AccountId: 011433970860
ContactId: b0e2e917-b128-4d7e-9f6e-1fb31c54613a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 652260 ms
Total Talk Time (AGENT): 198043 ms
Total Talk Time (CUSTOMER): 151150 ms
Interruptions: 1
Overall Sentiment: AGENT=0.9, CUSTOMER=-0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/b0e2e917-b128-4d7e-9f6e-1fb31c54613a_20250416T15:00_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] in customer services. How are you?
[AGENT][POSITIVE] I'm good. How are you doing today?
[CUSTOMER][POSITIVE] I'm good um I have a provider on the phone calling for benefits.
[AGENT][NEUTRAL] OK. Yeah, that's fine. You can send them my way. Do you have the policy number?
[CUSTOMER][NEUTRAL] I do it's 02592661.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, was she verified already?
[CUSTOMER][NEUTRAL] Uh, verified her name and date of birth, and the guy that's on the phone is [PII].
[CUSTOMER][NEUTRAL] He's the provider.
[AGENT][POSITIVE] OK, perfect. OK, thank you.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hi, [PII], uh, you were calling for [PII] for benefits.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And that policy number is 2592661, I see.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And then what's a good callback number in case our call gets dropped?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Perfect, thank you.
[AGENT][NEUTRAL] OK, and then what benefits did you have questions about?
[CUSTOMER][NEUTRAL] Uh, physical therapy.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Just one moment. Uh, let me pull up their information really quick. This might take a few minutes. Can I put you on a brief hold?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK, [PII], thank you for holding.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Um, yeah, could you, yes, hello, could you hold on for a second? I've been just right now, um, yeah, just needs one more minute or so.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Sorry.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is that fine?
[AGENT][NEUTRAL] Yeah, that's fine.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] So just relax for a second, OK, and thank you.
[CUSTOMER][POSITIVE] Thank you bye.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] Hi
[AGENT][NEUTRAL] OK. So it looks like physical, physical therapy is not covered, covered under this policy.
[CUSTOMER][NEUTRAL] All set?
[CUSTOMER][NEUTRAL] We were told previously that it was when we checked her benefits that she received 5 authorized visits.
[CUSTOMER][NEUTRAL] And the plan paid $75 towards the office visit. Um, she had no deductible, no co-insurance, and then there was some way that we could get her additional visits.
[CUSTOMER][NEUTRAL] So that's odd and there seems to be definitely then a some sort of issue there.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] Physical therapy would be different, so it looks like they quoted you the outpatient sickness writer that she has.
[AGENT][NEUTRAL] And that maximum maximum benefit per visit is the $75 maximum visits per calendar year, $5 per adult.
[CUSTOMER][NEGATIVE] So you're telling me with her health plan, even though we're in network with it that she has no benefit for physical therapy?
[AGENT][NEUTRAL] No, not for physical therapy.
[CUSTOMER][NEGATIVE] Um, just flabbergasted. I don't even understand how that's a thing. We've never seen that before ever. What does her health insurance cover then?
[AGENT][NEUTRAL] Uh, so she has an outpatient benefit that was the $75.
[AGENT][NEUTRAL] She has an intensive care, coronary care writer. That daily indemnity benefit is 1000. She also has wellness diagnostic test benefit.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that's per test, that's $250.
[AGENT][NEUTRAL] See.
[AGENT][NEUTRAL] So, uh, also, let's see, hospital confinement benefit, daily indemnity benefit is 200.
[AGENT][NEUTRAL] So she also has a surgical and anesthesia benefit rider, and that is $4000.
[CUSTOMER][NEGATIVE] What would happen if she needed surgery and then needed physical therapy after that surgery? What what is she supposed to do? That's where that sickness, $75 outpatient thing would come in for 5 visits.
[AGENT][NEUTRAL] See.
[CUSTOMER][NEUTRAL] I'm just trying to wrap my head around this whole thing.
[AGENT][NEUTRAL] Right. Yeah, I get that. Um, the certificate is very
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, it just says it doesn't say anything about physical therapy on her certificate. It just quotes the outpatient sickness benefit.
[AGENT][NEUTRAL] Is the $75 hold on.
[CUSTOMER][NEUTRAL] What is that what exactly is that? Just any outpatient office?
[AGENT][NEUTRAL] Yes, correct. Yes, it's, it's if she is not confined for under 18 hours.
[CUSTOMER][NEGATIVE] That bills
[AGENT][NEUTRAL] So say it was more than 18 hours that would be considered inpatient.
[CUSTOMER][NEUTRAL] Got you. So any outpatient offer that bills, she gets 5 visits per calendar year.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] Of whatever that is.
[CUSTOMER][NEUTRAL] And then what?
[AGENT][NEUTRAL] Let's see
[CUSTOMER][NEUTRAL] Is there any way to get more visits after that?
[AGENT][NEUTRAL] And so that's just per year, so that would have to, so it there would have to be a new year for her to qualify for more.
[CUSTOMER][NEUTRAL] Sending a progress note or.
[AGENT][NEUTRAL] So she only gets those 5 visits a year.
[CUSTOMER][NEUTRAL] I've never heard this for an insurance plan ever.
[AGENT][NEUTRAL] Yeah, it's a secondary insurance plan. It's just made to uh help.
[AGENT][NEUTRAL] Help the patient out. So she would have like her primary insurance.
[CUSTOMER][NEUTRAL] What would be, what would be the pri[PII], do you know what the primary insurance plan is?
[AGENT][NEUTRAL] No, that would be up to her.
[AGENT][NEUTRAL] She would have that information.
[CUSTOMER][NEUTRAL] But you don't see that.
[AGENT][NEUTRAL] No, we do not.
[CUSTOMER][NEUTRAL] You just know that this is a secondary insurance?
[AGENT][NEUTRAL] Yes, sir. Mhm.
[CUSTOMER][NEUTRAL] Like a supplement.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK, um, we will have to follow up with the patient then. OK, thank you very much.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK. Yeah. Yeah, of course. Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] Have a have.
[CUSTOMER][NEUTRAL] Nope, that is it.
[AGENT][POSITIVE] That's it. OK. Thanks for calling APL. Have a good day, [PII]. Mhm.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] You too.
[AGENT][NEUTRAL] Bye.