AccountId: 011433970860
ContactId: 342fd6b9-e1a2-4a97-94c1-5da99c55d08e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 534830 ms
Total Talk Time (AGENT): 318471 ms
Total Talk Time (CUSTOMER): 134059 ms
Interruptions: 4
Overall Sentiment: AGENT=1, CUSTOMER=1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/15/342fd6b9-e1a2-4a97-94c1-5da99c55d08e_20250115T16:10_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. What was your name?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Um, yes, I was calling to see if I can verify benefits for a patient, please.
[AGENT][POSITIVE] Yeah, I could check benefits for you, [PII]. Uh, can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][NEUTRAL] Got it, thank you. And then, uh, did you have the policy number?
[CUSTOMER][NEUTRAL] Yeah, it's 02564764.
[AGENT][POSITIVE] OK thank you
[AGENT][NEUTRAL] And what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] This is for [PII], [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that [PII]. Uh, so this policy is active. Effective date was [PII] and what benefits are we needing to verify?
[CUSTOMER][NEUTRAL] I need her benefits for a sick office visit, well woman exam, IUD, and then you go by CPT codes or description.
[AGENT][NEUTRAL] Description, um, bear with me just a moment let me get the policy pulled up here um let's see that was.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[AGENT][NEGATIVE] Sick office visits, wellness exam.
[CUSTOMER][NEUTRAL] Uh yes.
[CUSTOMER][NEUTRAL] And then the IUDs birth control contraceptive preventative and then also ultrasound and office surgery.
[AGENT][NEUTRAL] Ultrasound and what was it? I'm sorry.
[CUSTOMER][NEUTRAL] Office surgery, ultrasound is done in the office for medical, and then the surgery is done in the office for medical.
[AGENT][NEUTRAL] I see. OK.
[AGENT][NEUTRAL] Alright, bear with me just a moment. So just so that you are aware this is a limited indemnity medical plan, uh, so it can be a little bit particular and broad at the same time so bear with me just a moment let me get this pulled up here so I can get that correct information to you.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] I got you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Bear with me, I appreciate your patience.
[CUSTOMER][POSITIVE] Oh no problem thanks.
[AGENT][POSITIVE] Thank you. OK.
[AGENT][NEUTRAL] The first, of course I will let you know verification of coverage is not a guarantee of payment for claims so they do have a wellness and diagnostic test benefit um I will go through to make sure sometimes the diagnostic test, um, can be again really particular and limited as to what is considered a diagnostic test. Um, as for the wellness exam, uh, the benefit amount is $75 per exam, um, that's the maximum amount we would pay for that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I will double check on the diagnostic to see if the ultrasound would be considered that. I don't believe so, but if you'll give me one moment, I'll see. So the outpatient sickness benefit is also $75 and that is limited to uh 5 visits per insured per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then let's see, they do have a surgical and anesthesia benefit. So surgery, uh, surgical benefit is $1000 max that we would pay. Uh, anesthesia benefit is going to be, let's see.
[AGENT][NEUTRAL] Says 25% of surgical benefit amount.
[AGENT][NEUTRAL] Give me just a moment. What kind of surgery was it?
[CUSTOMER][NEUTRAL] So that's for office surgery. It's just an office like a biopsy of the cervix, OK.
[AGENT][NEUTRAL] Yeah, that's just surgery in general. Yeah, that's surgery in general, um, like I said, this policy can be very particular and also very, very vague, so let's see.
[CUSTOMER][NEUTRAL] I got you I understand.
[AGENT][NEUTRAL] Yeah, and that's going to be the extent of their benefits. Um, they do have.
[CUSTOMER][NEUTRAL] OK, so no IED coverage.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Their benefits are simply.
[CUSTOMER][NEUTRAL] And then the ultrasounds
[AGENT][NEUTRAL] That's, that's it, yeah. So hospital confinement, intensive care, uh, they have that wellness diagnostic benefit, uh, first occurrence being admitted to a hospital, anesthesia, or I'm sorry, uh, outpatient sickness, and then the surgery and anesthesia benefit. So that's going to be the extent of this. Let me check that diagnostic really quick. Give me just a moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just real quick, also maternity is not covered either, right?
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Bear with me just a moment, let's take a look.
[AGENT][NEUTRAL] You said the surgery was a biopsy?
[CUSTOMER][NEUTRAL] Yeah, it's like a biopsy of the cervix, just minor office surgery.
[AGENT][NEUTRAL] In the cervix?
[CUSTOMER][NEUTRAL] Yeah, we're an OBGYN so just we come for office procedures basically.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, the reason I ask is there, um, so essentially it's the $1000 is kind of the standard amount for the surgery, um, they do have a list of covered surgeries in which case it would be a specific percentage of the maximum surgical benefit, um, excuse me, I do see biopsy for.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Breast
[AGENT][POSITIVE] Oh my goodness.
[AGENT][NEUTRAL] Integumentary system skin.
[AGENT][NEUTRAL] I don't know what that is. There's a biopsy there too.
[AGENT][NEUTRAL] Let's see, joints dislocations, tendons.
[CUSTOMER][NEUTRAL] Sorry I'm trying to get my deaf foster dog to come back over here. She can't hear.
[AGENT][NEUTRAL] Oh.
[AGENT][NEGATIVE] Poor thing.
[CUSTOMER][NEUTRAL] I know like get back over here.
[CUSTOMER][NEGATIVE] I don't want you wandering the house.
[AGENT][POSITIVE] That's so sweet. OK, here we are. OK. Biopsy or removal of ser uh cervical lesion or polyps. Does that sound right?
[CUSTOMER][POSITIVE] Sure close enough.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] OK, so this one it states the maximum percentage of the, um, excuse me, percentage of maximum surgical benefit is 1.5%, so it would be 1.5% of 1000, so, um, just again so I make sure I give that correct information to you.
[AGENT][NEUTRAL] Oh there OK, so the diagnostic tests are limited to uh MRI, CT scan, and colonoscopy, so that ultrasound would not be a covered benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] I'm sorry I know this is very confusing.
[CUSTOMER][NEUTRAL] OK, and you said no to maternity. No, you're good. No, we're gonna stamp at limited coverage and then go from there.
[AGENT][NEUTRAL] It is a bit of a different policy.
[AGENT][NEUTRAL] That's, I think that covers it.
[AGENT][NEUTRAL] I mean you're more than welcome to file any of these claims even if you're not sure you know we're sure gonna say is hey that's not covered um but just so that you've got an idea.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah, and I'm sorry, you did say maternity was not covered. I, I keep asking that about forgetting to circle it, OK, and, and this is the multi-plan network.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] No, you're fine.
[AGENT][POSITIVE] This one is yes.
[CUSTOMER][NEUTRAL] Yeah, OK, great, I think that's all I needed, and she hasn't used any of her 5 office visits yet, has she?
[AGENT][NEUTRAL] Um, let me check. I know the year just started, but you never know. Give me just a moment.
[CUSTOMER][NEUTRAL] This is a calendar year plan?
[AGENT][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] OK, PPO?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, hang on just a yes, so none of this has been used so far this year. Um, I wouldn't say PPO as this is again limited. It's, um, does not have a set network and it just pays that, um, set dollar amount per procedure or office visit.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Oh yeah, that's right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, I got you thank you so much. Can I get a reference number? No, no, you're good you're good you're good. I appreciate it.
[AGENT][NEUTRAL] OK, did you have any other questions for me, [PII]? I'm sorry, that was like information overload.
[AGENT][NEUTRAL] Alright, yeah, reference number would just be my first name, last initial, and today's date, and so my name is spelled [PII] last initial is [PII]
[CUSTOMER][POSITIVE] OK thank you I appreciate it.
[AGENT][POSITIVE] Yeah, you're very welcome. Thanks for calling APL. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] Thanks you too.
[AGENT][POSITIVE] Thank you bye bye.
[CUSTOMER][POSITIVE] Thank you bye bye.