AccountId: 011433970860
ContactId: 72034af9-967e-499e-a432-7858f027dc17
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 280709 ms
Total Talk Time (AGENT): 124791 ms
Total Talk Time (CUSTOMER): 108754 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.3, CUSTOMER=1.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/72034af9-967e-499e-a432-7858f027dc17_20250408T18:20_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is Efi. How can I help you?
[CUSTOMER][NEUTRAL] Hi, good afternoon, [PII]. My name is [PII]. I'm calling from [PII]. I am thinking to verify benefits for a member, please.
[AGENT][NEUTRAL] I'm sure, [PII] I can assist you with benefits. Um, first, could I get a good callback number just in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. Now, I need the policy number, please.
[CUSTOMER][NEUTRAL] 02595723 ML 8.
[AGENT][NEUTRAL] Thank you. Now, please verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK, thank you. And just, uh, will please verify the first name again.
[CUSTOMER][NEUTRAL] Uh [PII], uh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, thank you. And um just let me advise you that verification of coverage does not guarantee payment of claims. The effective date on this policy was [PII] and the policy is still active. Um, is this for inpatient or outpatient benefits or an office visit?
[CUSTOMER][NEUTRAL] It's outpatient, she's um asking because she has an allergy testing on [PII], and she has to pay a high deductible on her primary insurance, so we wanna know if this will cover the allergy test in the doctor done in the specialist office.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I'm showing that for services provided in office, we cover up to 1000 per calendar year and that's for the co-insurance and the deductible after the primary insurance processes the claim, but the copay is not um for the office visit. And also, um, if the primary insurance does not cover it, then we don't cover it either.
[CUSTOMER][NEUTRAL] Yeah, um, let me ask, mhm, so then the allergy testing with the high deductibles should be covered by you by this insurance.
[AGENT][NEUTRAL] Um, if a portion of it is covered by the primary insurance, and also, um, if it's, uh, for illness or an injury. If it's just for um seasonal test and it's not related to an actual illness or an injury, then no, ma'am, it wouldn't be covered. It has to be related to an illness.
[CUSTOMER][NEUTRAL] To an illness or injury and the only way to know is once we process um we send you the claims with the nose, right?
[AGENT][NEUTRAL] Right. That's the only way we'll know for sure is when we receive the claim, we would have to review the diagnosis code. And again, if the diagnosis code is just for screening, then it won't be covered.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Yeah, OK, no, because I see that she has been coming to us for nasal conge congestion, runny nose, so this for sure is like a, like a new, more or less uh condition, I would say.
[AGENT][NEUTRAL] Um, yes, ma'am. As long as that's, um, as long as the doctor bills that on the claim, we have to go by the documentation we received.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Oh, OK, yeah, so right now, yeah, you are only able to, yeah, to see from this point like this and not even with the if I provide you a diagnosis code, right? It's until we send the claim.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, no, I'm gonna put it here and how much has been made so far from the 1000 please?
[AGENT][NEUTRAL] OK, sure. One moment.
[CUSTOMER][POSITIVE] Thank
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Um, so far, nothing has been met. Um, she hasn't used any of our benefits so far this year.
[CUSTOMER][POSITIVE] OK perfect thank you so much I uh do you have a reference number?
[AGENT][NEUTRAL] So the reference number, you can use my name and today's date. Um my last initial is M like [PII]. So it would be [PII] and today's date.
[AGENT][NEUTRAL] Is there anything else I can assist you with?
[CUSTOMER][POSITIVE] Mm, that will be all. Thank you so much. OK, have a nice day.
[AGENT][NEUTRAL] You do the same, [PII]. Thank you for calling APL. Mm bye.
[CUSTOMER][NEUTRAL] Bye.