AccountId: 011433970860
ContactId: 660e8882-92af-4e27-a4b3-2ef8b0e6c279
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 539500 ms
Total Talk Time (AGENT): 273773 ms
Total Talk Time (CUSTOMER): 241307 ms
Interruptions: 5
Overall Sentiment: AGENT=0.4, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/27/660e8882-92af-4e27-a4b3-2ef8b0e6c279_20250227T17:14_UTC.wav
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[AGENT][POSITIVE] Morning thank you for calling ATL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, how are you? I'm having a procedure done um with my gynecologist, and I just, you know, we have our and um PPO insurance, it covers a lot, but I, we also have APL as a secondary. Can you let me know if it covers what I'm gonna, the procedure I'm doing?
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] It's an outpatient procedure.
[AGENT][NEUTRAL] Um, I
[AGENT][NEUTRAL] OK, I can check on the policy and see exactly what it states on the policy. Um, may I have your name and uh call back number just in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, may I have your name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and may I have um the policy number, Miss?
[CUSTOMER][NEUTRAL] So it would be the group rate or the um outpatient, I don't know how outpatient in hospital group number. I don't know which one would it be?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Outpatient search.
[CUSTOMER][NEUTRAL] Alrighty, so it'll be 002.
[CUSTOMER][NEUTRAL] 502-535 M as in Mary L and the number 8.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And for security, may I have your date of birth and mailing address, Mr. [PII]?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK. And what type of procedure?
[CUSTOMER][NEUTRAL] So it was uh an abnormal, an abnormal the my Pap smear wasn't, it was abnormal. So they gave me codes. Can I give you these codes because I don't understand none of this, but I just wanna see if.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] We cannot
[AGENT][NEUTRAL] The thing is that we don't process claims over the phone. In order to use the code is basically to process a claim. Um, you can give me like details about what they're trying to do or what they're gonna do and the place of service and I can go.
[CUSTOMER][NEUTRAL] I think that, OK, so here.
[CUSTOMER][NEUTRAL] OK, so here I have CPT. I don't know what that is, CPT.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] That's the procedure code.
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] the CPT is a procedure code.
[CUSTOMER][NEUTRAL] OK then
[CUSTOMER][NEUTRAL] I don't know what to tell you. I don't know the exact.
[AGENT][NEUTRAL] What, what is that procedure called? What is that procedure called? Let me see if I can go to our system and check on that. Mhm.
[CUSTOMER][NEUTRAL] The code, OK, so I'm gonna, they gave me two different codes of two different things, OK? So the first one is 574.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 54
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And then the other one is 99214.
[AGENT][NEUTRAL] OK, 9921 for his office visit. OK.
[AGENT][NEUTRAL] So let me check on this 11 moment.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, and before I give you any benefit information, I need to let you know that this is not a guarantee of payment, just a verification of coverage and that's just a disclaimer.
[AGENT][NEUTRAL] And.
[CUSTOMER][NEUTRAL] Right, I just don't, I don't remember paying this before and they had to do it last year as well, but I don't remember me having to pay 1000.
[CUSTOMER][NEUTRAL] Something dollars for this. So they were asking me um in the gynecologist's office to call you guys and see what.
[CUSTOMER][NEUTRAL] This would cover.
[AGENT][NEUTRAL] OK, we cannot guarantee any payments over the phone. Uh, I can go ahead and give you benefits based on the benefits of your policy, OK?
[CUSTOMER][NEUTRAL] Well, I haven't done the procedure yet. This will be taking place on [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] I just wanna know, OK, go ahead and you continue and then I'll, I guess continue. I don't.
[AGENT][NEUTRAL] OK. Um, so, let me see the policy benefits for this, um,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Particular policy. OK, so you have um an outpatient maximum.
[AGENT][NEUTRAL] And the outpatient maximum benefit is 2500.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] That 2500 is to help with deductibles, co-payment, and co-insurance from the major medical, and this is for office treatment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, it'll be in their actual office facility where I go. So would this cover the those expenses?
[AGENT][NEUTRAL] Mhm. Yes. Yes. Mhm.
[AGENT][NEUTRAL] Um, correct, I cannot guarantee anything over the phone, but you do have benefits for office treatment.
[CUSTOMER][NEUTRAL] Office treatment. OK, so I'm gonna call back and.
[AGENT][NEUTRAL] OK. Mhm.
[CUSTOMER][NEGATIVE] And they have my card. I, I just don't understand why they told me that I wouldn't cover it, and that's weird because I've never paid this before. And they wanted me to pay 1, I think 300, I don't know what, on Monday after the procedure, but I, it was covered last year, I remember.
[CUSTOMER][NEUTRAL] Because it's, since it's a secondary, right, it's like a gap insurance, so it would take over.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] This is the secondary. Mhm.
[CUSTOMER][NEUTRAL] OK, because Aetna is my primary, but this will be our secondary.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So it should cover the expense of the quote I gave you.
[AGENT][NEUTRAL] Correct, I, I can log in. We cannot guarantee anything over the phone. You do have 2500 per calendar year that you can use for outpatient service, including office treatment.
[CUSTOMER][NEUTRAL] Are you there?
[CUSTOMER][NEUTRAL] OK, outpatient and office treatment. Let me write this here because I'm gonna have to call him back outpatient.
[CUSTOMER][NEUTRAL] An office treatment, 2500. OK.
[AGENT][NEUTRAL] Mhm. Yes, the only thing that is gonna cover just a flat amount will be the visit. So the 99214, which is the visit, that one has a separate benefit amount. Um, it is part of the $2500 but it's a set amount. So let me give you the amount that we cover for the office visit, OK? One moment.
[CUSTOMER][POSITIVE] Perfect. All righty.
[AGENT][NEUTRAL] Hold up.
[CUSTOMER][NEUTRAL] OK, so the outpatient would cover it covers 2500, correct?
[AGENT][NEUTRAL] The outpatient benefit is 2500 and that's for office treatments or office procedures. So basically, 57454 is a procedure or treatment, OK? So that benefit will be
[CUSTOMER][NEUTRAL] And then the office visit?
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] 574-554
[AGENT][NEUTRAL] Uh-huh, yes. Mhm. Yes.
[CUSTOMER][NEUTRAL] Right? OK.
[AGENT][NEUTRAL] OK, so that will be a procedure or treatment. So that's part of the benefit of the 2500. Now, for the office visit, um, the office visit is pay at, and this is a specialist because it's your OBGYN, um, so, uh, let's see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Bear with me, let me
[CUSTOMER][MIXED] I just paid my annual, but this is the well, the con the the annual is covered 100% with Aetna, but this is, I guess they're charging twice because it's an office visit plus a procedure, right? This is incredible they charge, but anyways, um, the office visit plus the procedure.
[AGENT][NEUTRAL] Yeah,
[AGENT][NEUTRAL] Yeah, yeah, that's different. Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, it's, it's, it's gonna be different because the first thing they did was preventative. Preventatives are usually covered 100% by the major medical, and that's why we do not cover any preventatives. So right now you're coming back because they found something, that means they're treating a sickness, um, or they're trying to find more information about a sickness. And that's why um you have the office visit, which is the 99214, and the specialist office visit is covered at $50. So we'll cover $50 for the co-payment.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Great.
[AGENT][NEUTRAL] And that's also part of your 2500.
[AGENT][NEUTRAL] But it's just a flat amount for that code 99214.
[CUSTOMER][NEUTRAL] OK, so what do you suggest I do when I get there because they're gonna ask me to pay for it and I don't wanna pay this and then have to provide a receipt and then have the money withdrawn. Should I have them bill you guys directly and take it from there?
[AGENT][NEUTRAL] If that's a possibility, um, there is some institution that they don't have a way of sending a secondary claim, and that's why we have the option that you can submit your own claim um you will have to ask them to see if they take the secondary policy if they do, all they need to do is call us to get benefit information so we can go ahead and verify this information with them and they can um see if they can submit the claim for you, but they're the only ones that can answer if they can send in the claim or not.
[CUSTOMER][NEUTRAL] So then I have an outpatient and office uh treatment.
[CUSTOMER][NEUTRAL] Um, coverage of 2500, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK, so that should cover. OK, let, let me call them and if anything I'll call you guys back with me. These people take like a 3 hour lunch, so they're probably not even there now, but OK, I'll call you guys at, at one point. Thank you so much.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm
[AGENT][POSITIVE] All right. No problem. All right. Is there anything else I may help you with today?
[CUSTOMER][POSITIVE] Alrighty.
[CUSTOMER][POSITIVE] That's it thank you so much.
[AGENT][POSITIVE] You're welcome and thank you for calling APO. Have a good day.
[CUSTOMER][NEUTRAL] You too bye.
[AGENT][NEUTRAL] Bye bye.