AccountId: 011433970860
ContactId: a6f9b798-f488-4fd6-9227-7c821046a68f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 603989 ms
Total Talk Time (AGENT): 342744 ms
Total Talk Time (CUSTOMER): 157427 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/29/a6f9b798-f488-4fd6-9227-7c821046a68f_20250129T23:37_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name's [PII]. I'm calling with Sutter Medical Foundation. Um, I have a patient that was seen by us, uh, and, uh, he requires further care. He needs another surgery. I am unfamiliar with this health insurance and I was calling to see if we are contracted, um.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, OK, we can get the policy pulled up, um, and I'll let you know what kind it is, um, let's see, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure it's [PII].
[AGENT][NEUTRAL] Thank you. Do you have the policy number?
[CUSTOMER][NEUTRAL] Uh yes.
[CUSTOMER][NEUTRAL] Is that the medical ID number? Yeah, OK, so D like David 43302057.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so that's actually not one of our policy numbers, [PII], that is through, uh, they're called 90 Degrees, um, do you maybe have their social? I could search for them that way.
[CUSTOMER][NEUTRAL] Uh, let me take a look and see, it is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK thank you one moment.
[AGENT][NEUTRAL] Uh, what was the name for the insured?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Do you have his date of birth?
[CUSTOMER][NEUTRAL] Yes, it is [PII].
[AGENT][NEUTRAL] Perfect. OK, so I did find his policy. So this plan, it's, uh, it is a bit different, um, it is a limited indemnity medical plan, so essentially it is limited as to what it does and does not cover. Um, it is also set to cover um a specific dollar amount per procedure or office visit.
[AGENT][NEUTRAL] Bear with me just a moment. I'm gonna get his policy pulled up here and we will take a look. So, you're saying he needs, um, he's had two surgeries? Are we just trying to see if those surgeries are covered?
[CUSTOMER][NEUTRAL] He had a surgery and he requires another.
[AGENT][NEUTRAL] OK, OK, give me just a moment, let me pull his benefits up here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And so first I don't know if you need his eligibility information. Um, it is active, uh, the effective date was [PII] and of course I will let you know verification of coverage is not a guarantee of payment for claims. So the way that this policy works is it's got a list of covered surgeries, um, and there's a base amount for surgery that is $1000 and then per procedure.
[AGENT][NEUTRAL] Per surgery, uh, it pays a percentage of that $1000 depending on the kind of surgery that it is. Uh, he also has an anesthesia benefit, which would be 25% of the surgical benefit amount.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Does that make sense?
[CUSTOMER][NEUTRAL] No, but um.
[AGENT][NEUTRAL] OK, no, that's fine. Um, again, this is a very different kind of, um, policy. So for the surgery itself, it's the baseline of $1000. Um, and then depending on what kind of surgery it was, it would be a percentage of that $1000 so higher or lower. And then the anesthesia benefit would be 25% of that surgical benefit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and that is what that that's what this indemnity plan covers or that OK and then he's responsible for the then and then he is responsible for the other amount.
[AGENT][NEUTRAL] Again, it's that set dollar amount.
[AGENT][POSITIVE] Correct, yes, yes, that's the benefit amount.
[AGENT][NEUTRAL] We do not say what is patient responsibility that would be up to the provider, um, but that would just be how this policy works.
[CUSTOMER][NEUTRAL] OK and then do we request authorization or does he just go get.
[AGENT][NEUTRAL] No, authorization is not required.
[CUSTOMER][NEUTRAL] No authorization is required.
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Alrighty um.
[CUSTOMER][POSITIVE] Alrighty, so
[CUSTOMER][NEUTRAL] You said it did give a list of surgeries that were covered though, right? Or that were allowed?
[AGENT][NEUTRAL] Yes, um, and it is.
[AGENT][NEUTRAL] Um, that would be considered cover. Well, it's would list those percentages. Oh, kidney stone. Um, oh goodness. Um, I have an exact name of the kind of procedure for that?
[CUSTOMER][NEUTRAL] He's got a kidney stone.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Cystourethroscopy with stone basketing, it's a ureteroscopy basically ureteroscopy with lithotripsy.
[AGENT][NEUTRAL] Could you spell that for me?
[CUSTOMER][NEUTRAL] Yep
[CUSTOMER][NEUTRAL] U R E T E R O S C O P Y.
[AGENT][NEUTRAL] Thank you. All right, give me just a moment, let me take a look here.
[AGENT][NEUTRAL] Alright, bear with me just a moment. I'm taking a look here. I don't see that particular term. um, I'm going to see.
[AGENT][NEUTRAL] The only thing I see with a kidney is a kidney transplant. Um,
[CUSTOMER][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] But I don't see that
[AGENT][NEUTRAL] Eroscopy listed.
[AGENT][NEUTRAL] Was there another name or anything else that might be.
[CUSTOMER][NEUTRAL] Try lithotripsy.
[AGENT][NEUTRAL] Could you spell that again? I'm sorry.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Yeah, [PII]
[AGENT][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Yes, awesome. OK, there it is cool that is under urinary system, so that is covered.
[AGENT][NEUTRAL] And that is
[AGENT][NEUTRAL] 25. OK, it's not giving me the exact amount um that is covered that they do specify that. Awesome. OK, percent of maximum surgical benefit.
[AGENT][NEUTRAL] OK and just so that I understand correctly, he had, he's gonna have to have this procedure twice it's the same procedure, is that right?
[CUSTOMER][NEUTRAL] Pretty much, yeah.
[AGENT][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] So he had one the other day like the [PII] I think and then I'm gonna be booking him for another one I think in March is when our next available is.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I see. OK, OK, just so that I understand, um, correctly, OK, so this one is stating that it was 25.0.
[AGENT][NEUTRAL] So that would be the percentage, so 25%.
[AGENT][NEUTRAL] Of 1000, which is his baseline surgical benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is is what paid?
[AGENT][NEUTRAL] Correct, um, and now bear with me just a moment because there are other.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] These plans are very different.
[AGENT][NEUTRAL] And they are, they, it's, it's funny because they're so specific yet extremely vague. Um, OK, let's see.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I imagine this is just going to like an outpatient surgery, correct? OK.
[CUSTOMER][POSITIVE] Yes it is, yes.
[AGENT][NEUTRAL] It's
[AGENT][NEUTRAL] Yeah that looks like that would be the only.
[AGENT][POSITIVE] Applicable uh benefit to this circumstance that he has under this policy.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Um, did you need our information for filing claims? I've got a, uh, mailing address, fax number, and a, um, a payer ID.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You know, I don't think it would hurt. OK, so what's the payer ID?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] It is 60801.
[CUSTOMER][NEUTRAL] OK and then um you said a mailing address?
[AGENT][NEUTRAL] Yes, I have a mailing address and a fax number. Um, our mailing address is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that is in [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] OK, and then a fax number?
[AGENT][NEUTRAL] Yes, that is 877-365.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 942 3.
[CUSTOMER][NEUTRAL] Alrighty, alright, well, and then your name is?
[AGENT][NEUTRAL] All right, it's [PII] I know that was extremely confusing. I, this is my job and it does not get easier for me, um, so did you have any other questions for me?
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] Just is there a call reference number or anything?
[AGENT][NEUTRAL] Yeah, reference number would just be my first name, last initial, and today's date, uh, so my last initial is A.
[CUSTOMER][NEUTRAL] OK, and then today's date?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] 129 2025. All right, thank you so much for your help, [PII]. Have a good day.
[AGENT][NEUTRAL] That's it.
[AGENT][POSITIVE] Alright, yeah, thanks for calling APL you too bye bye.
[CUSTOMER][NEUTRAL] Uh bye bye.