AccountId: 011433970860
ContactId: 23e9ff2e-b10b-48e0-bad5-13417a83d040
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 327470 ms
Total Talk Time (AGENT): 161219 ms
Total Talk Time (CUSTOMER): 155493 ms
Interruptions: 1
Overall Sentiment: AGENT=1, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/04/23e9ff2e-b10b-48e0-bad5-13417a83d040_20250604T21:33_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, uh, good afternoon. My name is [PII]. I'm calling from Epiphany dermatology. I was just calling, um, because I wanted to check and see if our provider shows in network with this plan and also to obtain uh benefits for a specialist office visit and surgical procedures for a patient.
[AGENT][NEUTRAL] OK, I can just uh check those benefits and then check that network as well. um I'm sorry, you said your name was [PII]?
[CUSTOMER][NEUTRAL] It's [PII]
[AGENT][NEUTRAL] [PII], sorry about that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK and then uh can I get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you and then do you have that policy number?
[CUSTOMER][NEUTRAL] Yes, I have 16820887.
[AGENT][NEUTRAL] Alrighty and then what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] Mhm. The first name is [PII], the last name is [PII], and date of birth is [PII].
[AGENT][NEUTRAL] Alright, thank you for verifying that. Uh, so this policy is active. Effective date was [PII], and this is a limited indemnity medical plan, uh, so it does not have any set network just pays a set dollar amount per covered procedure or office visit, uh, so it could be used potentially anywhere you just send that claim information directly to us.
[AGENT][NEUTRAL] And if you'll give me one moment, I will check those benefits and see if uh office visits are covered and then I'm sorry, did you say uh surgical benefits as well?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Correct, they'd be done in office um for outpatient.
[AGENT][NEUTRAL] In a physician's office, OK.
[AGENT][NEUTRAL] Got it. OK, so this policy, uh, does operate quite a bit differently, um, as it's a limited indemnity plan, um, and of course I will let you know verification of coverage is not a guarantee of payment for claims. Bear with me just a moment. So surgery in a physician's office is covered at.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let's see, it does not differentiate between uh inpatient or outpatient under this policy, um, except for the fact that if it were inpatient, you know, there's consignment benefits, um, it simply says surgery in a physician's office pays $125 per day.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then a physician's office visit is $75 per day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and then do they have a certain amount of visits um available?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh, yes, give me just a moment. That is, um, maximum of 6 days per calendar year. Uh, if you'll give me one moment, I will see if any of those have been used.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so no benefits have been used so far this year.
[CUSTOMER][NEUTRAL] OK. So 6 available. And then all of those 6 visits would go towards either office visit or the surgical visit, correct?
[AGENT][NEUTRAL] No, um, so the office visits are of course just that office, um, physician's office benefit and then surgery in a physician's office is a separate benefit at $125 per day. That one is a maximum of 4 days per calendar year.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, so they're all separate.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] So just to confirm with this plan, the patient.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, basically, is, you said the plan covers, so the patient is responsible for any amount over $75 for any specialist office visits per day and uh-huh.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] We don't say what is patient responsibility, uh, that is gonna be up to the provider.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][MIXED] OK, yeah, but the, the, I guess the plan pays up to $75.
[AGENT][POSITIVE] This is the maximum benefit amount, yes, that's correct.
[CUSTOMER][NEUTRAL] Mhm. Per day for office visits, um, and for any surgical procedures done in office, the plan pays up to $125 per day. Um, they have 6 visits for office visits and a total of 4 visits for any surgical benefit.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] In the physician's office, that's correct. In the physician's office, yes.
[CUSTOMER][NEUTRAL] Um, days I guess.
[CUSTOMER][NEUTRAL] Yes, OK.
[CUSTOMER][NEUTRAL] In office, yeah, yeah, they would all be in office here. OK, alright, in that case that was all of the information that I, oh,
[CUSTOMER][NEUTRAL] And you said the network doesn't matter because it covers any.
[AGENT][NEUTRAL] Right, you would just bill directly to us.
[CUSTOMER][NEUTRAL] OK, alright, in that case, just to confirm, um, whenever I pull a plan up in my system I show the.
[CUSTOMER][NEUTRAL] Payer ID 60801, is that correct?
[AGENT][POSITIVE] That's correct, yes.
[CUSTOMER][NEUTRAL] OK, alright, great, so in that case that was all I needed. Could I just get a reference number for this call please?
[AGENT][NEUTRAL] Sure, it would just be my first name, last initial and today's date and so my name is spelled [PII], and was there anything else I could help you with?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No ma'am, that would be it. Thank you so much for your help.
[AGENT][POSITIVE] Alright, of course, thanks for calling APL. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] You too thank you bye bye.
[AGENT][POSITIVE] Thank you. Bye-bye.