AccountId: 011433970860
ContactId: 3e05b491-2afb-48c1-a247-3926dfd3e7a6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 446980 ms
Total Talk Time (AGENT): 176942 ms
Total Talk Time (CUSTOMER): 196188 ms
Interruptions: 0
Overall Sentiment: AGENT=1.7, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/14/3e05b491-2afb-48c1-a247-3926dfd3e7a6_20250114T17:22_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, good morning. Uh, my name is [PII], and I'm calling to check the benefits for a patient.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the benefits, and [PII], may I have a good contact number in case we're disconnected and then the member's policy number?
[CUSTOMER][NEUTRAL] Yeah, sure, best callback number it would be [PII].
[CUSTOMER][NEUTRAL] Oh sorry [PII]?
[AGENT][POSITIVE] Thank you for that. And then the members, oh, go ahead.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah, OK. The member's policy number is 020246.
[CUSTOMER][NEUTRAL] 80
[CUSTOMER][NEUTRAL] M for Mary, L for Lima, number 8.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Uh yeah, sure, member's name is [PII]. Um, date of birth is, OK, [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And so I'm actually showing this policy is no longer active. Um, it was effective from [PII].
[AGENT][NEUTRAL] But there is an active policy number. Let me give you that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that policy number is 2175427.
[AGENT][NEUTRAL] And this policy has been active since [PII]?
[AGENT][NEUTRAL] And what type of benefits did you want to go over today?
[CUSTOMER][NEUTRAL] OK, let me ask you something first. This, uh, this policy is effective, effective since [PII] to the present, right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK, and just to confirm, the policy number is 2175427?
[AGENT][NEUTRAL] Yes. Mhm.
[CUSTOMER][NEUTRAL] OK, yeah, well, I would like to, can we check for a specific code or just for um general benefits?
[AGENT][NEUTRAL] Um, the calls really won't help because the policy is broken down into inpatient and outpatient. So are you considered an outpatient facility and what's being done?
[CUSTOMER][NEUTRAL] Yeah, it's an outpatient facility.
[AGENT][NEUTRAL] OK. And is it like
[CUSTOMER][NEUTRAL] It's the place of service is is it, yeah.
[AGENT][NEUTRAL] Is it diagnostic testing? Is it surgery? Like what's being done?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, is um is an OK let me check for the procedure here.
[CUSTOMER][NEUTRAL] OK, it's an ultrasound, yeah, it's an ultrasound diagnostic.
[AGENT][NEUTRAL] OK, so for
[AGENT][NEUTRAL] So for outpatient, the policy would pay up to $500 per calendar day.
[AGENT][NEUTRAL] That does include diagnostic testing in a hospital outpatient facility or MRI facility.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK perfect thank you so much. um, let me ask you something, yeah, what's the better, I mean, to in order to send the claims, do you receive electronic claims or paper claims?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Um, either or you can fax it, you can mail it, or you can send it electronically. Um, I can give you the payer ID, uh, which, whichever information you need, the mailing address.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Uh, the payer ID please.
[AGENT][NEUTRAL] OK, it's 60801.
[CUSTOMER][POSITIVE] OK, got it, thank you so much for that.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] OK, mhm, um, can I get the reference number for this one and uh I have another member that I would like to check the effectiveness of the policy if you.
[AGENT][NEUTRAL] OK. So,
[CUSTOMER][NEUTRAL] If you can help me with that?
[AGENT][NEUTRAL] So the um reference number for the entire call will be my name in today's date. So that's [PII].
[AGENT][NEUTRAL] And then today's day?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then you said you have another member as well?
[CUSTOMER][NEUTRAL] OK OK
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and that member's policy number?
[CUSTOMER][POSITIVE] Alright, thank you. Just one second here.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Alright, got it.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mm mm mm OK, it's 02174 02175436 M for Mary, L for Lima number 8.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure, member's name is [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Thank you. And so for this policy, I am showing it's active, it's been effective since [PII].
[CUSTOMER][NEUTRAL] To the person, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Alright, got it.
[CUSTOMER][NEUTRAL] 2.
[CUSTOMER][NEUTRAL] OK, there's a specific, um, I have a specific claim here that is for outpatient visits for the code 99213 is considered um a regular visit. Let me check for the diagnosis code.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Wait a minute, are you, wait, so you said there's a particular claim or you're just wanting to check the benefits?
[CUSTOMER][NEUTRAL] Yeah, yeah, I just want, no, no, I just wanna check the benefits like we did it before, mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, this is an office um for an outpatient visit for the evaluation of management of an established patient.
[AGENT][NEUTRAL] It's an outpatient office visit?
[CUSTOMER][POSITIVE] Exactly, yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Where is the well?
[AGENT][NEUTRAL] So the member doesn't have the office treatment rider or any like benefits for the office on this policy. This um policy really just covers like inpatient and then the outpatient facilities like emergency room, urgent care.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Um, physical therapy, but in terms of like office visits or office visits in the outpatient setting, there's no coverage for office visits.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][POSITIVE] Alright then, OK, I think that will be all thank you so much for your help.
[AGENT][POSITIVE] You're very welcome. Well again, thanks for calling APL and I hope you have a great day. Was there anything else I can assist you with?
[CUSTOMER][POSITIVE] Um, no, that will be all, thank you so much.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Bye-bye.
[CUSTOMER][POSITIVE] Mm bye bye thank you.