AccountId: 011433970860
ContactId: 476dcf41-f318-4979-801e-42faf11a013b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 579369 ms
Total Talk Time (AGENT): 174440 ms
Total Talk Time (CUSTOMER): 222428 ms
Interruptions: 3
Overall Sentiment: AGENT=-0.6, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/22/476dcf41-f318-4979-801e-42faf11a013b_20250522T16:10_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hello, [PII]. Good morning. My name is [PII] and the last initial is [PII], and I'm calling on behalf of the provider and I need to verify eligibility and benefits for the member's policy. So can you verify that information with me?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, I can verify benefits and eligibility for you. And [PII], what is the policy number, please?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The policy number is 02569352.
[AGENT][NEUTRAL] OK, thank you. Let me a moment. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Yes, it is [PII] and it's a direct line.
[AGENT][NEUTRAL] OK. And the patient's name, date of birth?
[CUSTOMER][NEUTRAL] Patient name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] OK, I'm showing his effective date is [PII]. He is active on the policy and what benefits you're needing for this patient?
[CUSTOMER][NEUTRAL] Yes, only the general benefits that was needed for specialist office visit.
[AGENT][NEUTRAL] I'm sorry, you're calling for what benefits?
[CUSTOMER][NEUTRAL] Only general benefits I was needed for specialist office visit.
[AGENT][NEUTRAL] 4 offices. OK, give me one moment, please.
[AGENT][NEUTRAL] OK, um, not a guarantee of payment, just a verification of coverage. Under this patient's policy, the max benefit payable for an office visit, whether specialist or general, is $75 per day, and they have a total of 6 visits per year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Is there anything else I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, yes, yes. And then 6 visits, how much is are available?
[AGENT][NEUTRAL] Uh one moment.
[AGENT][NEUTRAL] Uh, so far I show he has 5 visits remaining for this year.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK. And for the member's policy, I have uh one individual doctor. Can you check if the doctor was in and out of network?
[AGENT][NEUTRAL] Uh, we don't have a network, um.
[CUSTOMER][NEUTRAL] We don't have
[AGENT][NEUTRAL] The insurance can go to a multi-plan provider, but to verify if that doctor participates with them, you will have to contact multiplan either by phone or their website.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, give me the number then we move on the next information.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] Alright one moment.
[AGENT][NEUTRAL] Their phone number is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And their email or website is [PII].
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] Mhm. OK. And also for the member's policy, any PCP referral is required or not required?
[AGENT][NEUTRAL] I'm sorry, say again.
[CUSTOMER][NEUTRAL] For the member's policy, any PCP referral is required or not required?
[AGENT][NEUTRAL] Uh, it's not required.
[CUSTOMER][NEUTRAL] Mhm. OK. And for the member's policy, uh, this is a limited benefit plan, am I right? This isn't fully insured benefit plan. Mhm. Got it. So for the member's policy, some services I have, can you tell me that for these services are covered or not covered? And if the service is covered, so how much pay for these services? What is the benefit for these services and uh what is the visit for these services?
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] Correct.
[AGENT][NEGATIVE] I'm not understand what you're saying. Say that again, please.
[CUSTOMER][NEUTRAL] Yes, I have some services like radiology, PET scan, CT scan like that, and for that services I need to verify the services are covered or not covered for the patient's policy, and if the services are covered, so how much, uh, what is the benefits for this and like how much pay for these services and what is the visit limit for that services?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and what are the services you're inquiring about?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yes, the first one services is uh radiology.
[AGENT][NEUTRAL] Uh let's see.
[AGENT][NEUTRAL] Uh, it's not covered under the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For the next one, services, it's uh C for lung cancer screening. I have the CPD code. It's uh 71271.
[AGENT][NEUTRAL] Uh, there's no wellness screening benefit under the plan.
[CUSTOMER][NEUTRAL] Wellness and.
[AGENT][NEUTRAL] There is no wellness screening benefit on the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] It means this service is also not covered, am I right?
[AGENT][NEGATIVE] It is not covered per the policy.
[CUSTOMER][NEUTRAL] OK, and the two more CPT codes I have. Can you check the CPD codes are covered or not covered? It's.
[CUSTOMER][NEUTRAL] So 78815 and 18816.
[AGENT][NEUTRAL] What are those codes for?
[CUSTOMER][NEUTRAL] It's for CT scan and PET scan and, uh, yeah, CT scan and PET scan.
[AGENT][NEGATIVE] Not covered. The patient doesn't have any diagnostic benefits under their plan.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] The next one service is biopsy.
[AGENT][NEUTRAL] The patient doesn't have any surgical benefits under their policy.
[CUSTOMER][NEUTRAL] It means also the facility uh the service is not covered, am I right?
[AGENT][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] OK. The next one is mammogram.
[AGENT][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] Next one is psychology.
[AGENT][NEUTRAL] For mental health?
[CUSTOMER][NEUTRAL] No, for medical.
[AGENT][NEUTRAL] No, it's for mental health.
[CUSTOMER][NEUTRAL] No, it's not for mental health.
[AGENT][NEUTRAL] You said psychology, correct?
[CUSTOMER][NEUTRAL] Yes, psychology service.
[AGENT][NEUTRAL] That will fall under uh mental health, which is not covered under the policy.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Next one is radiation oncology.
[AGENT][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And next one is lab service.
[AGENT][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] And next one is the palliative care.
[AGENT][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] And for the member's policy, some uh some therapies I have. Can you check the therapies are covered or not covered like uh physical therapy, occupational therapy, speech therapy, and the last one is chemotherapy. So all therapies are covered or not covered for the member's.
[AGENT][NEUTRAL] Chemotherapy, chemotherapy is not covered under the policy. Physical speech and occupational therapy is. It pays a max of $15 once per calendar year.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And how much was it for this therapist?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] How much visits are available and maximum visit for this therapy services?
[AGENT][NEUTRAL] As I stated, for physical, speech, occupational therapy is up to one per year, and they have not used that benefit for this year.
[CUSTOMER][NEUTRAL] Occupational therapy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So for the all information, give me the reference number, your name and last name sir.
[AGENT][NEUTRAL] You may use my name in today's date as reference. My name is spelled [PII].
[CUSTOMER][NEUTRAL] Mhm. OK.
[AGENT][NEUTRAL] OK, and is there anything else I can assist you with? OK, thank you for calling APL. Bye.
[CUSTOMER][POSITIVE] OK. Have a nice day and have a good day. Bye-bye.
[CUSTOMER][NEUTRAL] No, OK, OK. Can you transfer to that multi-plan?
[AGENT][NEUTRAL] You will have to call them.
[CUSTOMER][NEUTRAL] Because then why the network participation status for providers, mm, OK, no worry.
[AGENT][NEUTRAL] You have to call them.
[AGENT][POSITIVE] Thank you have a great day.
[CUSTOMER][POSITIVE] Uh, OK, no worry. Have a nice day and have a good day. Bye-bye.
[AGENT][NEUTRAL] Bye.