AccountId: 011433970860
ContactId: 2974ac35-eafd-4912-8247-37e23d6f893e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 435690 ms
Total Talk Time (AGENT): 163638 ms
Total Talk Time (CUSTOMER): 83263 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/11/2974ac35-eafd-4912-8247-37e23d6f893e_20250611T19:39_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], this is [PII]. I was just calling to get benefits on a patient, please.
[AGENT][POSITIVE] OK, I could check benefits for you. uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you and then do you have that policy number?
[CUSTOMER][NEUTRAL] I have 23633.
[AGENT][NEUTRAL] OK, that's going to be a bit too small to be one of our policy numbers. um, do you maybe have their social? I could search for them that way.
[CUSTOMER][NEUTRAL] Let me check.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I have name and date of birth, but I don't see a social.
[AGENT][NEUTRAL] That's OK, um, if you wouldn't mind spelling out the first and last name for me please.
[CUSTOMER][NEUTRAL] Yeah, first name is [PII]
[CUSTOMER][NEUTRAL] Last name is [PII]
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][NEUTRAL] OK thank you one moment.
[AGENT][POSITIVE] Alrighty, awesome, so I did find her policy. Uh, let me know when you're ready and I can go ahead and give you that correct policy number.
[CUSTOMER][POSITIVE] Yes, please go ahead.
[AGENT][NEUTRAL] OK, that is 02.
[AGENT][NEUTRAL] 20
[AGENT][NEUTRAL] 383 7.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Of course, and so this policy is active.
[AGENT][NEUTRAL] 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 we're really need to look at inpatient or outpatient benefits uh for this member.
[CUSTOMER][NEUTRAL] Outpatient um we bill in an office setting professional.
[AGENT][NEUTRAL] OK, and of course I will let you know verification of coverage is not a guarantee of payment for claims, so this policy does not have uh office visit benefits um for visits uh however treatment received in office is covered.
[AGENT][NEUTRAL] The outpatient benefit is $5000 per calendar year and if you'll give me one moment, I will see if any of that has been used.
[AGENT][NEUTRAL] OK, none has been used so far this year.
[CUSTOMER][NEUTRAL] Um, I'm sorry, so you said that they cover up to $5000 per year?
[AGENT][NEUTRAL] Correct, uh, towards co-pay, deductible and co-insurance after major medical pays.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm not I understand you, sir. It doesn't cover office visit but does cover treatment.
[AGENT][NEUTRAL] Correct. So if they were simply going in for something like a consultation, that would not be covered. However, if they were receiving treatments such as an X-ray or something like that, that would be.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, what about if they're going in for, um, physical therapy?
[AGENT][NEUTRAL] Uh, let me see if physical therapy is a covered benefit. Give me just a moment. I'm gonna have to pull up the policy for that.
[CUSTOMER][POSITIVE] OK thanks that's what we're treating her for.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Of course, OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, physical therapy is covered in a physical therapy facility. So not going to be covered in an office environment.
[CUSTOMER][NEUTRAL] OK, so it covers it if it's in a facility but not billed as an office.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, what about the part where you said that um it covers treatment is done in an office? Is that different?
[AGENT][NEUTRAL] That one does not specify yes um and I can go particularly to that give me just a moment.
[AGENT][NEUTRAL] Yes, OK, so that's not going to be one of the treatments that is covered in office. So physical therapy has its own benefit. Again, for this policy, it does specify in a physical therapy facility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then if it was billed as a facility, then do they cover in full up to $5000?
[AGENT][NEUTRAL] Correct, yes, um, again, after, right after major medical pays, uh, all of that would go towards, uh, co-pay, deductible and co-insurance.
[CUSTOMER][NEUTRAL] What the primary doesn't pay?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. Was there anything else I could help you with?
[CUSTOMER][NEUTRAL] Um, is there any kind of referral required or authorization?
[AGENT][NEUTRAL] No, uh, again, as long as Major Medical is willing to pay this policy can.
[CUSTOMER][NEUTRAL] Is there a reference number for today's call?
[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 [PII]
[CUSTOMER][POSITIVE] All right, thank you.
[AGENT][POSITIVE] Of course, thanks for calling APL have a great rest of your day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you. Bye bye.