AccountId: 011433970860
ContactId: 252da2e4-631f-4b39-b957-54fc4836a996
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 758659 ms
Total Talk Time (AGENT): 362131 ms
Total Talk Time (CUSTOMER): 308437 ms
Interruptions: 2
Overall Sentiment: AGENT=0.2, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/04/252da2e4-631f-4b39-b957-54fc4836a996_20250204T15:50_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], um, my name is [PII].
[CUSTOMER][NEUTRAL] Um, and I have a patient that, um, I, I, uh, I could barely understand what he was saying this morning, um, so I, I'm taking it upon myself to call you guys to see if he had coverage for a specific day, um, and everything it's not hospital it was a, um, specialist office visit so but if you could help me I would appreciate it.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] Of course, absolutely I'll get that policy pulled up we'll make sure that uh they have coverage for specialist office visit and of course if they were active during that time um, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Yeah, it is [PII].
[AGENT][NEUTRAL] [PII]. OK, thank you. Uh, do you have that policy number?
[CUSTOMER][NEUTRAL] Um, OK, so.
[CUSTOMER][NEUTRAL] There's two different numbers. There's a policy number and a medical ID, so this policy number is 02064969.
[AGENT][NEUTRAL] OK thank you one moment.
[AGENT][NEUTRAL] All right. And what was the name and date of birth for the patient?
[CUSTOMER][NEUTRAL] OK, that is um [PII] [PII].
[AGENT][NEUTRAL] OK, I've got a different last name for [PII].
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Well, we've got [PII] maybe.
[AGENT][NEUTRAL] Oh, that's not what I've got. Um, are you able to verify the, uh, his, um, address?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Let me hold on just a second, let me go back and look at the.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Because I don't have a new card, it's old, um.
[AGENT][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so is it [PII], I guess?
[AGENT][NEUTRAL] Yes, yes, that is the name we've got. We've actually got him as [PII].
[CUSTOMER][NEUTRAL] OK, well,
[CUSTOMER][NEUTRAL] Uh-huh, I wonder why his name is not in there like that because he told me when he called it was [PII], so I don't know where that where that comes from.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Interesting. I'm not sure. I mean that's OK. It, it's all right just needed to make sure of course that this was the same number, um, so I do appreciate you verifying that information. Um, let me take a look here. So, um, his policy is currently active. Uh, it is the effective date was [PII]. Um, if you'll give me one moment, let me get his policy pulled up. So this is a, it's a limited indemnity medical plan.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So of course it is limited on the kind of coverage so let me see if office visits are covered um did he receive treatment in office or was it kind of just like a consultation?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, he had a, no, he had an office visit and it was [PII].
[AGENT][NEUTRAL] OK, so it was active at that time, um, but again, let me just verify, was it regarding a uh sickness or anything like that?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It looks like.
[CUSTOMER][NEUTRAL] It looks like he's gonna have just a screening colonoscopy, um, let me go back to his chart.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] So he had that done.
[CUSTOMER][NEUTRAL] That was an urgent care. That's not us.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah, it looks like had to treat it by the my.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Yeah it looks like he's just got he came in for.
[CUSTOMER][NEUTRAL] Um, a visit prior to a colonoscopy. So to go over, you know, his history, he was a new patient, and then it looks like he is going to have.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Um, let me look at my appointments.
[CUSTOMER][NEUTRAL] Um, on [PII] looks like, yeah, tomorrow he is supposed to have a colonoscopy.
[AGENT][NEUTRAL] A colonoscopy. OK. So let me, the way that this policy works again, it's a bit different. So he's got um a wellness exam benefit. He's also got um outpatient sickness benefit, so.
[AGENT][NEUTRAL] I, I think that would fall under that. But he's also got a separate benefit for diagnostic tests. Um, let me make sure, cause it can be very particular on what's considered a diagnostic test. Let me see if that would be covered under that benefit. Give me just a moment.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] OK, yes. Uh, colonoscopy is absolutely going to be covered under that diagnostic testing benefit. Awesome. Sometimes they can be a little broad, but it, yes.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] No, wait a minute.
[CUSTOMER][NEUTRAL] I, I hear you saying diagnostic testing benefit. Now will it cover what's considered a screening colonoscopy because he's not had one.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] You said a diagnostic that could be medical.
[AGENT][NEUTRAL] So the screening being the visit beforehand, correct?
[CUSTOMER][NEUTRAL] It.
[CUSTOMER][NEUTRAL] The first, no, the screening is the actual first colonoscopy period.
[CUSTOMER][NEUTRAL] So like he's not had he came in for an office visit to go over his history, different things like that so that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Is kind of like a a wellness type thing that they checked beforehand because he's a new patient, so I don't know if that would be covered under his wellness exam benefit because it has a primary diagnosis of a Z12-11, which is a screening for colonoscopy and then his colonoscopy would be diagnosed with the same thing because it's his first colonoscopy.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, I see.
[CUSTOMER][NEUTRAL] So I understand that if I understand if it was emergency medical, but this is just having a routine screening, that's two different colonoscopies.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I understand. OK, well, I kind of understand I think, um, so they, he again, he does have that wellness exam and so I do believe that would fall under this category, um, so this is just.
[AGENT][NEUTRAL] Part of a routine.
[AGENT][NEUTRAL] Kind of checking or is he experiencing any sort of pain or are we testing for anything in particular?
[CUSTOMER][NEUTRAL] No, it's just routine.
[AGENT][NEUTRAL] That you're aware of? OK, so it's just routine. OK, so yeah, uh that would fall under this well wellness exam and then of course the diagnostic testing that's exactly what this is. So give me just a moment let me get that amount for you, um.
[AGENT][NEUTRAL] And you said his uh the visit itself was the last November, right?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so I will double check to make sure because he's got so many visits allowed per year. Um, so I will go back to see if he's used any of those. Um, so the diagnostic testing benefit, uh, as this is an indemnity plan, it just pays a set dollar amount, uh, per procedure or visit.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So diagnostic testing benefit, um, oh, before I go any further, of course I will let you know verification of coverage is not a guarantee of payment for claims, um, that is $250 per test. Uh, the wellness exam is $75 per visit.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Is what?
[CUSTOMER][NEUTRAL] That's what you guys pay?
[AGENT][POSITIVE] Correct, yes, that is the benefit amount.
[CUSTOMER][NEGATIVE] Oh my gosh, because this is gonna be like $300 something dollars and you guys only pay 75 mm.
[AGENT][NEUTRAL] Yeah, with these this is uh.
[AGENT][NEUTRAL] Hm
[AGENT][NEUTRAL] Yeah, for the visit for the wellness exam, um, and this is again that limited indemnity medical plan, it is a bit different than uh traditional major medical. Um, so let me again, make sure.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Let me look at the wellness and see how many that's limited to, and then I'll see if he's used any of those last year.
[AGENT][NEUTRAL] Bear with me just a moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so it looks like it's not um a visit amount as much as it is a dollar amount, uh, so again that wellness exam visit is $75 that combined with the diagnostic tests cannot exceed $500 per calendar year. So let me just take a look at what he has used the last year to make sure that we would be able to pay that claim.
[CUSTOMER][NEUTRAL] Um, because his colonoscopy will be this year.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But his visit was in November of last year, so my thing is.
[AGENT][NEUTRAL] Right, OK.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] How do you guys, I understand, so you said that the procedure would only be covered at $500 and something dollars, is that right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's going to be combined so the individual diagnostic test, the maximum amount we would pay for that for one single test is going to be $250. That $500 is the total combined amount between the diagnostic tests and wellness exams combined per calendar year.
[CUSTOMER][NEUTRAL] OK, because I mean his colonoscopy could be anywhere from $600 and something up to 300 or $4000 that's just the physician portion that's not the hospital, so um he's gonna have to pay this.
[AGENT][NEUTRAL] Does that make sense?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Because if, if you guys only pay 20, we can't just get paid $250 for a $2000 colonoscopy.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure, I completely understand. Um, again, this plan is a bit different. It is just extremely bare bones, um, paying these specific dollar amounts for very specific things. So and of course we don't say what is patient responsibility. This is simply the maximum amount we would be able to pay per procedure or visit.
[CUSTOMER][NEUTRAL] OK, so would he pay up front and get reimbursed?
[AGENT][NEUTRAL] Um, that depends on how y'all want to operate. Um, you can just send us that claim and then it's again a completely up to the provider as far as patient responsibility. So if you wanted to just bill him the remaining after you file the claim, y'all can do that. It's mainly just however y'all's office works.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] My
[CUSTOMER][NEUTRAL] Mm, OK.
[AGENT][NEGATIVE] So I know this is extremely confusing.
[CUSTOMER][NEUTRAL] Uh yeah.
[AGENT][NEUTRAL] And I did look for last year it looks like he used one outpatient sickness benefit so that is a separate benefit so uh you're good to file that claim for November and then of course um whatever he receives to[PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Did you have any other questions for me, [PII]?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] No, I think that's all. I appreciate your help. um, can I get a ref can I get a reference number?
[AGENT][NEUTRAL] Yeah, of course.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Reference number would just be my first name, last initial, and today's date. Uh, so my name is spelled [PII] Last initial is [PII]
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Alright, yes ma'am, thanks for calling APL. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] You too bye bye.