AccountId: 011433970860
ContactId: 1fc9346b-8b93-4df8-b8c4-7f7e2e38db82
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 520679 ms
Total Talk Time (AGENT): 213791 ms
Total Talk Time (CUSTOMER): 164122 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/05/1fc9346b-8b93-4df8-b8c4-7f7e2e38db82_20250505T20:14_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Um, yes, good afternoon. Um, my name is. I'm calling for a provider's office. Um, I need to verify members benefit eligibility. Can you help me with that?
[AGENT][POSITIVE] Yes, I can help you with um eligibility and benefits. Can you please spell your first name?
[CUSTOMER][NEUTRAL] Yes, it's kind of staticky. Um, I'm not sure if it's my phone or yours, but, um, first name is spelled [PII], initial last name is [PII].
[AGENT][NEUTRAL] Thank you, yeah, and then what is your um callback number just in case the call gets dropped.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, uh, [PII].
[AGENT][NEUTRAL] Thank you ma'am and then can you give me the patient's name, date of birth and policy number?
[CUSTOMER][NEUTRAL] Yes, um, policy number is 02138624 for patient [PII]. Date of birth [PII].
[AGENT][POSITIVE] Thank you so much and let me pull up that policy real quick.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I do show that [PII] does have an active policy. The effective date of his policy is [PII].
[AGENT][NEUTRAL] And this is just to verify his benefits. It's not a guarantee of payment. He has a supplemental policy that's billed secondary to the primary.
[AGENT][POSITIVE] It helps with deductible, co-pay, and co-insurance.
[AGENT][NEUTRAL] He has an inpatient benefit amount per calendar year of $4000 and then he also has an outpatient per calendar year benefit of $3000.
[CUSTOMER][NEUTRAL] OK, I'm sorry, you said a deductible of 4000?
[AGENT][NEUTRAL] No, this policy um helps with deductible, co-pay and co-insurance.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oh, OK, OK, is this, and this is a supplement policy?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is there like a plan A, Plan B on there?
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] OK, and you said it covers the deductible coinsurance and co-pay?
[AGENT][POSITIVE] Yes, it helps with the deductible, co-pay and co-insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] Does it require an authorization for a CT scan?
[AGENT][NEUTRAL] No, ma'am, because it's not the um major medical insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so, um.
[CUSTOMER][NEUTRAL] Before I let you go, it, it, it's just this is like a an actual true supplement policy that will cover the prime uh help picks up the primary insurance copay co-insurance deductible, correct?
[AGENT][NEUTRAL] Uh, yes, it, it does help with deductible, co-pay and co-insurance. Um, it goes by facility. What type of facility are you guys going, is he going to be at?
[CUSTOMER][NEUTRAL] OK, so now, um, we do not build this as a facility, uh, we build the CT scan as office setting. Is that what we cover office setting?
[AGENT][NEUTRAL] Let me check and see if office visits are under his policy real quick.
[CUSTOMER][NEUTRAL] OK, now we're not billing for the any office visit, it's just for the CT scan.
[AGENT][NEUTRAL] OK, let me check and see.
[AGENT][NEUTRAL] It be just a moment while I pull up his policy.
[AGENT][NEUTRAL] Let me see what is
[AGENT][NEUTRAL] On his policy schedule, I'm trying to look to see what he has as far as outpatient goes, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's gonna be just a minute while I pull it in.
[AGENT][NEUTRAL] OK, so looking at the policy on his outpatient benefits.
[AGENT][NEUTRAL] Uh, he has a $3000 per covered person per calendar for covered outpatient services, a maximum of $9000 for family. Um, he does have a $1000 per covered person per calendar year outpatient deductible that needs to be met. Um, he gets 3 urgent care visits per per per calendar year, um.
[AGENT][NEUTRAL] He can go to an outpatient treatment for mental or emotional disorder that doesn't apply.
[AGENT][NEUTRAL] And then um he has diagnostic testing in a hospital outpatient facility or an MRI facility.
[CUSTOMER][NEUTRAL] OK, so, so because we build this as office setting, it will it cover?
[AGENT][NEUTRAL] It does not appear that he has office visits on his policy.
[CUSTOMER][NEUTRAL] OK, yeah, because I've been told with this policy before that the plan only covers outpatient facility hospital setting.
[AGENT][NEUTRAL] It's
[AGENT][NEUTRAL] Right. That's what it said, um, outpatient for diagnostic testing in a, in a hospital outpatient facility or an MRI facility.
[CUSTOMER][NEUTRAL] OK, so plan only
[CUSTOMER][NEUTRAL] Outpatient facility, um, hospital outpatient.
[AGENT][NEUTRAL] Or an MRI facility.
[CUSTOMER][NEUTRAL] Or MRI OK.
[CUSTOMER][NEGATIVE] And it doesn't cover um office setting.
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So this um CP will not cover under this policy.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, I think that's all I need to verify, um, do you provide a call reference number for our call today?
[AGENT][NEUTRAL] Yes, ma'am. You can use my name [PII], and today's date.
[CUSTOMER][NEUTRAL] OK, and what is the initial your last name if you don't mind?
[AGENT][NEUTRAL] It's A.
[CUSTOMER][NEUTRAL] OK, if you don't mind, what is the time stamp over there?
[AGENT][NEUTRAL] It is uh [PII].
[CUSTOMER][NEUTRAL] 322.
[CUSTOMER][NEUTRAL] Is that um um Central Standard Time?
[AGENT][NEUTRAL] Yes, central.
[AGENT][NEUTRAL] And Miss Ya, what is um
[CUSTOMER][POSITIVE] OK perfect thank you so much uh huh.
[AGENT][NEUTRAL] What is the name of the facility you're calling from?
[CUSTOMER][NEUTRAL] Um, Kemont Healthcare on behalf of Doctor [PII]'s office.
[AGENT][POSITIVE] OK, thank you. I appreciate that.
[CUSTOMER][POSITIVE] So we're like we're a station group uh huh you're welcome.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, is there anything else I can help you with before we go?
[CUSTOMER][POSITIVE] No, that was it thank you I appreciate your help.
[AGENT][POSITIVE] Well, we appreciate you calling APL and I hope you have a wonderful week.
[CUSTOMER][POSITIVE] Thank you you too bye bye.
[AGENT][NEUTRAL] Bye bye, ma'am.