AccountId: 011433970860
ContactId: 5476047d-4b86-4360-888d-95c3e35e07c8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 299700 ms
Total Talk Time (AGENT): 106483 ms
Total Talk Time (CUSTOMER): 121329 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/30/5476047d-4b86-4360-888d-95c3e35e07c8_20250430T17:06_UTC.wav
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[AGENT][NEUTRAL] For calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] with Family Prime Care. I'm calling about benefits on patient, please.
[AGENT][POSITIVE] Alright, I'm happy to check on benefits. Do we have a policy number?
[CUSTOMER][NEUTRAL] I do. It is.
[CUSTOMER][NEUTRAL] 02435572.
[AGENT][NEUTRAL] OK, let me just pull that up here one moment.
[CUSTOMER][NEUTRAL] I'm sorry, what was your name?
[AGENT][NEUTRAL] My name is [PII], that's [PII]
[CUSTOMER][POSITIVE] Thank you, [PII].
[AGENT][NEUTRAL] No problem. And then can I get the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yes, the patient's name is [PII]. Um, date of birth, um, [PII].
[AGENT][NEUTRAL] Thank you. So patient is active. Effective date on here is [PII]. We're the secondary insurance, so this would cover deductible, co-pay, and co-insurance of primary does not.
[CUSTOMER][NEUTRAL] OK, um, does the plan, does that, does this plan have office visit benefits?
[AGENT][NEUTRAL] Let me see. Sometimes it does just do treatment and not the office visit fee, so I can double check that. One moment.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, so it looks like the patient's plan is gonna cover treatment incurred in a physician's office, however, it does not cover the physician office visit fee.
[CUSTOMER][NEUTRAL] OK, so, um, labs, um, EKG, that sort of stuff?
[AGENT][NEUTRAL] Mhm, yeah.
[CUSTOMER][NEUTRAL] Labs are covered.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] OK, because, uh, when I called on [PII] to check benefits, I was told that the plan has no office visit.
[CUSTOMER][NEUTRAL] Um, office visit benefits or lab benefits, but it does have labs.
[AGENT][NEUTRAL] And it says.
[AGENT][NEUTRAL] Physician covered charges incurred by a covered person because of an accident or sickness necessary for treatment, services and supplies recommended by a physician incurred in a physician's office.
[AGENT][NEUTRAL] Um, all those things are covered charges, so
[CUSTOMER][NEUTRAL] OK, so if the lab work was done outside of the office, would that still be covered?
[AGENT][NEUTRAL] It looks like it needs to occur in a physician's office, otherwise it would not.
[AGENT][NEUTRAL] be covered under their outpatient benefits.
[CUSTOMER][NEUTRAL] That's what I thought. OK, OK, so, um, what percentage of the labs, anything that Aetna doesn't pay?
[AGENT][NEUTRAL] Correct, up to their outpatient benefit max for the calendar year is 3400, so that's the max that we're gonna cover.
[CUSTOMER][NEUTRAL] So they'll cover up to $3400.
[AGENT][NEUTRAL] Mhm, yes ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, anything done in a physician's office?
[AGENT][NEUTRAL] And they don't show the patient has used anything as of today, so they have the full amount remaining.
[CUSTOMER][NEUTRAL] OK, OK, just checking again because I called on [PII] and that's what they told me that the patient had no office visit.
[CUSTOMER][NEUTRAL] Benefits. There was no benefits when the patient was seen in a doctor's office.
[AGENT][NEUTRAL] I'm reading straight from the policy certificate word for word to you.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah, I understand. You know, I, and, you know, um, so the patients patients calling me and saying, hey, you know, you didn't quite the right benefits but I quoted the benefits that was told to me on [PII].
[CUSTOMER][NEUTRAL] So that's why I'm double checking.
[CUSTOMER][NEUTRAL] OK [PII], um, but it has to be done in the physician's office.
[AGENT][NEUTRAL] That's what it states on the certificate. Yes, ma'am.
[CUSTOMER][POSITIVE] Thank you very much, sir. I hope you have a blessed day.
[AGENT][POSITIVE] You as well. Take care.
[CUSTOMER][NEUTRAL] You too. Bye-bye.