AccountId: 011433970860
ContactId: a67b4942-6aad-4569-8269-dae2614aa3c8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 359260 ms
Total Talk Time (AGENT): 138928 ms
Total Talk Time (CUSTOMER): 142529 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/11/a67b4942-6aad-4569-8269-dae2614aa3c8_20250311T22:11_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is speaking. May I help you?
[CUSTOMER][NEUTRAL] Hi, I'm calling to verify benefits and eligibility on a patient.
[AGENT][NEUTRAL] OK, I can verify benefits and eligibility for you and your name is?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and Ms. [PII], what's that policy number, please?
[CUSTOMER][NEUTRAL] Sure, that would be sorry it's a policy number 02576313.
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] It's area code [PII].
[AGENT][NEUTRAL] OK, and the patient's name, date of birth?
[CUSTOMER][NEUTRAL] That would be for [PII]. Date of birth [PII].
[AGENT][NEUTRAL] OK, I've shown that his effective date is [PII], I'm sorry, [PII]. He is active on the policy and what benefits are needed for this patient?
[CUSTOMER][NEUTRAL] You said [PII] to current?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So this patient will be having a colonoscopy and an ambulatory surgical center billing for the facility, and it's a medical colonoscopy.
[AGENT][NEUTRAL] OK. Well, um,
[AGENT][NEUTRAL] The insured doesn't have any outpatient facility benefits other than for um ER urgent care, physician's office or clinic, but not for outpatient facility. The surgical procedure or the colonoscopy is covered, it's not the facility charge.
[CUSTOMER][NEUTRAL] Oh, that's really weird because the patient was just here today.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But he was not, uh, he had a poor prep so he's gonna come back tomorrow, but I called and I spoke to [PII].
[CUSTOMER][NEUTRAL] Uh, on [PII], and she said that you guys will pay maximum of $2000 for an ambulatory surgical center.
[AGENT][NEUTRAL] Mm, I'm not sure about that. Uh, one moment.
[AGENT][NEUTRAL] But that could be for the procedure, but not for the facility.
[CUSTOMER][NEUTRAL] Well she did not tell me what you're telling me.
[CUSTOMER][NEUTRAL] Do you know the patient is where?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, they should be, uh, it's in their policy and what is covered, but the policy doesn't cover it. Like I said, they have an outpatient sickness benefit rider, and that constitutes for ER urgent care, physician's office or clinic. As far as any outpatient facility, there's not a benefit for outpatient facility.
[CUSTOMER][NEUTRAL] So you're trying to say you guys will not cover anything?
[AGENT][NEUTRAL] Well I'm saying is the facility charges will not be covered, but she does have a, uh, or he has a benefit for colonoscopy that goes on a surgical benefit, that is covered, not the facility charge.
[CUSTOMER][NEUTRAL] So the colonoscopy is covered but not the facility so how when when we bill you, how would you guys go about that?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] It probably process is not covered.
[CUSTOMER][NEUTRAL] So the patient will be responsible fully.
[AGENT][NEUTRAL] Well, we don't give patient responsibility. It would just process if it's covered or not, but they don't have any outpatient facility benefits under the plan.
[CUSTOMER][NEGATIVE] So does that mean you guys wouldn't cover you guys wouldn't pay anything to us?
[AGENT][NEUTRAL] Um.
[AGENT][NEGATIVE] Not to the facility, no, it's not covered.
[CUSTOMER][NEGATIVE] So then the patient will not be responsible, but you guys will not pay either.
[AGENT][NEUTRAL] Well, I can't give patient responsibility. I can always verify benefits or how a claim has been processed, but we don't give patient responsibility.
[CUSTOMER][NEGATIVE] So then we, OK, I mean it's, it's just a little confusing because like I'm saying I called on the [PII] and this was never brought up to my attention.
[CUSTOMER][NEUTRAL] And the patient was just here, so they're planning to come tomorrow again.
[AGENT][NEUTRAL] Uh, is there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] I just don't have clarification. I mean, I, I would.
[CUSTOMER][NEGATIVE] Be more comfortable if you tell me it's not covered at all so the patient cannot come here.
[CUSTOMER][NEUTRAL] Is that what you're saying?
[AGENT][NEUTRAL] No, that's not what I'm saying. I can't say that the colonoscopy is not covered because it is covered under the policy, just not the facility.
[CUSTOMER][NEUTRAL] And we're billing for the facility.
[AGENT][NEGATIVE] Well, facility is not covered.
[AGENT][NEUTRAL] Per the policy.
[CUSTOMER][NEUTRAL] OK, so I'll have the patient call you guys so you could explain to him and you could tell him if you guys would be the ones to be paying for that if they're gonna be paying for that or I mean.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Because obviously.
[CUSTOMER][NEUTRAL] You know we're billing for the facility and and what is your name?
[AGENT][NEUTRAL] My name is [PII], last initial [PII].
[CUSTOMER][NEUTRAL] And can I have a reference number for this call?
[AGENT][NEUTRAL] We don't give reference numbers. If you like, you may use my name in today's date.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome. Thank you for calling APL. Have a great day.
[CUSTOMER][NEUTRAL] Bye bye.