AccountId: 011433970860
ContactId: ac39cb6d-917e-4502-80e6-421673749ce6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 662890 ms
Total Talk Time (AGENT): 281800 ms
Total Talk Time (CUSTOMER): 201337 ms
Interruptions: 1
Overall Sentiment: AGENT=1.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/04/ac39cb6d-917e-4502-80e6-421673749ce6_20250204T16:25_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling from provider's office, Clear Vision Ophthalmology.
[AGENT][POSITIVE] Yes, [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Yes, um, so I called previously and I just wanted to make sure that I, um, writing everything down correctly and I don't wanna under overcharge the patient, so I just wanted to verify that information.
[CUSTOMER][NEUTRAL] Under medical specialist.
[AGENT][NEUTRAL] So you're wanting to verify.
[AGENT][NEUTRAL] So you're wanting to verify eligibility and benefits again on the on the member you said you had already called about was that correct?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][POSITIVE] Yes ma'am, I can help you with that. And [PII], what is your call back number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and the member's policy number?
[CUSTOMER][NEUTRAL] 02584921
[AGENT][POSITIVE] Thank you one moment.
[AGENT][NEUTRAL] And any information that is provided today would be a verification of benefits and not a guarantee of payment. What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] Sorry about
[CUSTOMER][NEUTRAL] Uh, [PII] uh date of birth [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] It's showing as
[AGENT][NEUTRAL] OK, so I do show that he is the subscriber on this limited benefit plan. This is not major medical insurance.
[AGENT][NEUTRAL] This is a hospital indemnity limited benefit plan.
[AGENT][NEUTRAL] So what type of benefit information were you inquiring on inpatient, outpatient or office?
[CUSTOMER][NEUTRAL] Office specialist.
[AGENT][NEUTRAL] OK, so on this plan, he has an outpatient um benefit for sickness related to sickness or accident. The benefit amount is $50 per day and a maximum of 4 days per calendar year per covered person.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So this only covers accident?
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Accident and sickness. Mhm.
[CUSTOMER][NEGATIVE] And sickness.
[CUSTOMER][NEUTRAL] OK, so it doesn't uh doesn't um cover medical the medical specialist.
[CUSTOMER][NEUTRAL] In the office visit.
[AGENT][NEUTRAL] Yes, an office visit that is related to one of these two categories, the benefit amount is $50 per day and a maximum of 4 days per calendar year per covered person.
[AGENT][NEUTRAL] That is the benefit on this limited benefit plan.
[CUSTOMER][NEUTRAL] 00.
[CUSTOMER][NEUTRAL] OK, I spoke with another young lady, uh, what's her name?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um, I didn't get that information from her, but thank you very much for letting me know so if it's related.
[AGENT][POSITIVE] Yeah, thank
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] So just to make sure if it, if there's an accident related.
[CUSTOMER][NEUTRAL] Or sickness related then uh patient will be responsible for $50.
[AGENT][NEUTRAL] No, that is the maxim this that is the benefit that this policy would pay. Mhm.
[CUSTOMER][NEUTRAL] Plan will pay.
[CUSTOMER][NEUTRAL] Oh OK.
[AGENT][NEUTRAL] Again, it's a limited benefit plan. This is not a major medical plan that he has with us.
[CUSTOMER][NEUTRAL] OK, got
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] And give me, yeah, and give me just one moment while I'm looking at one other piece of information on his policy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So yes, that is correct. I was looking to make sure there's no difference and if it's a specialist or say primary care physician, the physician's office benefit is $50 per day, maximum of 4 days per calendar year per covered person.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then just to make sure then diagnostic testing if it's rendered under specialist only one testing is allowed per per year.
[AGENT][NEUTRAL] For diagnostic testing, there are certain tests that are covered, but uh.
[CUSTOMER][NEUTRAL] Per day.
[AGENT][NEUTRAL] The maximum benefit for a covered diagnostic test under this plan would be $100 per day and a maximum of 1 day per calendar year per covered person.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] $120?
[AGENT][NEUTRAL] $100.
[CUSTOMER][NEUTRAL] 0 $100.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] $100.
[CUSTOMER][NEUTRAL] OK and then uh for in office procedures.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] And just so you know, the diagnostic testing benefit, it has certain tests, as I explained, and those tests are an MRI, CAT scan, an RAIU, a CT or a PET scan.
[CUSTOMER][NEUTRAL] Testing.
[CUSTOMER][NEUTRAL] OK, so let me write this down.
[CUSTOMER][NEUTRAL] MRI.
[AGENT][NEUTRAL] And if he
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] CAT scan.
[CUSTOMER][NEUTRAL] And what was that? What what else was it?
[AGENT][NEUTRAL] An RAIU.
[AGENT][NEUTRAL] CT or pet?
[CUSTOMER][NEUTRAL] Um, I am.
[CUSTOMER][NEUTRAL] RIAU test.
[AGENT][NEUTRAL] R A I U.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what else?
[AGENT][NEUTRAL] A CT and a PET scan?
[CUSTOMER][NEUTRAL] 15
[CUSTOMER][NEUTRAL] CAT scan.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then they, he also would have benefits for an.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Pa
[CUSTOMER][POSITIVE] And you can make adjustment
[AGENT][NEUTRAL] And the follow-up test that it would be covered under this plan or, or an angiogram.
[AGENT][NEUTRAL] A barium enema or lower GI series.
[AGENT][NEUTRAL] A myelogram
[AGENT][NEUTRAL] Nuclear stress test.
[AGENT][NEUTRAL] Arteriogram.
[AGENT][NEUTRAL] A barium swallow upper GI series.
[AGENT][NEUTRAL] A sleep study.
[AGENT][NEUTRAL] And a TEE.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] And that benefit for a follow-up.
[AGENT][NEUTRAL] Um, any of those tests, the benefit amount on that is $25.
[AGENT][NEUTRAL] I'm sorry. Let me make sure on that. Yes, $25 per day, also a maximum of 1 day per calendar year per covered person.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So the MRI CAT scan and the RI.
[CUSTOMER][NEUTRAL] R A sorry, RAI you test uh.
[AGENT][NEUTRAL] R A I U.
[CUSTOMER][NEGATIVE] You guys cover uh cover up to.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] $100 for that, correct?
[AGENT][POSITIVE] The benefit for those 5 tests.
[AGENT][NEUTRAL] Would be the max would be $100 per day and a maximum of 1 day per calendar year.
[AGENT][NEUTRAL] If approved.
[CUSTOMER][NEUTRAL] One
[CUSTOMER][NEUTRAL] Oh, if approved.
[AGENT][NEUTRAL] Yes, ma'am, I explained, we, I can't guarantee payment. I can only verify what his benefits are with you.
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] We would have to receive a claim for review.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK and then um.
[CUSTOMER][NEUTRAL] For the outpatient, uh, ambulatory surgical center for the outpatient facility, I have you guys cover up to $250.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Yes. Surgery that's done in a hospital or outpatient facility or freestanding outpatient surgery center, yes, that benefit is 250 per day and also a max of 1 day per calendar year.
[CUSTOMER][NEUTRAL] Yeah, oh
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I think that's that's about it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And there's no deductibles, no copays, no.
[AGENT][NEUTRAL] No, because it is, no, because it's not a major, mhm, that is correct.
[CUSTOMER][NEUTRAL] Out pocket
[CUSTOMER][NEUTRAL] A limited plan.
[AGENT][NEUTRAL] And do you and then if we receive a claim once we have processed it, [PII], you should be able to check claim status by going to our portal.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] At [PII] did or had the other representative already provided you that website?
[CUSTOMER][NEUTRAL] No thank you, so it's uh secure. sorry.
[AGENT][POSITIVE] OK, well, you're welcome.
[AGENT][NEUTRAL] Secured with [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] [PII] OK.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][POSITIVE] OK, thank you for clarifying that information, [PII].
[AGENT][POSITIVE] Well, you're very welcome. So is there anything else, [PII], that I can help you with today?
[CUSTOMER][NEGATIVE] Uh, no thank you.
[AGENT][POSITIVE] Well, you're certainly very welcome. Absolutely. Uh, no, you're, no worries. So if that is all for the moment, then, thank you again for calling APL and I hope you have a great day.
[CUSTOMER][POSITIVE] If I have any questions I'll give you guys a call back thank you sorry.
[CUSTOMER][POSITIVE] You too thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] OK.