContactId: 16fdbdbb-169a-434b-b206-edb3f0ba7be0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 238169 ms
Total Talk Time (AGENT): 142109 ms
Total Talk Time (CUSTOMER): 64530 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/21/16fdbdbb-169a-434b-b206-edb3f0ba7be0_20250321T19:08_UTC.wav
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[AGENT][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes, hi. My name is Ma[PII]rom Pediatric Associates. I'm trying to check eligibility on a patient.
[AGENT][NEUTRAL] Sure, I can assist you with that. Did you say your name was Ma[PII]?
[CUSTOMER][NEUTRAL] Ma[PII]yes.
[AGENT][NEUTRAL] Ma[PII]can I have a callback number for you and that policy number that you're inquiring for eligibility.
[CUSTOMER][NEUTRAL] 75[PII]
[CUSTOMER][NEUTRAL] [PII]olicy number is 02538149 M as in Mary, L as in Larry 8.
[AGENT][NEUTRAL] Thank you, could you verify the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh, Ma[PII]12[PII].
[AGENT][NEUTRAL] You're calling to verify benefits and eligibility. Is this for outpatient inpatient office visits?
[CUSTOMER][NEUTRAL] It's, it's a for secondary policy for office visits.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] This policy has been active since Au[PII]nd is currently active. The member has outpatient benefits of $250 per calendar year, and this is not a guaranteed benefits, just a disclaimer of the policy's coverage. And if, however, office visits are not covered, but the treatment received in the office falls under the outpatient benefits of the $250 per calendar per calendar day.
[CUSTOMER][NEUTRAL] Uh, I'm sorry, say that again cause I got kind of confused there. Office visits are not covered or?
[AGENT][NEUTRAL] Office visits are not covered. However, the treatment received in the office is covered under the outpatient benefits of the $250 per calendar day.
[CUSTOMER][NEUTRAL] OK, so we should just.
[AGENT][NEUTRAL] So the treatment is covered but not the office visit itself.
[CUSTOMER][NEUTRAL] OK, but I should just bill it anyway to get the denial or because I'm kind of confused.
[AGENT][NEUTRAL] Well, I can't, I'm not sure what, how I'm, well, I don't know what you're confused on because I, I literally, I stated that the benefits only cover the treatment received in the office. So maybe the member won't just come for an office visit, but it may come for treatment in office.
[AGENT][NEUTRAL] Which pretty, I'm pretty sure it actually does happen when I, when we go to an office visit, we actually get treatment done to us. That's why we are at the doctors. And I'm not being sarcastic when I say this, but it doesn't cover the office visit itself, but the treatment would be received, say if I have to go because my thumb hurts. He's the physician is gonna look at it. That's treatment in the office. He's gonna look at it and see what's going on with it. Then maybe he need to wrap it up. That's treatment to received in the office.
[CUSTOMER][MIXED] OK, but OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Um, may I have, uh, is there a reference number?
[AGENT][NEUTRAL] We don't provide those, but you can use my name in today's date as a reference.
[CUSTOMER][NEUTRAL] And your name, please?
[AGENT][NEUTRAL] It's Sh[PII].
[CUSTOMER][NEUTRAL] OK, I, I didn't mean to give you a hard time. It's uh.
[AGENT][NEUTRAL] No, I'm no, I want, I'm trying to explain it the best that I can because when I say that there's no office visits, a lot of people be like, no office visits, but the treatment received in the office is covered. Yes, I didn't take it as you was giving me a hard time. I'm just trying to explain it so when you leave this phone call, you won't be still confused about something and you've called us, which is the secondary insurance to verify the benefits.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Right, right. OK. No problem. Thank you. I appreciate your help.
[AGENT][POSITIVE] You're welcome, Ma[PII]Thanks for calling APL and have a great day.
[CUSTOMER][NEUTRAL] You too. Bye-bye.