AccountId: 011433970860
ContactId: 1735ecce-63be-46b3-ab2f-7232d2860603
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 552580 ms
Total Talk Time (AGENT): 165425 ms
Total Talk Time (CUSTOMER): 84721 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/07/1735ecce-63be-46b3-ab2f-7232d2860603_20250407T19:38_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, good afternoon, this is [PII]. I'm calling to obtain eligibility and benefits on a member.
[AGENT][NEUTRAL] OK, [PII], I can help you with eligibility and benefits. Do you have a good policy number for the patient?
[CUSTOMER][NEUTRAL] Yes. Are you ready?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I have D41.
[CUSTOMER][NEUTRAL] 203597
[AGENT][NEUTRAL] What's the last name of the patient?
[CUSTOMER][NEUTRAL] Huh
[AGENT][NEUTRAL] Yeah, first name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] So [PII]?
[CUSTOMER][POSITIVE] You got it.
[AGENT][POSITIVE] You got it. OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Do you have a good callback number, [PII]?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] to look for.
[AGENT][NEUTRAL] I'm pulling it up, give me one moment.
[AGENT][NEUTRAL] Do you by chance have her social?
[CUSTOMER][NEUTRAL] No, I don't.
[AGENT][NEUTRAL] OK, do you have a group number?
[CUSTOMER][NEUTRAL] Let's see, uh, no, the trip number.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Let me see if I can
[CUSTOMER][NEUTRAL] No, I don't have a group number no.
[AGENT][NEUTRAL] What kind of benefits are you needing?
[CUSTOMER][NEUTRAL] I'll be needing uh general benefits for specialist office visit, DME and X-rays study in office.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see if I can find.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Do you have her date of birth?
[CUSTOMER][NEUTRAL] Um, yes, [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, looks like I found her, OK.
[AGENT][NEUTRAL] Um, let's see, I've got a different policy number. Can I give that to you?
[CUSTOMER][NEUTRAL] Yes, OK.
[AGENT][NEUTRAL] Um, it's 2606091.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and this is not a guarantee of payment. It's a basic outline of her policy. Uh, she is effective [PII], currently active.
[AGENT][NEUTRAL] And let me see.
[AGENT][NEUTRAL] Uh, pulling up your policy. Give me one moment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so
[AGENT][NEUTRAL] Again, not a guarantee of payment based outline of the policies. So she, this is a hospital indemnity policy, so it pays a certain dollar amount for certain types of services. Um, you said diagnostic testing, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] Um, they do have a diagnostic testing benefit. Um, it will pay $250.
[AGENT][NEUTRAL] Per diagnostic test.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] And that's the max for the calendar year as well.
[CUSTOMER][NEUTRAL] That what it is.
[AGENT][NEUTRAL] So, let's see.
[AGENT][NEUTRAL] So that's the max it'll pay in a calendar year.
[CUSTOMER][NEUTRAL] Go meditate
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it does specify um what is a diagnosis. So it does specify what is a diagnostic test and it will only pay for MRIs, CAT scans, and diagnostic colonoscopies.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm, go ahead.
[AGENT][NEUTRAL] And then did you say outpatient or a physician visit?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let's see what we have for that.
[AGENT][NEUTRAL] Um
[AGENT][NEGATIVE] Um, I don't show any benefit for just physician office visit.
[CUSTOMER][NEUTRAL] So no coverage for office visit?
[AGENT][NEUTRAL] Um, let me make sure there's not something else. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, actually that does include, that's gonna pay, looking at the definition for outpatient sickness. It's gonna be $75 maximum payout per visit.
[AGENT][NEUTRAL] And there is a max visit per calendar year of 5, so only 5 visits per calendar year.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] All right. And for DME, do they have any coverage?
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEGATIVE] I do not show any coverage for durable medical equipment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Now, can we go back to the X-ray? I just want to confirm, um, what about for like an in-office X-ray? Would that be covered or just the MRI CT scan?
[AGENT][NEUTRAL] Um, just the MRI, CT scan, and diagnostic colonoscopy.
[CUSTOMER][NEUTRAL] OK, got you.
[CUSTOMER][POSITIVE] OK. All right. Well, thank you so much for your help. One more thing, what is the time's address?
[AGENT][NEUTRAL] Uh, claims address is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] 1 to 4.
[CUSTOMER][POSITIVE] OK. All right. Thank you so much. Can I just get a reference number?
[AGENT][NEUTRAL] Uh, reference number will be my name, [PII], first initial of my last name, [PII], and today's date.
[CUSTOMER][POSITIVE] OK. All right. Thank you so much. You have a great day.
[AGENT][POSITIVE] OK, thanks for calling APL. Have a great day too.
[CUSTOMER][NEUTRAL] Bye-bye.