AccountId: 011433970860
ContactId: 60f44ec6-d57a-4278-88d1-b51631c79860
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 986419 ms
Total Talk Time (AGENT): 364121 ms
Total Talk Time (CUSTOMER): 295624 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/08/60f44ec6-d57a-4278-88d1-b51631c79860_20250508T13:31_UTC.wav
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[AGENT][NEUTRAL] My name is [PII]. How may I help you?
[AGENT][POSITIVE] Good morning. Thank you for contacting ATL. Yes, good morning. Thank you for contacting ATL. My name is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEGATIVE] Uh, actually, your voice is not clear. I'm not able to hear your voice clearly.
[AGENT][POSITIVE] Good morning.
[AGENT][NEUTRAL] OK, can you hear me now?
[AGENT][NEUTRAL] Are you able to hear me now?
[CUSTOMER][POSITIVE] Yeah, better, better.
[AGENT][NEUTRAL] OK, yes, my name is [PII]. Yes, and I'm with ATL. How may I help you?
[CUSTOMER][POSITIVE] Yeah, yeah, yeah. Better.
[CUSTOMER][NEUTRAL] OK. My name is [PII] and I'm calling from provider's office for the patient's benefits and eligibility information. And by the way, I missed your name. Please spell out your first name and the initial of your last name.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] It's [PII] and the first letter of my last name is [PII]. And [PII], I can help with benefits and eligibility. What is that policy number, please?
[CUSTOMER][NEUTRAL] Yes, yes, yes, sure. So, [PII], right?
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] OK. How are you doing, [PII]? How's your day?
[AGENT][NEUTRAL] I'm, I'm fine. Uh, how are you, [PII]?
[CUSTOMER][POSITIVE] Oh, thank you for asking. I'm good, I'm good.
[AGENT][NEUTRAL] Uh, do you have the policy number that I can look?
[CUSTOMER][NEUTRAL] And the member ID.
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] Yes, yes, yes. Uh, let me give you that. That is 025993997.
[AGENT][NEUTRAL] Thank you. And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] His name is [PII], and date of birth, [PII].
[AGENT][POSITIVE] I appreciate that. Is there a callback number I can have in the event that we're disconnected?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yes, that is [PII].
[AGENT][NEUTRAL] Thank you. The policy went into effect on [PII].
[AGENT][NEUTRAL] And it is active now the benefits, [PII], this is a hospital indemnity policy and so what it does is it pays a flat rate benefit for certain services, certain very specific services. So could you tell me what, what it is that we're looking for? Is it, is it this for uh um a surgery or is it for a doctor's office or?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. OK, OK, OK. Let me tell you, [PII]. So, uh, I'm calling from the provider's office. So you need to check first that uh we in-network provider or out of network provider. And if we are out of network provider, you need to check as well that the patient have any out of network coverage or not, OK?
[CUSTOMER][NEUTRAL] So, can you check this uh by your side at the initial level?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] What
[AGENT][NEUTRAL] Yes, I certainly can. Um, [PII], the, the, this is a, let me go ahead and tell you about the policy. There is no network.
[AGENT][NEUTRAL] Because it is a hospital and this is, this is not major medical. So because this is a hospital indemnity policy.
[AGENT][NEUTRAL] It it they go anywhere they want to. It's going to pay the same no matter where you go. So what we will do is we will pay a flat rate benefit for, yes, so, so like for an office visit, we'll pay a flat rate benefit no matter where they go. If they have surgery, it doesn't matter what type of surgery it is, we pay a flat rate benefit. So you see there is no network.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Yeah, so it's it, so, uh, this is gonna be, yeah. So what's um, yes, sir.
[CUSTOMER][NEUTRAL] OK, OK. Thank you. Actually, uh, yes, yes, I can understand. Yes, I can understand. But I'm looking for mostly uh the benefits for infertility.
[AGENT][NEUTRAL] For, I'm sorry, for what?
[CUSTOMER][NEUTRAL] For infertility.
[AGENT][NEUTRAL] Oh, yes, thank you. OK, let me see if I can look that up. OK.
[CUSTOMER][NEUTRAL] Yes. So, uh, check first as general, listen. Can you please listen?
[AGENT][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] You need to check first that uh patient have any coverage for infertility treatments and testings are not, OK. Because if the patient don't have the infertility coverage, I'm not gonna give you those quotes for infertility, OK?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I understand. Yes, thank you. So, um, [PII], this policy is for uh sickness or accident. So let's see what we have here. I'm just checking the benefits right now.
[AGENT][NEUTRAL] Um, I'm not sure that it has anything for that, but let me just check.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Uh, so let's just see right here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, I'm not
[AGENT][NEUTRAL] I don't see anything. I don't see that this is covered. I think it's actually has to be.
[AGENT][NEUTRAL] A sickness or an accident.
[AGENT][NEUTRAL] Um, now there is health screening, but that's not really the same thing.
[AGENT][NEUTRAL] Um,
[AGENT][NEGATIVE] So it doesn't, it doesn't look like they have any benefits.
[AGENT][NEUTRAL] For that
[CUSTOMER][NEUTRAL] OK. So, patients don't have the infertility benefits. So, can you uh check the patient have any coverage for diagnostic X-ray or not? If you want the codes, I can give you the codes as well.
[AGENT][NEUTRAL] Uh, yes, what is the code for that please, [PII]?
[CUSTOMER][NEUTRAL] OK. For diagnostic X-ray and surgery, the codes are 76831.
[CUSTOMER][NEUTRAL] 74,740
[CUSTOMER][NEUTRAL] 58,340.
[CUSTOMER][NEUTRAL] And [PII].
[AGENT][NEUTRAL] OK. Let me just check here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, 4.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Sorry, I'm still just checking here really quickly.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, [PII], I'll be right back. Excuse me just one moment, please.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, so for um.
[AGENT][NEUTRAL] A diagnostic exam.
[AGENT][NEUTRAL] Let's see what we have here.
[AGENT][NEUTRAL] OK, thank you for holding. OK, it looks like for a diagnostic exam.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Uh, like an ultrasound or an X-ray.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh, they, uh,
[AGENT][NEUTRAL] That will pay up to $100 per day. That's just a verification of the benefits, not a guarantee of payment.
[AGENT][NEUTRAL] Um, they have 3 of those days throughout the calendar year. Let's see what else we have, um.
[AGENT][NEUTRAL] OK, yeah, it looks like that's all the same thing, so um.
[AGENT][NEUTRAL] The, the diagnostic testing, it's, it's under that $100 per calendar day. So regardless of what the, the total cost of the uh diagnostic testing is the ultrasound, the X-rays, um, it will pay $100 per calendar day. That's just a verification of the benefits, not a guarantee of payment.
[AGENT][NEUTRAL] And um.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right, so that's going to be it. Uh, that's, that's the only thing that's going to be covered, uh, it looks like, uh, but it doesn't matter where they go, it doesn't matter where she goes with that.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, OK, OK. I can understand. The basic uh co-pay will be $100.
[CUSTOMER][NEUTRAL] So, uh, what is the patient's individual deductible and out of pocket max?
[AGENT][NEUTRAL] Well, for there, uh, let's see for the total maximum.
[AGENT][NEUTRAL] For uh outpatient services.
[AGENT][NEUTRAL] That's, it just really depends on.
[CUSTOMER][NEUTRAL] I'm sorry I didn't get you.
[AGENT][NEUTRAL] Pardon?
[AGENT][NEUTRAL] See, it really, it, it.
[CUSTOMER][NEUTRAL] So, uh, the patient don't have
[AGENT][NEUTRAL] Uh, I'm sorry.
[CUSTOMER][POSITIVE] Yes, please continue.
[AGENT][NEUTRAL] Oh yes. What I was gonna tell you, [PII], is that um there isn't a calendar year maximum. Um, what it does is that it goes by the procedures. So, um, it covers very specific services like outpatient surgery.
[AGENT][NEUTRAL] Um, or, or anesthesia or the diagnostic tests, so there's not a calendar year maximum now for that procedure for the diagnostic procedure for the X-ray, the ultrasound, whatever, it's a, it's pays a total of $100 per day with a maximum of 3 days per calendar year.
[AGENT][NEUTRAL] Again, I, and I have to say and I'm sorry, the verification, not a guarantee of payment, but that's the way that the policy works. So there's not a calendar year maximum for everything. It's just we go by the procedure and how much it will pay and how many days they're covered.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So $100 and with $100.03 days will be covered, correct?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Yes, so if you did this 3 different days, then, you know, maybe $100 per day. If you did it all in one day, it would be that $100.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK. And anything related to infertility is not covered, correct?
[AGENT][NEUTRAL] Uh, no, it's, uh, that's not, not specifically, um.
[AGENT][NEUTRAL] If you, if there's no other, I mean if you did an X-ray, if you did if you did the ultrasound that would be covered, um, but, uh.
[AGENT][NEUTRAL] That would be it.
[CUSTOMER][POSITIVE] All right. Thank you.
[AGENT][NEUTRAL] Now, is there anything else at all I can tell you about this uh limited benefit policy?
[CUSTOMER][NEUTRAL] All right, all right. So,
[CUSTOMER][NEUTRAL] There is no patients individual deductible.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK. And what is uh
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Coinsurance.
[AGENT][NEUTRAL] No, no, I'm sorry. There's no coinsurance. It's just, it's just that flat rate benefit. There's, there's nothing else.
[CUSTOMER][NEUTRAL] All right. Uh, no out of pocket max as well.
[AGENT][NEGATIVE] Uh, no.
[AGENT][NEUTRAL] No, there isn't.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And fertility is not covered. Thank you.
[AGENT][NEUTRAL] Is there anything else that I can help with?
[CUSTOMER][NEUTRAL] OK. Uh.
[CUSTOMER][NEUTRAL] Yes, just bear with me.
[CUSTOMER][NEUTRAL] Help me with the pay ID please.
[AGENT][NEUTRAL] The payer ID is 60801.
[CUSTOMER][NEUTRAL] 60801. All right. So, it's not a major medical. Uh, the policy, the patient have, it's not a major medical plan, but the patient will take the service for diagnostic X-ray and outpatient surgery by $100 co-pay for 3 days. Correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] All right. So, diagnostics are covered, but infertility is not covered. Thank you treatments are not covered. testings are covered. Thank you for this information.
[CUSTOMER][NEUTRAL] Now, moving on.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you have another patient for me to look at?
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Uh, no, actually, I'm confused for the ben I mean, benefits you have given to me. Um, I'm a little bit confused.
[CUSTOMER][NEUTRAL] And uh for these 4 codes, any pre-certification is required or no[PII]?
[AGENT][POSITIVE] No, no, it's not required. It's, you can certainly.
[AGENT][NEUTRAL] Send it in for pre-certification, but it's not required.
[CUSTOMER][POSITIVE] OK. Preserve is not required. Thank you.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Can you tell me once again that what type of plan is this?
[AGENT][NEUTRAL] It's called the hospital indemnity Policy.
[CUSTOMER][NEUTRAL] All right. So group hospital indemnity policy. So in network or out of network doesn't matter, it will cover. OK, thank you.
[AGENT][NEUTRAL] OK. Is there anything else at all that I can help with, [PII]?
[CUSTOMER][NEUTRAL] May I
[CUSTOMER][NEUTRAL] Yes, uh, give me the call reference number.
[AGENT][NEUTRAL] My name is [PII]. The first letter of my last name is [PII], and we're gonna use that in today's date as our reference.
[CUSTOMER][POSITIVE] OK. Thank you, [PII], for your help. Have a great day.
[AGENT][NEUTRAL] OK, thank you for contacting ATO have a.
[CUSTOMER][NEUTRAL] Bye for now.