AccountId: 011433970860
ContactId: 493a5bf4-ee1a-4667-af22-c11ed06be7c0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 375959 ms
Total Talk Time (AGENT): 153278 ms
Total Talk Time (CUSTOMER): 139591 ms
Interruptions: 0
Overall Sentiment: AGENT=1.3, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/29/493a5bf4-ee1a-4667-af22-c11ed06be7c0_20250129T14:52_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Good morning, [PII]. My name is [PII]. I'm calling for benefits for a patient that we have in common.
[AGENT][NEUTRAL] OK, and [PII], what is your callback number if we are disconnected please?
[CUSTOMER][NEUTRAL] It is [PII]. It is a direct line.
[AGENT][NEUTRAL] OK, thank you, [PII] and you're calling for eligibility and benefits or claim status?
[CUSTOMER][POSITIVE] Uh eligibility and benefits actually.
[AGENT][POSITIVE] OK. All right, thank you. I can assist with that. Do you have that policy number for the member?
[CUSTOMER][NEUTRAL] Of course, I have one. Give me one second. It is 02.
[CUSTOMER][NEUTRAL] 4969
[CUSTOMER][NEUTRAL] 25 M as in Mike L as in Lima number 8.
[AGENT][NEUTRAL] OK. Thank you very much. Verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Is [PII], um.
[CUSTOMER][NEUTRAL] Yes, Oh [PII], [PII].
[AGENT][NEUTRAL] OK, thank you so much for the verification process. Give me one second here. OK, I have that number pulled up. The member shows effective as of [PII] and this policy shows active as a supplemental medical.
[AGENT][NEUTRAL] One moment, let me go in those fits for you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Thank you. Please note verification of benefits provided does not guarantee payment. We pay up to $2500 for the calendar year for covered services.
[CUSTOMER][NEUTRAL] OK. So the patient is, the patient is covered, um,
[CUSTOMER][NEUTRAL] Um, for minor, uh, for diagnostic services, outpatient diagnosis services?
[AGENT][NEUTRAL] Yes, if it's due to sickness or injury, yes, and then we pay up to $2500 of course we got process comes over the phone. We haven't had that claim in office to process, but we pay up to $2500 for the calendar year, and that's for all covered outpatient services. If you like, I can check to see if anything has been accumulated towards that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I would like to.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Currently the member has not accumulated anything towards that outpatient max of 2500.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, you cover up all the copays, the co-insurance and the deductible for the primary?
[AGENT][NEUTRAL] We do help with the deductible, co-pay, and co-insurance based on coverage, yes, ma'am.
[CUSTOMER][POSITIVE] Excellent. Um, also, we would like to know um if you cover up the office visits for specialist?
[AGENT][NEUTRAL] Let me check that benefit for you, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] The patient does have a benefit to cover office visit fee uh with a PCP and a specialist. Give me one second.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] May I place you on a brief hold please, [PII]?
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Can you please repeat one more time?
[AGENT][NEUTRAL] May I place you on a brief hold?
[CUSTOMER][NEUTRAL] Of course.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK, thank you so much for your patience. I appreciate that. For a specialist office visit, thank you. We will pay up to $50 per visit with a max of 4 visits per year per person.
[CUSTOMER][POSITIVE] Thanks to you then.
[CUSTOMER][NEUTRAL] OK, cover up.
[AGENT][NEUTRAL] And that's 8 total for the family.
[CUSTOMER][NEUTRAL] 50. Cover up to 550, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Per visit, OK.
[CUSTOMER][NEUTRAL] And only has 4 visits available.
[AGENT][POSITIVE] Correct, correct, and it's up to 8 for the family for the calendar year.
[CUSTOMER][NEUTRAL] OK. 884 for individual and 8 for the family.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. The patient has accumulated, accumulate anything of that $50 of the visit?
[AGENT][NEUTRAL] OK, for 2025, no visits have been used.
[CUSTOMER][NEUTRAL] OK, no business excellent.
[CUSTOMER][NEUTRAL] Let me check everything I have anything that I need. So, just to recap. Outpatient diagnosis services are covered up up to $2500 even. $0 has been met so far.
[CUSTOMER][NEUTRAL] And you pick up all the deductible, the copays of the insurance from the primary, and office visit is covered up to up to $50 and nothing has been met uh per visit and the patient has um
[CUSTOMER][NEUTRAL] For 4 visits available for individual, um, specialist office visit.
[AGENT][NEUTRAL] We pay up to $2500 for all covered outpatient services we have with the major medical deductible copay co-insurance based on coverage.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that's, it's not necessarily just all diagnostic, so that's all covered outpatient services up to $2500. Nothing has been accumulated towards that. And as far as the specialist office visit, we pay 50 up to $50 per visit with a max of $4 per individual, and that's up to $8 total for the family. Nothing has been met towards that as well.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] OK. Excellent. Thank you, [PII]. May I have the reference number?
[AGENT][NEUTRAL] You're welcome, [PII]. We do not provide call reference numbers. You can use my name. My last initial is [PII], and today's date.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK. OK. Got it. Thank you so much for your help. Really appreciate it. Thank you.
[AGENT][POSITIVE] You're welcome and thank you for calling APL. Take care bye.
[CUSTOMER][POSITIVE] Bye-bye. Take care. You too. Bye-bye.
[AGENT][NEUTRAL] Yeah.