AccountId: 011433970860
ContactId: 4182caa6-f281-4951-825c-4d5cca6b09e6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 249559 ms
Total Talk Time (AGENT): 88700 ms
Total Talk Time (CUSTOMER): 117746 ms
Interruptions: 0
Overall Sentiment: AGENT=1.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/21/4182caa6-f281-4951-825c-4d5cca6b09e6_20250421T21:39_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes ma'am, I just had a question about this plan. Is this not for doctors visits? Is it only for emergency room visits or hospital care?
[AGENT][NEUTRAL] Um, it depends on the plan. Is it for yourself?
[CUSTOMER][NEUTRAL] No, I'm calling from a provider's office and um I can give you the policy you want the certipo er certificate number?
[AGENT][POSITIVE] Yes, that'd be perfect.
[CUSTOMER][NEUTRAL] OK great it's 02479853.
[AGENT][NEUTRAL] And can I get your name and a good callback number, please?
[CUSTOMER][NEUTRAL] Yes, it's [PII], and it's [PII].
[AGENT][POSITIVE] OK, thank you so much, [PII]. OK, we're checking on benefits under this policy.
[CUSTOMER][NEUTRAL] Yeah, I, I received a um an, an EOB and it stated I thought I thought it said that nothing was being paid because it wasn't a hospital, but when I called on the plan initially they said that it would cover her deductible and copay and co-insurance for a benefit max of $500 that it says it included treatment and exams but that's, that's not what the.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] EOB said so I just wanted to check on it.
[AGENT][NEUTRAL] What was that patient name and date of birth, please?
[CUSTOMER][NEUTRAL] OK, her name is [PII] and her birth date, oh, where is she? It's uh [PII].
[AGENT][NEUTRAL] And what date of service was that for?
[CUSTOMER][NEUTRAL] That was for they had processed um.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. Let me see what we've got here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, so typically it'll cover, um, it looks like this was not covered because it was billed as an office visit, so it doesn't actually cover office visits and then let me see what.
[AGENT][NEUTRAL] Let me see what the actual policy says. Hold on one moment.
[CUSTOMER][NEUTRAL] So what's the differentiation of an office visit versus what?
[AGENT][NEUTRAL] So it would be based on
[CUSTOMER][NEUTRAL] I mean, what would have been
[AGENT][NEUTRAL] The CPT code.
[AGENT][NEUTRAL] Um, so, for this policy,
[AGENT][NEUTRAL] So they get a $500 per occurrence payout after primary processes the claim. Um, this is gonna be for, this is not a guarantee, just a basic outline. Um, it'd be like for outpatient surgery in a hospital, um, diagnostic testing in a hospital outpatient facility or MRI facility, um, outpatient treatment and uh mental or emotional disorder in a hospital, outpatient facility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] Uh, it does cover.
[CUSTOMER][NEUTRAL] So is it only an
[CUSTOMER][NEUTRAL] So is it just outpatient hospital visits?
[AGENT][NEUTRAL] Correct, yeah, so it covers the only thing.
[CUSTOMER][NEUTRAL] I mean, it has to be affiliated with the hospital.
[AGENT][NEUTRAL] Yeah, yeah, it's, it's unfortunately just for those types of services and they have an inpatient hospital.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, because I mean this is out it's this is outpatient treatment but it's just not in a hospital setting.
[AGENT][NEUTRAL] Yeah, it has to be rendered in a hospital.
[CUSTOMER][NEUTRAL] And I thought that's what the
[CUSTOMER][NEUTRAL] Oh OK, well that would have been really nice if they would have told me that when I called to verify this benefits.
[AGENT][POSITIVE] I'm so sorry.
[CUSTOMER][NEUTRAL] Oh [PII]
[CUSTOMER][POSITIVE] All right well thank you for your help.
[AGENT][POSITIVE] OK, thank you for calling APL. Have a good evening.
[CUSTOMER][NEUTRAL] You too bye bye.