AccountId: 011433970860
ContactId: 6251e8f8-ddf6-484e-8756-a888555996a7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 582190 ms
Total Talk Time (AGENT): 264271 ms
Total Talk Time (CUSTOMER): 250816 ms
Interruptions: 3
Overall Sentiment: AGENT=0.9, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/02/6251e8f8-ddf6-484e-8756-a888555996a7_20250602T21:57_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, I was just trying to follow up on something that I filed uh for my wife and just had some questions about how it how it comes across to you guys um just trying to get to to understand a little bit better because when she was in the doctor's office.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] They did some a procedure that they filed a er that they call insurance calls it surgery.
[CUSTOMER][NEUTRAL] Uh, but you guys called it an office visit, so I was just trying to understand if I could please.
[AGENT][NEUTRAL] Interesting. OK, uh, we can definitely get some clarification regarding that claim, um, what.
[CUSTOMER][NEUTRAL] And it's uh it's under [PII]
[AGENT][NEUTRAL] OK, what was your name, please?
[CUSTOMER][NEUTRAL] My oh I'm sorry, my name is [PII].
[AGENT][POSITIVE] OK, thank you. uh [PII], can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And do you have that policy number?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Let's see, let's try this 02076760.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, thank you one moment.
[AGENT][NEUTRAL] All right. Uh, is [PII] available that I could speak with her and verify her information?
[CUSTOMER][NEUTRAL] You bet. Hang on just a second.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Uh, that verify who you are.
[CUSTOMER][NEUTRAL] The title sound like you I guess.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hi [PII], how are you?
[CUSTOMER][NEUTRAL] Doing fine. How are you?
[AGENT][NEUTRAL] Doing well, thank you. I'm just gonna verify some information really quick if that's all right. Um, can I get your date of birth, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And then can I get your mailing address?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Perfect. The last thing I need is the email address we've got on file for you. uh, looks like it's through your employer.
[CUSTOMER][NEUTRAL] Can you say that again please?
[AGENT][NEUTRAL] Uh, the email address that we have on file, uh, looks like it's through her employer.
[CUSTOMER][NEUTRAL] ASN.
[CUSTOMER][NEUTRAL] Oh, [PII].
[AGENT][POSITIVE] That's it. Awesome thank you so much for verifying all of that and then of course, do we have your permission to speak with [PII] on your behalf?
[CUSTOMER][NEUTRAL] Of course.
[AGENT][POSITIVE] All right, I appreciate it. Thank you.
[CUSTOMER][POSITIVE] Thank you very much.
[AGENT][NEUTRAL] All righty, I appreciate that. Uh, now, do you have the uh claim number that we're looking at, [PII]?
[CUSTOMER][NEUTRAL] Let's see here.
[CUSTOMER][NEUTRAL] Claim number 3589235.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] Now I understand that part of it, part of the date is [PII], so I'm not talking about the [PII] part. I'm talking about the [PII].
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] The [PII]. Yes, OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Alright, let's take a look here. Give me just a moment.
[AGENT][NEUTRAL] OK. So, and then you stated this was a surgery, correct?
[AGENT][NEUTRAL] Excuse me.
[CUSTOMER][NEUTRAL] Well, it's they call it a surgery on insurance and they gave her a light sedative and they, you know, bless her heart they put tools up her nose and they were looking to uh monitor and yes ma'am, all, all kinds of stuff it was not just, you know, uh uh uh a uh little uh what do you call the handheld where he looks up your nose a little bit stuff like that I mean there.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Oh my goodness.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] They they go up inside the nasal and clean it out and stuff like that and, and uh they've done it to her several times. So that was what I was curious about how that fit under office visit because when I, according to the paper.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me check
[CUSTOMER][NEUTRAL] Yeah, please go ahead.
[AGENT][NEUTRAL] Go ahead I'm sorry. Yeah, no, no, you're fine, um, so it could be a number of different reasons, namely these kinds of policies, they're all very different, but if it was treatment received in office that might be what they're kind of falling under that same category um was it in uh the physician's office setting?
[CUSTOMER][NEUTRAL] I was just
[CUSTOMER][NEUTRAL] Yes, it was in the office, uh, in one of the special rooms, uh-huh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Got you. OK, that's most likely what that is because most uh covered procedures under this policy, the way that this one works, um, it's going to be separated by facilities so urgent care has a separate benefit than like outpatient surgery in a hospital, things like that. Let me get the exact um.
[AGENT][NEUTRAL] Exact verbiage here under the policy.
[CUSTOMER][NEUTRAL] So what you're saying is because of the because of the location.
[CUSTOMER][NEUTRAL] Being in his office.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] They basically call that an office.
[AGENT][NEUTRAL] OK, so it's a little bit different, um, she has a writer under this policy that's a physician outpatient treatment benefit is what that's called, and it does state uh treatment in hospital outpatient facility, freestanding emergency care clinic, urgent care facility clinic, or physician's office, and that's $25 per visit, maximum of 4 visits per covered year or per covered person per calendar year. So that.
[AGENT][NEUTRAL] A separate little add on to this policy and that's what this is going to fall under as on the actual policy itself, the base policy, there is no coverage at all for office visits or treatment received in a physician's office.
[CUSTOMER][NEUTRAL] OK, yeah, so that's what I'm trying to find out. So though, so though even though my Blue Cross Blue Shield calls it surgery.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, according to the, to the writer and the attachments to my uh gap policy that this is not considered surgery.
[AGENT][NEUTRAL] Correct, um, again, as it's especially because it's taking place in a physician's office. So even if it was considered surgery, it would not be covered, uh, because that's where it was. So outpatient surgery in an outpatient hospital or outpatient, excuse me, hospital outpatient facility or a free standing outpatient surgery center, that is on the base policy, that's separate, but that's if it was in one of those kinds of facilities. Does that make sense?
[CUSTOMER][NEUTRAL] Right, OK, well, I was just trying to understand so that because the convenience of being able to do it this office.
[AGENT][NEUTRAL] Yeah, it's, it's a bit difficult. Yeah, it is a little bit different, um, but that's essentially what that is, is that that writer is what's adding that benefit of getting treatment in a physician's office.
[CUSTOMER][NEUTRAL] Right, OK. All right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So basically,
[CUSTOMER][NEUTRAL] OK, so basically anything that happens in the doctor's office is just considered a doctor visit, correct? Is that, is that kind of a layman's term? OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct, it would.
[AGENT][NEUTRAL] Well, yes and no for for this particular policy, yes. Now some of we do have other policies where they are separate. There's um benefits for an office visit or treatment received in office for this particular policy under this writer, it's going to be kind of one and the same.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, well, that's what I'm trying to understand. So my policy, what I've got basically in in office then it's, that's all it is, that's all it's good for. OK, alright, now you mentioned free standing, is there a if.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] We basically have either been in the doctor, this is just for clarification for me. We've either been basically in the doctor's office or she had some surgery where we went to the hospital and they put her on a gurney and, you know, put her on and rolled her off away from me and all that stuff.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] The, the, the, the buildings that fall in between kind of like the uh the free standing ERs or things like that.
[CUSTOMER][NEUTRAL] How do they fit into this? If I had, if we were to have, what if we had had this done at a, at a, um, I can't think of the right word I'm looking for. I, I don't visit them much, the, you know, these free standing.
[AGENT][NEUTRAL] At one of these, um, outpatient surgical center, yeah. Um, if it was a freestanding surgical center, yes. If that was how it was, if it was billed as a surgery, uh, as you said, then that's how that would fall under that category. So if it was in one of those, we would be able to have paid a benefit.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] OK, OK, so I'm just trying to, OK, because we basically fall from one side to the other. OK, I appreciate your time. I, I thought that's kind of what it meant, but I thought it's worth, worth the call to be sure.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Of course, yeah, I know it's pretty confusing.
[AGENT][POSITIVE] Absolutely. Do you have any questions for me at the moment?
[CUSTOMER][NEUTRAL] Yeah, well,
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Do what?
[AGENT][NEUTRAL] Did you have any other questions for me at the moment?
[CUSTOMER][POSITIVE] No, I don't. I appreciate it. Thank you for your time.
[AGENT][POSITIVE] Alrighty, absolutely of course thanks for giving us a call and I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] All right, thank you very much. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye bye.