AccountId: 011433970860
ContactId: 9b30fe00-abcf-43c2-b421-404bf6cd94f2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 348480 ms
Total Talk Time (AGENT): 164575 ms
Total Talk Time (CUSTOMER): 100420 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/02/9b30fe00-abcf-43c2-b421-404bf6cd94f2_20250502T15:21_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, uh, I'm calling from a facility and I was just needing to get the eligibility and benefits on one of our patients.
[AGENT][NEUTRAL] Yeah, I could check eligibility and benefits for you. Uh, what was your name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Hey [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And then do you have that policy number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um, 0254.
[CUSTOMER][NEUTRAL] 468 4.
[AGENT][NEUTRAL] Got it. And what was the name and date of birth for the member, please?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Perfect, thank you for verifying that. Uh, so this policy is active. Effective date was [PII], and this is a limited indemnity medical plan. So essentially pays a set dollar amount uh per covered procedure or office visit. Um, what, uh, excuse me, what benefits are we needing to check today?
[CUSTOMER][NEUTRAL] Ambulatory surgical center facility.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] She's having surgery.
[AGENT][NEUTRAL] All righty. One moment while I get that pulled up.
[AGENT][NEUTRAL] All right. I appreciate your patience. Thank you. Uh, and of course, I will let you know verification of coverage is not a guarantee of payment for claims. So she does have a sur surgical benefit, excuse me. Let see.
[AGENT][NEUTRAL] This is an outpatient, it is an outpatient facility you said? I'm sorry.
[AGENT][NEUTRAL] Outpatient hospital, OK, yeah, so that benefit amount is $500 per day.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And let's see.
[AGENT][NEUTRAL] Was this surgery in regards to um an accident or a sickness?
[CUSTOMER][NEUTRAL] Uh, well.
[CUSTOMER][NEUTRAL] I mean
[CUSTOMER][NEUTRAL] She has a thyroid nodule.
[CUSTOMER][NEUTRAL] I don't know if that like what you're all sickness.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Sure, I think that would fall under that category for sure, OK.
[CUSTOMER][NEUTRAL] You know.
[AGENT][NEUTRAL] And then of course she also does have a hospital admission benefit as well that would be an additional $500.
[CUSTOMER][NEUTRAL] OK, so you guys would only cover 500?
[AGENT][NEUTRAL] 500 for the surgery and then 500 for the hospital admission.
[CUSTOMER][NEUTRAL] Well, that wouldn't pertain to this, uh, because they just come in and go home same day.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, I see. I see. OK.
[AGENT][NEUTRAL] Then yes, that seems to be the extent of the benefits for this policy.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEGATIVE] OK, so I just called literally like an hour ago and talked to someone else and they said that they, this patient does not have any outpatient surgery benefits.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] So I'm a little confused because this is my 3rd call to you all and the 1st time they told me what you just told me and the 2nd time they said they don't have benefits and then now you're telling me that it's 500.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I don't know.
[AGENT][NEUTRAL] Sure, I apologize for the confusion.
[CUSTOMER][NEUTRAL] It, it's, it's a pretty big surgery.
[AGENT][NEUTRAL] Yeah, definitely, and I know that confusion can lie in the fact that of course as this is a limited indemnity plan, it is of course very limited and very specific as to the coverage. So I would recommend um you obviously file that claim with us regardless, but I do see specifically on here accident and sickness surgical benefit.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, surgery in hospital, hospital outpatient facility, or freestanding outpatient surgery center is $500 per day, maximum of 1 day per calendar year. So let me check for good measure, um, just to see if she has used that benefit.
[AGENT][NEUTRAL] And that might be where that confusion is. Give me just a moment, let me see.
[AGENT][NEUTRAL] This was for [PII].
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, no, she's not used this benefit so far this year.
[CUSTOMER][POSITIVE] OK, so she is good to go.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, well that is all that I was.
[CUSTOMER][NEUTRAL] That's it, uh, could I have your first name again?
[AGENT][POSITIVE] All right, well, I apologize for the confusion.
[CUSTOMER][NEUTRAL] No, that's OK. Uh, can I have your first name again and then a reference number?
[AGENT][NEUTRAL] Yeah, it's OK. Uh-huh. Reference number would just be my first name, last initial, and today's date. Uh so my name is spelled [PII], last [PII] And was there anything else I could help you with?
[CUSTOMER][POSITIVE] Uh, nope, that's it, thank you so much.
[AGENT][POSITIVE] Alright, yeah, thanks for calling APL. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] Thank you you as well.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.