AccountId: 011433970860
ContactId: 95ed9640-367d-473d-832e-37bb1fa48ab5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 516280 ms
Total Talk Time (AGENT): 224186 ms
Total Talk Time (CUSTOMER): 216500 ms
Interruptions: 6
Overall Sentiment: AGENT=0.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/23/95ed9640-367d-473d-832e-37bb1fa48ab5_20250623T18:04_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, [PII], this is [PII]. I'm calling from AMeds ENT of Anderson. I'm not sure if I'm calling the the correct um line. I was calling to try to obtain benefits on for an outpatient surgery for a patient.
[AGENT][NEUTRAL] OK, yeah, I can check benefits for you. I know you said that was for an outpatient surgery?
[CUSTOMER][NEUTRAL] Well, actually this, yes.
[AGENT][NEUTRAL] OK, yeah, I can check that for you. uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh yes, it is [PII].
[AGENT][NEUTRAL] Thank you and then do you have that policy number?
[CUSTOMER][NEUTRAL] Yes, it is. Let me grab them.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] If I can read this little bit of card it's D as in Delta 43,733,350.
[AGENT][NEUTRAL] OK, so that is not going to be one of our policy numbers that is through, uh, they're called 90 degree benefits.
[CUSTOMER][NEUTRAL] OK, hold on.
[CUSTOMER][NEUTRAL] OK, hold on, cause it's got a lot of different numbers on it to make sure I'm looking at the right. Hold on.
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] No worries.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Uh let's see what other number we can get. Uh.
[CUSTOMER][NEUTRAL] OK, sorry, on this one, it's 64556.
[AGENT][NEUTRAL] You're fine. Mhm.
[CUSTOMER][NEUTRAL] The payer ID, is that correct?
[AGENT][NEUTRAL] No, um, OK, no, um, do you have their social by chance? I could search for them that way.
[CUSTOMER][NEUTRAL] So what about a group number?
[CUSTOMER][NEUTRAL] Do what now?
[AGENT][NEUTRAL] Uh, do you have their social? Yeah.
[CUSTOMER][NEUTRAL] Do I have a social?
[CUSTOMER][NEUTRAL] I can probably get it. Hold on one second. Let me go.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Cause it's got a lot of ID numbers, so I'm not sure which.
[AGENT][NEUTRAL] No, you're fine. I will say ours typically starts with a 01 or a 2.
[CUSTOMER][NEUTRAL] So well, let me see if anything like that on here.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] No, so let me just try to get.
[CUSTOMER][NEUTRAL] Come on, [PII].
[CUSTOMER][NEUTRAL] Let me go to one area and see if you can provide me with something.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, I have [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and that is the member's social?
[CUSTOMER][NEUTRAL] Yes, the members also. I'm assuming this is what this.
[AGENT][NEUTRAL] Got it. OK.
[AGENT][NEUTRAL] Sure, um, what was the name for the member?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, do you have her date of birth?
[CUSTOMER][NEUTRAL] It's that he's [PII] [PII].
[AGENT][POSITIVE] Awesome. OK, thank you so much for verifying that. So I was able to find her policy. Um, did you want me to go ahead and give you that correct policy number that she has with us?
[CUSTOMER][POSITIVE] Yeah, that would be great.
[AGENT][NEUTRAL] Sure, let me know when you're ready for that.
[CUSTOMER][NEUTRAL] I'm really.
[AGENT][NEUTRAL] OK, that is 0261.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] 7161.
[CUSTOMER][NEUTRAL] OK, can I read it back? Hold on. I mean, [PII], I'm sorry. 02617161.
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] Sure.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, policy number, OK.
[AGENT][POSITIVE] All righty.
[AGENT][NEUTRAL] And so this policy is of course active. Uh, that effective date was [PII], and this is a limited indemnity medical plan, so it just pays a set dollar amount per covered procedure or office visit.
[CUSTOMER][NEUTRAL] Oh, OK, so did I.
[CUSTOMER][NEUTRAL] OK. Now, this is what I was calling about with surgery. Does he have any surgical benefits with this plan?
[AGENT][NEUTRAL] Give me just a moment. Let me get that information pulled up and of course I will let you know verification of coverage is not a guarantee of payment for claims.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So, yes. Uh, do you see a surgical and anesthesia benefit? Let's see. That benefit looks like that is the surgical benefit is $1000. Anesthesia benefit is going to be 25% of that. So, um, let me see if I can get some more information on that for you.
[CUSTOMER][POSITIVE] Perfect anesthesia will be 25% of the 1000.
[AGENT][NEUTRAL] Right, um, give me just a moment though, let me see if I can get some more information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. So it does state the surgery can be performed in a hospital, ambulatory surgical center, or a physician's office.
[AGENT][NEUTRAL] And then I believe.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So I think uh and that's what I'm gonna get clarification for is uh that $1000 is typically a baseline um of uh the different kinds of operations would typically be a percentage of that so let me get to that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and but that is all that it would cover for surgery with the $1000.
[AGENT][NEUTRAL] Right, yes.
[CUSTOMER][NEUTRAL] OK, so this is, OK.
[AGENT][NEUTRAL] Let's see, and of course the, the confusion is going to be with um this is part of a multi plan. I'm sure that's why you've got a million different policy numbers and such, so it's possible that this number does have um other coverages outside of APL um I could just simply tell you of course this information, but let's see, so percent of maximum surgical benefit, what kind of surgery is this going to be?
[CUSTOMER][NEUTRAL] Uh, I think I may need.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] He's gonna have an excision of a left neck mask.
[AGENT][NEUTRAL] That was removing a lesion you said? I'm sorry.
[CUSTOMER][NEUTRAL] Uh, they're gonna be moving uh a mask from his left neck.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see if I can find that. Is it, it's not a malignant tumor, is it?
[CUSTOMER][NEUTRAL] Um, not, mm mm, he's not saying it's been right as of right now.
[AGENT][NEUTRAL] Oh,
[AGENT][NEUTRAL] I see. OK. So not.
[AGENT][NEUTRAL] Would that be considered a biopsy, I wonder?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] He could possibly if he sees something that looks kind of fun, that, yeah, cause they let a do a biopsy, yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right now, he said it's gonna like basically remove it, but I guess it's something does look different. They probably possibly will send it for do a biopsy on it if need be.
[AGENT][NEUTRAL] OK, so that that specific kind of what it could be is going to depend on how much of that benefit we would be able to pay, but from what I can see it does look like that 1000 is the maximum.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That's the max, OK.
[AGENT][NEUTRAL] I don't see anything that would exceed that, yes.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEUTRAL] Alright, and then [PII], do you have a reference number for this call?
[AGENT][NEUTRAL] Sure, yeah, it would just be my first name, last initial, and today's date. Uh, so my name is spelled [PII] Last initial is [PII] Did you have any other questions for me?
[CUSTOMER][NEUTRAL] And also, if the, I don't know if they'd be able to use this plan or not cause sometimes we could consider it like a self-pay plan, so I guess I don't need the authorization information.
[AGENT][NEUTRAL] No authorization is not required for this policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right. That's what I need, [PII]. You have a great day.
[AGENT][POSITIVE] All right. Well, thank you, Miss [PII]. I hope you have a great rest of your day. Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Uh-huh. Bye-bye.