AccountId: 011433970860
ContactId: 4bb07bd9-aea9-4500-83d1-8a82744ca81c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 437010 ms
Total Talk Time (AGENT): 226593 ms
Total Talk Time (CUSTOMER): 145214 ms
Interruptions: 3
Overall Sentiment: AGENT=0.2, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/25/4bb07bd9-aea9-4500-83d1-8a82744ca81c_20250425T15:32_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], my name is [PII]. I'm with a surgery facility in [PII]. Can I get benefits for outpatient surgery and see if we need a prior authorization?
[AGENT][NEUTRAL] Yeah, absolutely. Let's take a look. What is the patient's policy number, [PII]?
[CUSTOMER][NEUTRAL] OK, it is D as in delta 43,730,090.
[AGENT][NEUTRAL] Do you have their card by chance, [PII]?
[CUSTOMER][NEUTRAL] I don't. I got the uh the ID number from the doctor's office.
[AGENT][NEUTRAL] OK, yeah, we can't pull them with that number. There's a number on the card that says certificate number, which is what we need, but I can do a search by their name or social if you have that.
[CUSTOMER][NEUTRAL] Oh, thank you. OK, the name, OK, the first name is [PII]
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and so that's [PII] and then you're saying [PII], correct?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then [PII], or I'm sorry, after the [PII], it's an [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] OK, and then what's the first name?
[CUSTOMER][NEUTRAL] That is the first name and the last name.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] OK, perfect. Let me take a look.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK let's see what we can find here.
[AGENT][NEUTRAL] All right. And then what is patient's date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, perfect
[AGENT][NEUTRAL] All right. So patient does have an active plan with us. Would you like the policy number?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK. So that's gonna be 02456565.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that's the certificate number, right? OK.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mhm. Yes, ma'am. Yeah. And it looks like the active date for the patient is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let me pull.
[CUSTOMER][NEUTRAL] Does this plan fall under any particular network?
[AGENT][NEUTRAL] No, it doesn't and no pre-authorization is needed. It's a, it's a limited benefit plan, so it's um going to just pay that set amount depending upon what the patient's being seen and treated for. So I'm trying to pull up their policy certificate here and I'll give you what the surgery benefit is um sorry for the wait.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, you're fine.
[CUSTOMER][NEUTRAL] Do you know what that D number is for that.
[CUSTOMER][NEUTRAL] That number that starts with a D.
[AGENT][NEUTRAL] So that
[CUSTOMER][NEUTRAL] Does that mean anything?
[AGENT][NEUTRAL] That number is usually on their card as like an employee identifier. It's just not something that we can pull like in our system to verify benefits yeah yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] OK, good to know.
[AGENT][NEUTRAL] Yeah, OK, so, um, it looks like
[AGENT][NEUTRAL] The surgical benefit on the member's plan is $1000. So it's gonna pay $1000 towards the surgery.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] does have an anesthesia benefit, which is 25% of the surgical benefit amount.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, I don't know if you need this or not. It does have a hospital confinement benefit. Are they gonna be inpatient or is it an outpatient, outpatient? OK.
[CUSTOMER][NEUTRAL] No, outpatient, outpatient, yeah, it's cataract surgery, so does it pay 1000 per surgery or per year?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So it would be 1000 per surgery. And let me just make sure there's, yeah, let me make sure there's no exclusions for like cataracts or eyes cause
[CUSTOMER][NEUTRAL] Per surgery, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] No. OK.
[CUSTOMER][NEUTRAL] And is the mailing address um [PII]?
[AGENT][NEUTRAL] That is for us, but for this particular plan, the claims actually go to a different address with a different payer ID, but I'm happy, yeah, I can give that to you.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um,
[CUSTOMER][POSITIVE] OK, I'm ready.
[AGENT][NEUTRAL] So claims are gonna go to attention IMA Inc.
[CUSTOMER][NEUTRAL] Like um [PII] [PII].
[AGENT][NEUTRAL] Mhm. Yup.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] And it's [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that's in [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the payer ID is 64556.
[CUSTOMER][POSITIVE] Perfect. OK.
[CUSTOMER][NEUTRAL] And you said prior op is required.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] No, it's not. No, it's not required.
[CUSTOMER][POSITIVE] 00, it's not required, not required, perfect. OK, excellent. OK, I think, yeah, what else?
[AGENT][NEUTRAL] Yeah. And
[AGENT][NEUTRAL] Yeah, I was just gonna say, I don't see anything on the exclusions that talks about any sort of eye. So I think the patient should be fine as far as coverage goes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, perfect. All right, wonderful. [PII], do you, do you have a call reference number or do I just use your name?
[AGENT][NEUTRAL] You just use my name with my last initial and then put today's date. The initial to my last name is gonna be [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Perfect, thank you so much.
[AGENT][POSITIVE] You're welcome. I hope you have a good rest of your day and a great weekend.
[CUSTOMER][POSITIVE] You too you too take care bye bye.
[AGENT][NEUTRAL] Mhm bye bye.