AccountId: 011433970860
ContactId: 531e3071-d1d5-4595-95ce-64a9d5546fe2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 956150 ms
Total Talk Time (AGENT): 268369 ms
Total Talk Time (CUSTOMER): 306693 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/04/531e3071-d1d5-4595-95ce-64a9d5546fe2_20250604T19:15_UTC.wav
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[AGENT][NEUTRAL] Good afternoon and thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, good afternoon. This is [PII]. I'm calling from Texas Digestive Consultants. I need help with some benefits for one of your members, please.
[AGENT][NEUTRAL] OK. Do you have a phone number I can get in case we get disconnected, I can call you back?
[CUSTOMER][NEUTRAL] Sure. It's [PII] with no extension.
[AGENT][NEUTRAL] And do you
[AGENT][NEUTRAL] Thank you, [PII]. And do you have the policy number?
[CUSTOMER][NEUTRAL] It's 02623153.
[AGENT][NEUTRAL] Thank you. Hold on one moment, please.
[CUSTOMER][POSITIVE] Sure thanks.
[AGENT][NEUTRAL] And what's the patient's name?
[CUSTOMER][NEUTRAL] It's [PII] and the date of birth is [PII].
[AGENT][POSITIVE] Thank you, [PII]. And you were just needing benefits?
[CUSTOMER][NEUTRAL] Yeah, I need benefits, please.
[AGENT][NEUTRAL] OK, I can help you with that. The effective date is [PII].
[AGENT][NEUTRAL] The policy is active. Any benefits given over the phone is not a guarantee of payment. And is it for an office visit or?
[CUSTOMER][NEUTRAL] Yes, it's for office visit for a specialist office visit.
[AGENT][NEUTRAL] OK. Hold on one moment. I'll check those benefits for you.
[AGENT][POSITIVE] OK. Sorry about that.
[AGENT][NEUTRAL] For the for the office visit.
[AGENT][NEUTRAL] We pay $50 per office visit 4 times per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And do you have, uh, how many are you?
[AGENT][NEUTRAL] Hold on just a moment, I can check for you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You're welcome. She hasn't used any.
[AGENT][NEUTRAL] She has, has no history.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, thank you. And also, I need to know if this member has outpatient surgical benefits.
[AGENT][NEUTRAL] OK, hold on just a moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Is it in an outpatient facility or doctor's office?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Yes, that's a letter, please.
[AGENT][NEUTRAL] It's what now?
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] Did you say it was in a doctor's office or outpatient facility?
[CUSTOMER][NEUTRAL] Outpatient facility, please.
[AGENT][NEUTRAL] OK, hold on one moment. Um, I'll get someone that can help you with that benefit. Hold on one moment, I'll transfer you. Is there anything else I can help you with?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Um, um, well, for accumulations.
[CUSTOMER][NEUTRAL] Uh, it's with you or with somebody else in this case.
[AGENT][NEUTRAL] What did you say?
[CUSTOMER][NEUTRAL] Um, sorry, for accumulations in this case for um deductibles and out of pocket, uh, it's with you or
[AGENT][NEUTRAL] There's no deductible on this policy. This is not a major medical policy.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And no.
[AGENT][POSITIVE] It has certain benefits.
[CUSTOMER][NEUTRAL] OK, and out of pocket too.
[AGENT][NEUTRAL] Right. It just, for certain benefit, it has certain maximum and certain.
[CUSTOMER][NEUTRAL] Mhm OK and.
[AGENT][NEUTRAL] Like the office visit has 4, but I'm not sure about the outpatient benefits, so I'm gonna let you speak to someone else, OK?
[CUSTOMER][POSITIVE] OK. OK, thank you so much.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Or would you like for someone to call you back on it?
[CUSTOMER][NEUTRAL] Um, well, I, I can wait if you can transfer, I don't have any problem, thank you.
[AGENT][NEUTRAL] OK, hold. Thank you, [PII], for calling APL. You have a good day, OK?
[CUSTOMER][NEUTRAL] You too. Bye-bye.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] Sorry.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] I don't know about that.
[CUSTOMER][NEUTRAL] Afternoon, thanks for calling ATL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], can you help me with the HR policy?
[CUSTOMER][NEUTRAL] OK, what's the policy number?
[AGENT][NEUTRAL] It is 02623153.
[AGENT][NEUTRAL] I gave her the office visit.
[CUSTOMER][NEUTRAL] For Marco.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] I gave her the office visit benefit, but I do not know about the outpatient benefits she's asking about.
[CUSTOMER][NEUTRAL] OK, let me take a look.
[CUSTOMER][NEUTRAL] So, for outpatient, the plan only covers outpatient accident and sickness in the ER which it covers
[CUSTOMER][NEUTRAL] In urgent care, physician's office, and then physical speech, occupation therapy.
[CUSTOMER][NEUTRAL] It pays emergency room, it pays at $50 urgent care is $50 physician's office is $50.
[CUSTOMER][NEUTRAL] Um, and then the physical,
[AGENT][NEUTRAL] Yeah, I gave her the physician office benefit. I know, I know the office visit benefit, but not the outpatient.
[CUSTOMER][NEUTRAL] So that this would be the outpatient services.
[AGENT][NEUTRAL] For ER.
[CUSTOMER][NEUTRAL] Yes, for the emergency room, it covers $50 per day. It's a max of 2 days per calendar year. And then the urgent care is $50 per day. It, they get a max of 4 days for calendar year.
[AGENT][NEUTRAL] Urgent care.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] 4 days per calendar year for what now?
[CUSTOMER][NEUTRAL] Urgent care.
[AGENT][POSITIVE] Alright thank you.
[AGENT][NEUTRAL] And that's $50 also.
[CUSTOMER][NEUTRAL] Yes, it's 50 for emergency room, it's 50 for urgent care, it's 50 for physician's office, and then it's 30 for physical therapy, speech, and occupational therapy.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And do they have a surgery benefit if it's outpatient surgery?
[CUSTOMER][NEUTRAL] No. Well, yes, they do have the surgery benefit. It's all on the PIBFT screen. Do you have that pulled up? They have the accident sickness surgery benefit. It covers 500 per day. They get 1 per calendar for the surgery, and that's surgery in a hospital, hospital outpatient surgery facility or free-standing outpatient surgery center.
[AGENT][POSITIVE] Yes, I do.
[CUSTOMER][NEUTRAL] And they also have surgery in the physician office and it covers 250 per day, and they get 2 per calendar year.
[AGENT][NEUTRAL] That ASS is surgery.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Is that what that is?
[CUSTOMER][NEUTRAL] But yes.
[CUSTOMER][NEUTRAL] Mhm. Are you looking at the new, new screen because it tells you exactly what it is, the new PIBFT screen.
[AGENT][NEUTRAL] Accidentals, OK, I see. Surgery benefit facility.
[CUSTOMER][NEUTRAL] Yeah, accident, sickness, surgical benefit. Mhm.
[AGENT][NEUTRAL] OK, I'll tell him.
[CUSTOMER][NEUTRAL] And then on the policy certificate shows it too.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] Mm bye.
[AGENT][NEUTRAL] Ma'am, are you still there?
[CUSTOMER][NEUTRAL] Yeah, I'm here.
[AGENT][NEUTRAL] OK. You were asking for outpatient surgery?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yes, I would like to know if if this member has um
[CUSTOMER][NEUTRAL] Surgical, outpatient surgical benefits.
[AGENT][NEUTRAL] Yes, ma'am. Let me pull the policy up.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Is it, and you said it's gonna be in an outpatient facility?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] I apologize.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] I know nothing.
[AGENT][NEUTRAL] OK. Accident and sickness surgery benefit, surgery?
[AGENT][NEUTRAL] In a hospital hospital outpatient, 500 per day, maximum of 1 day per calendar year per COVID person.
[AGENT][NEUTRAL] And that's in a surgery in a hospital, hospital outpatient facility or freestanding outpatient surgical center or surgery in a physician's office.
[AGENT][NEUTRAL] A surgery in a physician's office is 250 per day, maximum of 2 days per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you. And just one more question. In the case of routine uh routine screening colonoscopy, it's over 100%.
[CUSTOMER][NEUTRAL] For you.
[AGENT][NEUTRAL] No, ma'am. Hold on one moment. Let me, for wellness, you said?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, first of all, for preventative.
[AGENT][NEUTRAL] Hold on just a moment, I'm checking.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] I'm not showing where it says anything about, uh, preventative wellness.
[CUSTOMER][NEUTRAL] I know.
[AGENT][NEUTRAL] Accident and sickness only.
[CUSTOMER][NEUTRAL] OK, so in this case no.
[CUSTOMER][NEUTRAL] Um, so in this case, the certification is required for any other.
[AGENT][NEUTRAL] What was the question?
[CUSTOMER][NEUTRAL] In this case for certification is required.
[CUSTOMER][NEUTRAL] Or.
[AGENT][NEUTRAL] Pre-certification? No, ma'am. It's not.
[CUSTOMER][NEUTRAL] Mm, OK.
[CUSTOMER][NEUTRAL] And is telehead cover?
[AGENT][NEUTRAL] It's what now? Telehealth?
[CUSTOMER][NEUTRAL] So he mhm.
[AGENT][NEUTRAL] That I'm not sure. I'm gonna have to find out and give you a call back or have someone call you back.
[CUSTOMER][NEUTRAL] OK. OK, it's OK.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Would you like me to call you back?
[CUSTOMER][POSITIVE] Yes, yes, it doesn't have any problem. It's OK.
[AGENT][NEUTRAL] Is there anything else that you want those is covered?
[CUSTOMER][POSITIVE] No, no. Just, just that. It's OK. Thank you.
[AGENT][NEUTRAL] I'll call you back on the telehealth, is that all?
[CUSTOMER][POSITIVE] OK. OK. I will like, thank you so much.
[AGENT][POSITIVE] Thank you, [PII], for calling APL. You have a good day.
[CUSTOMER][NEUTRAL] You too. Bye-bye.
[AGENT][NEUTRAL] Bye-bye.