AccountId: 011433970860
ContactId: 19042cb4-b233-4ed0-a809-47698c9cc457
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 441730 ms
Total Talk Time (AGENT): 196532 ms
Total Talk Time (CUSTOMER): 119795 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/13/19042cb4-b233-4ed0-a809-47698c9cc457_20250313T18:48_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Um, hi. Good day. This is [PII] from provider's office. I'm just calling to check for benefits and eligibility.
[AGENT][POSITIVE] OK, well, I'll be more than happy to assist you with the benefits and the eligibility. May I have your name and a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Um it's [PII] and for my callback number, [PII].
[AGENT][NEUTRAL] Thank you for that, and [PII], may I have the member's policy number?
[CUSTOMER][NEUTRAL] Um, for the policy number, it's 24831112.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And you said 248-311-12?
[CUSTOMER][NEUTRAL] Mhm. Yes.
[AGENT][NEUTRAL] And what is the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Um, this is for, um, [PII], [PII].
[AGENT][NEUTRAL] So that's not pulling up a policy and it's 248-31112?
[CUSTOMER][NEUTRAL] Mhm. Yes.
[AGENT][NEUTRAL] Does it have an ML 7 or 8 at the end?
[CUSTOMER][NEUTRAL] Um, that's the only thing I used last time when I called.
[AGENT][NEUTRAL] When you
[CUSTOMER][NEUTRAL] As well.
[AGENT][NEUTRAL] OK, because there's no policy here with that policy number. It was for APL?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm. Yes.
[AGENT][NEUTRAL] What's the member's first and last name?
[CUSTOMER][NEUTRAL] How much for is the ES for this?
[AGENT][NEUTRAL] Can you spell it for me, please?
[CUSTOMER][NEUTRAL] Mm it's as in, I'm sorry, for the last name, it's [PII]
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, so last name [PII]?
[CUSTOMER][NEUTRAL] Um, it's [PII]
[AGENT][NEUTRAL] OK, wait a minute. Can you give the alphabet and the, the, so the beginning letter, is it a P like Paul or T like [PII]?
[CUSTOMER][NEUTRAL] Um, it's [PII]. Yes, [PII].
[AGENT][NEUTRAL] Oh, and then [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then where's the T?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]?
[CUSTOMER][NEUTRAL] Um, [PII] only.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm, yeah.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Hold on one moment. And the first name is?
[CUSTOMER][NEUTRAL] First name is [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, here it is.
[AGENT][NEUTRAL] So there's no 2 at the end, it's 248-3111.
[CUSTOMER][POSITIVE] Oh, OK. Thank you for that.
[AGENT][POSITIVE] You're very welcoming. Um, you already gave the um date of birth, but just since I'm in the policy, um, can you repeat the date of birth for me?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. It's [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. I am showing the policy is active. It's been effective since [PII].
[AGENT][NEUTRAL] And what type of benefits did you want to go over?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, I, I just want to check if office visits are covered and um, what is the maximum benefit for the patient.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] So I'm just pulling up all of the benefits so that I can check for the office visits.
[AGENT][NEUTRAL] OK, it's coming up now. Hold on one moment.
[AGENT][NEUTRAL] OK, so the policy will pay up to $9100 for outpatient expenses. Um, the physician office would be under outpatient.
[AGENT][NEUTRAL] There's no like per visit or anything. Um, it would just be, we could pay out on the claims up to that, um, I'm sorry, $9100 max per year.
[AGENT][NEUTRAL] And you want, and you wanted to see if it's been used for this year?
[CUSTOMER][NEUTRAL] Mm, OK.
[CUSTOMER][NEUTRAL] Um, just, I, I just want to double-check if office visits are covered.
[CUSTOMER][NEUTRAL] It is, uh, the, the provider is a specialist.
[AGENT][NEUTRAL] So for specialist office or or um physician's office, it will still be the same benefit um under outpatient um treatment in a physician's office or specialist. It's the physician considered specialist as well.
[CUSTOMER][NEUTRAL] Oh, OK. So, office visits are still covered.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Um, office visits are still covered, correct?
[AGENT][NEUTRAL] Right, so if you, so I guess I can say like this, if you, if you bill for 99213, like a place of service code, that would probably be denied because there is no coverage for the office visit itself, but there is coverage for the treatment in a physician's office.
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] As long as it's not cosmetic.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Mhm. OK, got it. So, for the
[CUSTOMER][NEUTRAL] Uh, office are not covered for the specific ones.
[AGENT][NEUTRAL] If you're speaking in terms of facility charges or codes, no, office visits are not covered. If you're speaking of the treatment done in the office, yes, you can file for that in the office treatment rider could be applied.
[CUSTOMER][NEUTRAL] Mhm. OK. Got it. Thank you. And may I just have a reference number for your call?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date, and again, that's [PII] The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Mhm. OK. Thank you very much, [PII], and I guess, um, I got all the information needed. Thanks again for your help. You have a great day. Thank you.
[AGENT][NEUTRAL] You're welcome, [PII]. Was there anything else I can help with?
[CUSTOMER][POSITIVE] Um, that would be all. Thank you. Have a great day.
[AGENT][POSITIVE] Alright, thanks for calling APL. You also. Bye-bye.