AccountId: 011433970860
ContactId: 9a2ff308-599e-49f4-b969-1562b64a70c5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 828440 ms
Total Talk Time (AGENT): 214086 ms
Total Talk Time (CUSTOMER): 245510 ms
Interruptions: 1
Overall Sentiment: AGENT=0.9, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/20/9a2ff308-599e-49f4-b969-1562b64a70c5_20250320T13:53_UTC.wav
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[AGENT][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], this is [PII] in customer service. How are you doing today?
[AGENT][NEUTRAL] I'm fine thanks how are you?
[CUSTOMER][POSITIVE] I'm good, thank you. I have a provider calling to verify benefits um on a patient.
[AGENT][NEUTRAL] OK, sure. Give me just a minute, please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and what was the policy number?
[CUSTOMER][NEUTRAL] It is 260.
[CUSTOMER][NEUTRAL] 6091
[AGENT][NEUTRAL] OK, and you said this this was a provider on the other line?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Do you have their name?
[CUSTOMER][NEUTRAL] Uh, his name is [PII].
[AGENT][NEUTRAL] And the callback number?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the ID number he gave me, I don't know where he got that from. I had to I had to search it by the social.
[AGENT][NEUTRAL] OK. And the insured's name is uh [PII].
[CUSTOMER][NEUTRAL] Um, yes, and he verified her name and date of birth.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] You're welcome. Here you come.
[AGENT][POSITIVE] Thank you for holding, this is [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, how can I help you today?
[CUSTOMER][NEUTRAL] Uh, my name is [PII] calling from the provider's office to know the patient eligibility and benefits.
[AGENT][NEUTRAL] OK, sure. You need eligibility and benefits for a hospital indemnity policy?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, sure I can help you with that. Bear with me just a moment.
[AGENT][NEUTRAL] OK, so the um effective date of the policy was [PII] and the policy is currently active.
[AGENT][NEUTRAL] And what benefits were you needing to verify?
[CUSTOMER][NEUTRAL] Plan name and plan type.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Plan name and the plan type.
[AGENT][NEUTRAL] This is a hospital indemity plan.
[CUSTOMER][NEUTRAL] Hospital indemnity plan. I need benefits for specialist office visit.
[CUSTOMER][NEUTRAL] And I have some CPT codes. I need benefits for that codes.
[AGENT][NEUTRAL] OK, let's see here. So let's see.
[AGENT][NEUTRAL] OK, the policy does have an outpatient sickness writer for treatment in a physician's office. I mean this is just verification of benefits, not guarantee of payment, and it does cover a maximum per calendar year of 5 visits.
[AGENT][NEUTRAL] Oh hello?
[AGENT][NEUTRAL] Oh, [PII], can you hear me?
[CUSTOMER][POSITIVE] Yes, ma'am. Thank you for waiting.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mm, yes, uh, I need, you said, uh, how much?
[AGENT][NEUTRAL] It's $75 per visit.
[AGENT][NEUTRAL] Is the maximum benefit amount.
[CUSTOMER][NEUTRAL] How many visits per year?
[AGENT][NEUTRAL] 5 per adult.
[CUSTOMER][NEUTRAL] May I know how many is it, are remaining?
[AGENT][NEUTRAL] None have been used this calendar year, so they have a remaining of 5.
[CUSTOMER][NEUTRAL] The remaining 5 visits. OK. May I know?
[CUSTOMER][NEUTRAL] I have CPD codes. Do you want me to provide codes or a description for the codes to provide the benefits?
[AGENT][NEUTRAL] Um, yes, when you file the claim, you can just, um, attach the copy of the itemized bill with the codes for review.
[CUSTOMER][NEUTRAL] No, no. I'm asking, I have some services along with the office visit. I want to know those services are covered or not covered by this plan.
[AGENT][NEUTRAL] OK, what type of services?
[CUSTOMER][NEUTRAL] Like minor diagnostics.
[CUSTOMER][NEUTRAL] PET scan, DME, Part B injection.
[AGENT][NEUTRAL] OK, there is a wellness and diagnostic test benefit under this policy, and it's a maximum benefit of $250 per diagnostic test. And for a wellness exam or a test benefit, it's $75 per test.
[CUSTOMER][NEUTRAL] Is it $250 for maximum benefit for diagnostic testing?
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] But the diagnostic testing is up to 250 per calendar year.
[CUSTOMER][NEUTRAL] Like minor diagnostics, diagnostic testing, 250 for the plan a year.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] May I know, may I know how much, how much amount used?
[AGENT][NEGATIVE] None has been used.
[CUSTOMER][NEUTRAL] Nothing has been here. May I know PET scan, DMEs, and Part B injections are covered or not covered by this plan?
[AGENT][NEUTRAL] So under the diagnostic testing benefit, it covers for MRIs, CT scans, or colonoscopies.
[CUSTOMER][NEUTRAL] Yes, MRI, CT scan, PET scan.
[CUSTOMER][NEUTRAL] Covered?
[AGENT][NEUTRAL] It's MRI, CT scan, or colonoscopy.
[CUSTOMER][NEUTRAL] Under the same amount, and the two.
[CUSTOMER][NEUTRAL] It's a CT scan, ma'am.
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] It's the top 3.
[CUSTOMER][NEUTRAL] Is it covered or not covered?
[AGENT][NEUTRAL] It is covered under the diagnostic testing benefits. Correct.
[CUSTOMER][NEUTRAL] And the same amount, $250.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, may I know the Part B injection? Injection covered or not covered? Part B injections, DME and that 250 mode.
[AGENT][NEUTRAL] I'm sorry, can you say that again?
[CUSTOMER][NEUTRAL] DME and Part B injection.
[AGENT][NEUTRAL] OK, I got DME and I, I can't, I didn't hear the last part.
[CUSTOMER][NEUTRAL] That is Part B, Part B as in Bravo.
[AGENT][NEUTRAL] You said Part B?
[CUSTOMER][NEUTRAL] Yes, it's an outpatient injection, ma'am, regarding on Part B injection.
[AGENT][NEUTRAL] Is that a wellness exam?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Not wellness exam, ma'am.
[CUSTOMER][NEUTRAL] That's the injection drug, Part B drug.
[AGENT][NEUTRAL] OK, so, like I said, under this policy, it would cover for a wellness diagnostic testing, um, either hospital confinement or outpatient sickness, and if this and, um, or also, it also covers surgical or anesthesia benefits.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let's do ship.
[AGENT][NEGATIVE] And uh there is not a benefit for DME.
[CUSTOMER][POSITIVE] OK, no problem.
[CUSTOMER][NEUTRAL] Could you please check code-wise, codes are covered or not covered.
[CUSTOMER][NEUTRAL] EKG diagnostic testing codes.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] I'm, I'm sorry, you said diagnostic testing cords?
[CUSTOMER][NEUTRAL] Diagnostic testing and EKG.
[CUSTOMER][NEUTRAL] Covered or not covered by this plan.
[AGENT][POSITIVE] Yes, sir. The diagnostic testing is a benefit under this plan.
[CUSTOMER][NEGATIVE] And $50 a month. Nothing has been used. OK. Authorization, any of these services require authorization.
[AGENT][NEUTRAL] Uh, I'm sorry, can you repeat that please?
[CUSTOMER][NEUTRAL] Prior authorization is required or not required.
[AGENT][NEUTRAL] No prior authorization is not required.
[CUSTOMER][NEUTRAL] But the DMA not covered, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] PCP referrals is required or not required.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Primary care physician referrals, PCP referrals.
[AGENT][NEUTRAL] Uh, no, we do not require referrals.
[CUSTOMER][NEUTRAL] May I know the claim's mailing address?
[AGENT][NEUTRAL] Yes, it is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Yes sir, and was there anything else I could do to help you today?
[CUSTOMER][NEUTRAL] Yes, yes. Just wait a second, ma'am.
[CUSTOMER][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] Mm, may I know the pay ID or fax number for claims?
[CUSTOMER][NEUTRAL] Is there any payer ID fax number?
[AGENT][NEUTRAL] Payer ID.
[AGENT][NEUTRAL] Yes, it's 60801.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the fax number is [PII].
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] timely filing limit.
[AGENT][NEGATIVE] But we don't have timely filing.
[CUSTOMER][NEUTRAL] Attention
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Attention.
[AGENT][NEUTRAL] Attention to the claims department is is fine.
[CUSTOMER][NEUTRAL] Claims department.
[CUSTOMER][NEUTRAL] Uh, call reference number.
[AGENT][NEUTRAL] We don't have reference numbers, but you're free to use my name and today's date.
[CUSTOMER][NEUTRAL] Spell your name.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] Thank you for giving me this information. Have a nice day. Nice to talk to you. Bye.
[AGENT][POSITIVE] Thank you for calling APL Jack. You have a good day.
[CUSTOMER][NEUTRAL] Uh uh.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Yeah.