AccountId: 011433970860
ContactId: b74d429c-7221-4ba1-bb05-96c454268824
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 748469 ms
Total Talk Time (AGENT): 215015 ms
Total Talk Time (CUSTOMER): 162224 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/19/b74d429c-7221-4ba1-bb05-96c454268824_20250619T17:46_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, I'm calling from a physician's office and I wanted to get uh coverage, um, get some coverage information on this patient, please.
[AGENT][NEUTRAL] I can help you with eligibility. Um, who am I speaking with?
[CUSTOMER][NEUTRAL] My name is [PII]
[AGENT][POSITIVE] And a good call back number in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII] and my extension is [PII].
[AGENT][NEUTRAL] And do you have the policy number with you?
[CUSTOMER][NEUTRAL] Yes, it's 02477078.
[AGENT][NEUTRAL] Give me just a moment to look that up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you verify the patient's name and date of birth for me please?
[CUSTOMER][NEUTRAL] [PII]. Her birthday is [PII].
[AGENT][POSITIVE] OK. Thank you so much.
[AGENT][NEUTRAL] Alright, it looks like this policy is active with an effective date of [PII].
[AGENT][NEUTRAL] And this is their secondary gap insurance that helps cover co-pay, co-deductible, and co-insurance. Um, was there anything, any benefits in particular, inpatient or outpatient, that you wanted to check on?
[CUSTOMER][NEUTRAL] Yes, please. Um, it's, she's supposed to have a um diagnostic colonoscopy as outpatient at an ambulatory center.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] I'm not sure if this one will cover it. Um, it is due to, um, it will pay 100% if it's due to, uh, sickness or an accident, um, if you believe that is the case, this is a verification of benefits, not a guarantee of payment, but they have an outpatient benefit maximum of $5000 per calendar year.
[CUSTOMER][NEUTRAL] OK, um, it's not a routine, um, colonoscopy. She's doing it because she has a problem.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So that would fall under thickness then I guess.
[AGENT][NEUTRAL] Um, yes, and so this is their secondary gap insurance, so we will, when you file the claim, we'll need the primary insurances EOB, um, as well.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, EOB and you said it pays a max of $500 5000 dollars, and that's for, so we would submit it to Aetna. They would kick it back and then we'd submit the claim with the EOB to you guys for payment.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK, has she used any of that $5000 yet?
[AGENT][NEUTRAL] Let me check.
[AGENT][NEGATIVE] It looks like she has not.
[CUSTOMER][NEUTRAL] OK, and the, the $5000 benefit is that for the provider, the facil facility anesthesia, is that for everything for the procedure?
[AGENT][NEUTRAL] Uh, it looks like it'll pick up, um, if it's a covered service, like if it really is due to an accident or, I'm sorry, or a sickness, um, then it will pick up whatever the, her primary insurance does not cover.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So is there a way to to find out if that that colonoscopy is considered sickness then because I don't want her to have it done and then she can't afford to pay your bill if you guys don't pay it.
[AGENT][NEUTRAL] Um, let me see.
[CUSTOMER][NEUTRAL] It's not like routine or wellness she had she's having a problem and that's why she needs to have the procedure.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Let me check on that real quick.
[CUSTOMER][POSITIVE] OK, I appreciate it.
[AGENT][NEUTRAL] Oh, anytime.
[AGENT][NEUTRAL] Let me check
[AGENT][NEUTRAL] All right, it looks like.
[AGENT][NEUTRAL] It would cover treatment and the kidney dialysis, but I'm not seeing, excuse me.
[AGENT][NEUTRAL] But this would be covered.
[AGENT][NEUTRAL] There's no surgery, um, I'm assuming.
[CUSTOMER][NEUTRAL] Well, some, they consider colonoscopy surgery cause anesthesia is used, but we don't, the only time the doctor would cut is if there's polyps and they need to send to pathology.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] But I don't wanna
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Talk my way through it, you know, I just wanna make, I don't wanna give the patient the wrong information.
[AGENT][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] Um, it does say on their outpatient benefit that if it's surgery in a hospital outpatient facility or freestanding outpatient surgery center or a physician's office.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um, it could be covered. As far as the diagnosing, diagnostic testing goes, it's, uh, limited to an MRI.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] I am double checking here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] No, it looks like the other thing is diagnostic testing in an independent lab facility. So it sounds like it could be um covered due to the surgery in an outpatient facility or free or out outpatient surgery center. Um.
[AGENT][NEUTRAL] I would call Aetna and see if they approve it for uh if they approve it because if they're not going to approve it this plan won't cover it uh it has to be at least approved by the.
[CUSTOMER][NEUTRAL] Should I
[AGENT][NEUTRAL] Primary first.
[CUSTOMER][NEUTRAL] Yeah, I called them first. It, it, the colonoscopy is applied to the deductible.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And her deductible is $5000. She hasn't met, she's me less than $100 so it's all going to be her responsibility.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] And it doesn't need pre-approval.
[CUSTOMER][NEUTRAL] Should I have the patient call in and speak to member services? Would they be able to help her further if she knows what kind of colonoscopy it is?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, let me check on something real quick. Um,
[AGENT][NEUTRAL] Because it is covered, let me check and see real quick, OK? Give me one moment.
[CUSTOMER][POSITIVE] OK, thank you, no problem.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK. I did get confirmation that if it's a diagnostic colonoscopy, that would be considered a sickness.
[CUSTOMER][POSITIVE] OK perfect that's exactly what it is OK I think you answered all my questions. Thank you for double checking that for me um.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] And, and feel free if you want to do a, a, a prior authorization. It's not required, um, but if you would like to, you're more than welcome to and we can check on that as well. Um, but I did get confirmation that a diagnostic colonoscopy is considered a sickness.
[CUSTOMER][NEUTRAL] OK, uh, you guys would do prior off or are you talking about the primary insurance?
[AGENT][NEUTRAL] Um, you can do it with us, but it's not a requirement. I don't know if that would be beneficial to you or not, but we, we can do that. It's just, it's not a requirement. It's just if you wanna take that extra step.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, she's not scheduled yet because she needed me to find it, look into this first, but if she does get scheduled then I will definitely call back and do it um I think that's everything. Can I just get a reference number for our call please?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] So we don't have call reference numbers but you can use my name and last initial in today's date, so [PII] and then today's date.
[CUSTOMER][NEUTRAL] Oh OK.
[CUSTOMER][POSITIVE] Perfect, thank you again for all your help.
[AGENT][POSITIVE] Great, thank you for calling APL. I hope you have a great day.
[CUSTOMER][POSITIVE] Thanks you too bye bye.
[AGENT][NEUTRAL] Bye.