AccountId: 011433970860
ContactId: 3a0c4513-fa90-4d6f-a91e-85d852dffdc3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 349890 ms
Total Talk Time (AGENT): 113945 ms
Total Talk Time (CUSTOMER): 113932 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/13/3a0c4513-fa90-4d6f-a91e-85d852dffdc3_20250613T15:21_UTC.wav
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[AGENT][NEUTRAL] This is [PII] with APL. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. I'm calling from Queen City, ear, nose and throat, and I was calling to get benefits for a patient of ours.
[AGENT][POSITIVE] I can help you with benefits. Uh, can I get a good callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] And what's the policy number?
[CUSTOMER][NEUTRAL] It is 02519532.
[AGENT][NEUTRAL] OK, give me just one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Can you verify the patient's name and date of birth for me, please?
[CUSTOMER][NEUTRAL] Uh, [PII] and his date of birth is [PII].
[AGENT][POSITIVE] Thank you so much. All right, let me pull up this policy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And were you wanting inpatient or outpatient?
[CUSTOMER][NEUTRAL] Um, it's for outpatient surgery.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, and this is just a verification of benefits, not a guarantee of payment. It looks like he has an outpatient benefit maximum of up to $2,025 per plan year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, it is, it will need to be due.
[CUSTOMER][NEUTRAL] You said 2025?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK sorry.
[AGENT][NEUTRAL] It's OK.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] And this, um,
[CUSTOMER][NEUTRAL] You said an outpatient.
[AGENT][NEUTRAL] Yeah, it's per plan year, it's per plan year, so it's August to August.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] For this plan.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then it looks like it needs to be due to a sickness or an accident.
[CUSTOMER][NEUTRAL] OK, mm.
[AGENT][NEUTRAL] Let me look.
[CUSTOMER][NEUTRAL] Do you know if his surgery would
[CUSTOMER][NEUTRAL] Qualify under either sickness or.
[AGENT][NEUTRAL] Qualify?
[CUSTOMER][NEUTRAL] I don't think it's definitely not an accident, but probably sickness. It's for like nasal obstruction.
[AGENT][NEUTRAL] OK, let me look.
[AGENT][NEUTRAL] It does look like the surgery will need to be a surgery in a hospital outpatient facility or a free-standing outpatient surgery center. Um,
[AGENT][NEUTRAL] or a physician's office and let me see.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, it is at an ambulatory surgery center.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, I'm not seeing that as a um.
[AGENT][NEUTRAL] An exclusion, so I would file the claim. I will say this is his secondary gap insurance, um, so we'll need the primary's explanation of benefits um with the claim documents.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, and do you know if I need to pre-cert it through you guys? I with this um primary it said I don't need pre-cert.
[AGENT][NEGATIVE] Uh, you don't with us.
[CUSTOMER][NEUTRAL] No, OK.
[CUSTOMER][NEUTRAL] Alright, and then just so I'm clear on his plan, he just has an outpatient max of up to $2,025. That's how much they would pay.
[AGENT][POSITIVE] Yes, and this helps with co-insurance, co-pay, and co-deductible.
[CUSTOMER][NEUTRAL] Coinsurance copay.
[CUSTOMER][NEUTRAL] And what was the last one?
[AGENT][NEUTRAL] Uh, co-deductible.
[CUSTOMER][NEUTRAL] OK. Now.
[CUSTOMER][NEUTRAL] Sorry, um.
[AGENT][NEUTRAL] It's
[CUSTOMER][NEUTRAL] So his primary insurance, he does have a deductible of 6500 that he hasn't met. You guys wouldn't, I guess help with that portion of it. He would have to meet his deductible before.
[CUSTOMER][NEUTRAL] Your plan kicks in.
[AGENT][NEUTRAL] Uh, we can help with the deductible. It, it might be that the benefits goes towards the deductible if it's a covered service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, but it would only be up to 25 or 2025?
[AGENT][NEUTRAL] Right, the 2025, yeah, yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, all right, well thank you for letting me know.
[AGENT][NEUTRAL] Alright, is there anything else I can help you with?
[CUSTOMER][NEUTRAL] Um, no, is there just a reference number?
[AGENT][NEUTRAL] So we don't have reference numbers, but you can use my name and last initial in today's date. So [PII] in today's date.
[CUSTOMER][NEUTRAL] OK alright.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] Great, thank you for calling APL. I hope you have a great day.
[CUSTOMER][POSITIVE] You as well thank you bye bye.
[AGENT][NEUTRAL] Bye.