AccountId: 011433970860
ContactId: 17b3dd2e-04e8-488f-ae67-42a796146be2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 393350 ms
Total Talk Time (AGENT): 199383 ms
Total Talk Time (CUSTOMER): 112610 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/13/17b3dd2e-04e8-488f-ae67-42a796146be2_20250513T14:53_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, good morning. I'm calling from provider's office. I need to check if a member has benefits for specialist office visit, please.
[AGENT][NEUTRAL] OK, I could check those offices benefits. Um, what was your name? I'm sorry.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK [PII], can I get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] Thank you. And then do you have that policy number?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I have 02519076.
[CUSTOMER][NEUTRAL] I'm missing the ML.
[AGENT][NEUTRAL] OK, and then what was the name and date of birth for the member, please?
[CUSTOMER][NEUTRAL] [PII] OK, I don't know if you guys have. I'm just gonna give you his full names and.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, I have [PII].
[AGENT][NEUTRAL] Got it. And then do you have his date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Awesome, thank you so much for verifying all of that. OK, so of course this policy is active. Effective date was [PII], and this is a secondary medical policy, so it is designed to help with co-pay, deductible and co-insurance after major medical pays. And give me just a moment, let me take a look to see if any sort of office visits are covered.
[AGENT][NEUTRAL] OK, and of course I also will let you know verification of coverage is not a guarantee of payment for claims. So under this policy office visits are not covered. However, treatment received in office is. So if it were simply something like a consultation, um, that would not be covered. But if you were to receive treatment in office, that is.
[CUSTOMER][NEUTRAL] OK perfect and your name?
[AGENT][NEUTRAL] [PII] And was there anything else I could help you with, [PII]?
[CUSTOMER][NEUTRAL] Uh, yes, but I, I don't know if you have to transfer me, so I'm actually a member of you guys as well.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] And I have an upcoming procedure and I wanted to see if you guys cover that because last time I did it like 2 years ago and you guys did cover uh the deductible.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, this was for your individual policy, [PII]?
[CUSTOMER][NEUTRAL] Uh yes.
[AGENT][NEUTRAL] OK, yeah, give me just a moment, um, let me, I'm just gonna finish notating his account and then um I can get that information from you, one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] OK, thanks for your patience. Um, do you have your policy number, [PII]?
[CUSTOMER][NEUTRAL] Yeah, give me one second.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] 02556478 ML 8.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK and then what was your last name please?
[CUSTOMER][NEUTRAL] [PII] first name [PII].
[AGENT][NEUTRAL] Got you. OK, um, and then if I could get your date of birth as well please.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. I'm just gonna verify uh if you got your mailing address please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Awesome thank you for verifying all of that. OK, so what was the uh procedure? What's, what is it that we were needing to look and make sure that's going to be covered?
[CUSTOMER][NEUTRAL] Uh, OK, give me one second.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, do you need the the CPC or?
[AGENT][NEUTRAL] No, I have no way of looking for something, uh, particularly through a CBT code. Um, if it's something like, uh, is it gonna be a surgical procedure?
[CUSTOMER][NEUTRAL] Uh yes, it's, it's a hysteroscopy. I did it, I believe [PII].
[AGENT][NEUTRAL] Hysterectomy.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, and then was this just going to be in an outpatient hospital?
[CUSTOMER][NEUTRAL] Uh, it's going to be in office.
[AGENT][NEUTRAL] Oh, in office, OK, alrighty, give me just a moment, let me make sure that is going to be covered uh with this kind of policy, it is very uh particular about where, not so much what so let me make sure that that's going to be covered in an office setting.
[CUSTOMER][NEGATIVE] No, yeah, I'm, I'm asking because when I did it last time you guys covered I believe it was the deducted when I didn't have to pay anything.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right. Let's see.
[AGENT][NEUTRAL] OK, so for this one, you do have that where office treatment is covered, so absolutely, uh, treatment received in office is covered under your outpatient benefit.
[CUSTOMER][NEUTRAL] OK, and what is the amount that I have?
[AGENT][NEUTRAL] Sure, so your outpatient benefit that is $8700 per calendar year. If you give me one moment, I will double check to see if any of that has been used.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] OK, so so far this year you have used $4,599.27 of that outpatient benefit.
[CUSTOMER][NEUTRAL] OK, you told me 4,599?
[AGENT][NEUTRAL] Yes, um, if you'll give me one moment, um, math is not my strong suit, so I will tell you your total remaining balance. Give me just a moment.
[AGENT][NEUTRAL] 7. OK, sure, so of that total benefits so far for the remainder of [PII] you have 410 excuse me, $4100.73 of that outpatient benefit.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] OK perfect OK perfect thank yo[PII]
[AGENT][NEUTRAL] Of course. Was there anything else I could help you with?
[CUSTOMER][NEUTRAL] No, that will be it.
[AGENT][POSITIVE] Alright well thanks for giving us a call. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] Thank you too bye bye.
[AGENT][POSITIVE] Thanks. Bye-bye.