AccountId: 011433970860
ContactId: 567b4d0c-b4e4-469a-8a71-72f79c3d5b59
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 298000 ms
Total Talk Time (AGENT): 165258 ms
Total Talk Time (CUSTOMER): 142514 ms
Interruptions: 2
Overall Sentiment: AGENT=1.3, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/27/567b4d0c-b4e4-469a-8a71-72f79c3d5b59_20250227T19:26_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hey [PII], how you doing?
[AGENT][POSITIVE] Good doing well thank you how are you?
[CUSTOMER][NEUTRAL] I'm great, thanks for asking, [PII]. Um, Lord [PII], I'm just change your whole name, [PII], this is [PII] claims and claims. I have a member on the phone, a provider on the phone. She's calling about a HI claim, I mean a HI policy, and she wants to provide procedure codes. Now I could have read the policy benefits to her, but when it comes to the procedure codes and stuff, I can't help her with that.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me know when you're ready for the policy number.
[AGENT][NEUTRAL] Um, yeah.
[AGENT][NEUTRAL] Go ahead, child.
[CUSTOMER][NEUTRAL] It is 253-791-1. It's 253-791-1 is for [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the caller name is [PII]. I verified all [PII]'s information, and [PII]'s callback number is [PII].
[AGENT][NEUTRAL] And you said it's a provider correct?
[CUSTOMER][NEUTRAL] Yes, that's correct. So let me transfer over to you.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] That's fine. Thank you so much.
[CUSTOMER][POSITIVE] Thank you, [PII]. Have a good one.
[AGENT][NEUTRAL] You too.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Hello [PII], I'm gonna transfer you over to [PII] so she can better assist you, but thanks for calling APL, and you have a great day. You're welcome. Goodbye.
[AGENT][NEUTRAL] Hi [PII], good afternoon. This is [PII] in the claims department. How are you?
[CUSTOMER][NEUTRAL] on
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][POSITIVE] I am good how about yourself?
[AGENT][POSITIVE] Doing well, thank you. So I understand you have a question about some benefits for uh Miss [PII]?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes, she actually we're a specialty office and she came in our office today as a new patient and our doctor has ordered some tests for her and I was just curious basically if they needed some kind of prior authorization or if they were even covered under her plan.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so let me pull up her plan here, just to let you know there is a verification of coverage only, not a guarantee of payment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So, um, this policy is a limited medical, uh, hospital indemnity policy. So it does have limited medical benefits. Now, um, for, yeah, for the, um, now for the office visit, um, there is a, a rider on the, uh, plan for outpatient sickness visit. So as long as it's not injury, accident or injury, um, the sickness.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] That's what I figured.
[CUSTOMER][NEUTRAL] S
[CUSTOMER][NEUTRAL] It wasn't, it's she's having some heart issues like cardiovascular.
[AGENT][NEUTRAL] OK. OK. So that, yeah, OK. So this policy again, does have that outpatient sickness benefit rider, which would cover that physician encounter in the physician's office. So there is a benefit for that. Now, you're asking about diagnostic testing, is that right?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yes, yes, one of them would be done at the hospital and then one of them would be done in our office.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. So this, um, again, it is limited, um, limited coverage. Now, there is a diagnostic testing benefit that's allowed under this plan. However, it is limited to um a CT scan.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Um, either a, a CT scan, an MRI, or colonoscopy only. So those are the only diagnostic tests that would be covered um under this plan. Now, um, as far as the one done in the office, if it's done in the physician's office, will it be done like with the office visit itself? Cause again, that office encounter will, OK. So,
[CUSTOMER][NEUTRAL] E
[CUSTOMER][NEUTRAL] Email it
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] It's not, it's considered a procedure like an echocardiogram.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So as long as that's done in the physician's office and it will be done on a separate day from that office visit, if there's benefits available again for that outpatient sickness, um, that may be covered based on the place of service, but again, the diagnostic testing itself would not be covered.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I got you, uh, and then the other one is a CTA at the hospital.
[CUSTOMER][NEUTRAL] But it's it's advanced it's like a hard I mean it's a.
[CUSTOMER][NEUTRAL] So it's a CTA of the coronary arteries.
[AGENT][NEUTRAL] OK. Look, again, it would be that benefit for the diagnostic testing would either be a CT scan, MRI or colonoscopy. So if it, um, if it's considered, yeah, it would not be, uh, if it's not one of those three, then it would not be considered under the diagnostic testing benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so it's not
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so it's not a basic CT scan, it's a little bit more advanced, so we probably wouldn't be covered, OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK, well that's what I needed to know.
[AGENT][NEUTRAL] Did you have any other questions, [PII]?
[CUSTOMER][NEUTRAL] Mhm, no, ma'am, that'll be it.
[AGENT][POSITIVE] Alright, thank you so much for calling APL. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] mhm
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] You too thank you bye bye.