AccountId: 011433970860
ContactId: 679b60ba-594c-4fca-ac48-e98da25ae2d9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 478579 ms
Total Talk Time (AGENT): 242434 ms
Total Talk Time (CUSTOMER): 187820 ms
Interruptions: 5
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/19/679b60ba-594c-4fca-ac48-e98da25ae2d9_20250319T19:33_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] in customer service. How are you?
[AGENT][POSITIVE] I'm good. How are you, [PII]?
[CUSTOMER][POSITIVE] I'm good thank you. I have a provider on the line calling to verify benefits and eligibility.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, what's that policy number?
[CUSTOMER][NEUTRAL] It is 258-064-4.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Is there a specific question that I can help with, or?
[CUSTOMER][NEUTRAL] They're wanting to know what type of benefits would be covered under this plan.
[CUSTOMER][NEUTRAL] Um, her name and she's wanting to know if they're, if they need an authorization. I know I don't think that they do. I don't think we.
[CUSTOMER][NEUTRAL] Give authorizations like that um but she, she had some questions on what the insurance would cover.
[AGENT][NEUTRAL] No, we don't.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, I have the policy pulled up. What was her name?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Uh, her name is [PII], last initial [PII] and her callback number is different than what's on the screen. It is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK perfect I'll have it.
[CUSTOMER][POSITIVE] Alright, thank you, here she comes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] This is [PII].
[CUSTOMER][NEUTRAL] Yes, this is her.
[AGENT][NEUTRAL] Hey, this is [PII] with the claims department. How are you?
[CUSTOMER][NEUTRAL] I'm well. How are you?
[AGENT][NEUTRAL] I'm doing well. um, so Miss [PII] was saying that you had questions about benefits and eligibility for um a Miss [PII]?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] That that.
[CUSTOMER][NEUTRAL] The museum.
[AGENT][NEUTRAL] OK, uh, what kind of questions can I answer for you?
[CUSTOMER][NEUTRAL] So, he was scheduled for a an imaging procedure at our facility. And I've never seen this insurance before. I'm trying to figure out if she's eligible.
[CUSTOMER][NEUTRAL] Um, if it covers outpatient imaging and if she needs a prior authorization.
[AGENT][NEUTRAL] OK. Uh, what kind of imaging procedures she having done?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, nuclear medicine, he had a biliary scan. The CBT code is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And is this due to a sickness or an injury?
[CUSTOMER][NEUTRAL] Due to right upper quadrant pain.
[CUSTOMER][NEUTRAL] Which is
[AGENT][NEUTRAL] Like is there gallstones and stuff suspected?
[CUSTOMER][NEUTRAL] We're talking in the last
[CUSTOMER][NEUTRAL] Medical visit.
[CUSTOMER][NEUTRAL] There was some abnormal glucose, low blood pressure.
[CUSTOMER][NEUTRAL] Abdominal pain?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It will probably take me a couple of minutes to try to figure out.
[AGENT][NEUTRAL] That's OK. I can discuss like the benefits and stuff while, while you're looking at that. Um, so this policy is a limited benefit hospital indemnity plan. So it's not major medical and it's not a gap plan.
[CUSTOMER][NEUTRAL] Why they wouldn't.
[AGENT][NEUTRAL] Um, the best way I can describe it is because most people have heard of Aflac and it's very similar in its limitation of benefits. It has certain benefits that pay certain amounts for, you know, maybe it's 1 day, maybe it's 10 days, maybe it's 30 days. It's limited in nature in that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Way
[CUSTOMER][NEUTRAL] Can I cut you off one second just to ask a question? Basically, if the hospital gonna have to put in a claim and then at that point, once the claim is created, y'all will determine what is and isn't covered, how much is and isn't covered for all of this.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Basically, yes. Basically, yes, but to let you know, they do have imaging benefits. She does have accident and sickness surgery benefits. Um,
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] That's
[AGENT][NEUTRAL] But she doesn't have like office visits or anything like that. So she does have diagnostic testing, she does have the surgery for outpatient. Um, whether those are accident or sickness related is all going to.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Be determined by the bill that we receive, you know, like what we get, we'll be able to better determine now we don't require an authorization.
[AGENT][NEUTRAL] So that's not needed um but yeah it's one of those things where once we get the bill we're we're really not going to know until we see OK this is what was done, this is why it was done you know stuff like that um so it's really.
[AGENT][NEUTRAL] You know, most insurance companies don't process over the phone, but it's really difficult to give you a yes or no as well because they could do imaging and they may go in there with a diagnosis but come out with a different one. Your initial may be covered but your final may not your initial may not be covered but your final may be um so that's one of those things where.
[CUSTOMER][NEUTRAL] So this is.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Yeah, this is the liability, this is the liability that they took. They seem to have hepatic statatosis, so.
[CUSTOMER][NEUTRAL] I guess it's uh no offer required at the risk of the patient to pay whatever she needs to pay, cause this is the insurance she chose.
[AGENT][NEUTRAL] Right, yeah, because we don't do coordination of benefits either, so if she does not have any other insurance if it's covered, there could be some payment coming your way, um, what that is, I'm not 100%, um, if there's no payment coming your way and she doesn't have any other insurance then you know I don't that's up to you guys on how to handle it because with not having a coordination of benefits or anything we're not going to say well this is patient responsibility.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] That is it.
[CUSTOMER][NEUTRAL] The days are coming.
[CUSTOMER][NEUTRAL] 100%.
[CUSTOMER][NEUTRAL] You know
[CUSTOMER][NEGATIVE] That does not.
[AGENT][NEUTRAL] Um, we don't make those determinations. It's really up to you guys on how to handle any balances outside of what we do or do not pay.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] And is there a call reference number I can obtain?
[AGENT][NEUTRAL] Yeah, it would just be my name, so that's [PII], last initial [PII] with today's date.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] This is just reminding me of like an auto claim whatever first you have to put it in, then maybe it's going on.
[AGENT][NEUTRAL] Yeah it's I mean I hate to say it's similar but it kind of it kind of is you know like benefits will be determined once the claim is actually submitted and then whether you're covered or not is up in the air. The only thing that I can tell you for sure is.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] The coverage is for sickness or injury or accident, however you want to, to verbalize that. Um, if it is outside of that, they don't have wellness. So, you know, obviously there's something going on or she wouldn't be having this. So I feel like you're at least that far into it, but as far as what she has done and whether that's covered or not.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] I, I just can't say for sure. I'm not 100% certain there.
[CUSTOMER][POSITIVE] Great. Thank you.
[AGENT][POSITIVE] You're very welcome. I hope you have a great day.
[CUSTOMER][NEUTRAL] You too. Bye.
[AGENT][POSITIVE] Thank you bye bye.