AccountId: 011433970860
ContactId: b88ed9b1-134b-4d8e-aeee-987b299c8aec
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 558380 ms
Total Talk Time (AGENT): 335732 ms
Total Talk Time (CUSTOMER): 122707 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/28/b88ed9b1-134b-4d8e-aeee-987b299c8aec_20250228T16:51_UTC.wav
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[AGENT][POSITIVE] Thank for contacting APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] My name's [PII] and I am calling um.
[CUSTOMER][NEUTRAL] To verify benefits.
[AGENT][NEUTRAL] I can help with benefits. [PII], what's that policy number, please?
[CUSTOMER][NEUTRAL] It's 02588133.
[AGENT][NEUTRAL] Thank you and the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] [PII] date of birth is [PII].
[AGENT][POSITIVE] I appreciate that if I could just have a callback number please in the event we're disconnected.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. Now, would you like the benefits for the uh for the hospital or the uh um dental?
[CUSTOMER][NEUTRAL] Um, actually I'm calling regarding an office visit, especially office visit.
[AGENT][NEUTRAL] Oh, yes. OK. All right, fine. Um, so the policy went into effect on [PII], excuse me, please forgive me. [PII]. It is active. This is a hospital indemnity policy. It pays a flat rate benefit for um certain things like physician's office. So, uh, [PII] has 4 of those throughout the calendar year. We pay $50 per office visit.
[AGENT][NEUTRAL] Um, that's just a verification of the benefits, not a guarantee of payment. It doesn't look like he has used any of those benefits so far, so that is the maximum that it will pay for an office visit.
[CUSTOMER][NEUTRAL] OK, and what would the patient's co-pay be for that?
[AGENT][NEUTRAL] Well, there's not, it's not really major medical, so there's not a, a co-pay. It just, this is a flat rate benefit policy. So what it does is it just pays that benefit. And anything above and beyond that is going to be between the, the provider and the insured. So it will pay up to $50 for, for this office visit. And again, that's just the verification again to your payment.
[CUSTOMER][NEUTRAL] And the patient doesn't pay anything upfront.
[AGENT][NEUTRAL] Well, it's, are you going to be doing more than just the office visit? Um
[CUSTOMER][NEUTRAL] More than likely, um, let me see here what they're coming in for.
[AGENT][NEUTRAL] Because, um,
[CUSTOMER][NEUTRAL] Right, more than likely they're gonna have a colonoscopy, so I would need to know if they have surgical benefits as well.
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] Usually do have something like that so let me just see what we have here.
[AGENT][NEUTRAL] I apologize. I'm just trying to pull this up with my uh.
[CUSTOMER][NEUTRAL] Oh, you're fine.
[AGENT][NEGATIVE] So slow here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] While you're looking, do you know what network, what network do you all use?
[AGENT][POSITIVE] There is no network, um, because it is a limited benefit policy, uh, there, uh, he can go to any provider. There's, there's not a problem with where he's going, so, um, we don't have to worry about that at all. It's just gonna pay that flat rate benefit, so it's not going to matter where he goes.
[AGENT][NEUTRAL] So let's see what we have here or.
[AGENT][NEUTRAL] Trying to find a speed schedule here.
[CUSTOMER][NEUTRAL] So do you use like Medicare allowables or?
[AGENT][NEUTRAL] Well, it's um
[AGENT][NEUTRAL] No, we don't. Uh, what we do is we just, um, so let's, let's look at the, the, uh, the surgical benefit, OK?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Surgery in a hospital, outpatient facility, or in a physician's office.
[AGENT][NEUTRAL] We're only gonna pay $250 per day for one day for one calendar year. It's a flat rate benefit. And, and again, just a verification, I guarantee a payment, but there, but there's no, there's no deductible, no co-payment, no coinsurance. It's just a flat rate benefit. So however much his colonoscopy is, it doesn't matter where he goes, what physician he sees, it's just gonna pay that $250.
[CUSTOMER][NEUTRAL] And anything other than that, would the claim flat out be denied if it were sent in or would some of that be applied as patient responsibility?
[AGENT][NEUTRAL] Well, it's, it's, uh, I can't really tell you that it's patient responsibility. The only thing I can tell you is that, that.
[AGENT][NEUTRAL] Our contractual obligation will be met with that payment. Now, because this is just a flat rate benefit, a limited benefit policy, it's very possible that [PII] has another policy to go along with this because this is not major medical. This isn't a supplement plan, all it is is it just pays a very limited benefit for for the services that are covered.
[CUSTOMER][NEUTRAL] OK, I'm not showing another one, so yeah, so they must not have sent in all of the insurance.
[AGENT][NEUTRAL] So, yeah, I would certainly ask him because um that's the most of this, it'll, it'll pay that, that benefit that we, we talked about for the uh office uh and then what the benefit for that, that limited benefit for the surgery and anything above and beyond that, um, you know, we, we won't pay.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, hold on just a second for me, OK?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] So for, so we be, we're an ambulatory surgery center and we're outpatient and we build facility professional and anesthesia when it comes to the colonoscopy.
[CUSTOMER][NEUTRAL] The $250 would that be for each of those or would that be the total amount for all three entities that you all would pay?
[AGENT][NEUTRAL] Uh, the, um,
[AGENT][NEUTRAL] The $250 is going to be just for his, uh, just for that surgery. Um, so that the, uh, there is a, a benefit for um
[AGENT][NEUTRAL] Uh,
[AGENT][NEUTRAL] The anesthesia. Just let me check that. And so it's not gonna be in the physician's office, it's gonna be in a, in a, uh, in the ambulatory surgery center, is that correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Because the benefit is different. OK, so let me, let me pull it up again and then we can go over that.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, I'm just waiting for this to pop up here.
[AGENT][NEUTRAL] Yeah, it's, it pays differently. Uh, it pays more if you're in a, uh, OK, so the uh surgery in an outpatient facility, that's $500 per day with a maximum of 1 per calendar year. And again, I just have to say it, just a verification, not going to your payment. Now, the um uh uh anesthesia, um.
[AGENT][NEUTRAL] I don't show that there is uh an anesthesia uh benefit. Uh, sometimes they have one, sometimes they don't. I'm not showing one here. um, so it, it doesn't look like there is. I'm just gonna, I'm still checking. Just let me see here.
[AGENT][NEUTRAL] OK, so it doesn't mention anesthesia at all. Um, so it's, we're just talking about the surgery and so, um, I realized that there are different, different charges involved with the surgery. It's, it's just going to pay that, that, uh, $500 and that's it. That's for everything.
[CUSTOMER][NEUTRAL] OK, bottom line $500 no matter what, that's all.
[AGENT][NEUTRAL] So, uh, if he had
[AGENT][POSITIVE] That is exactly right. No matter what. That is correct, yeah.
[AGENT][NEUTRAL] And we're still looking at an office.
[CUSTOMER][NEUTRAL] Whichever claim you receive first you would apply the $500 too, OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm. That's exactly it. And we'd still pay that $50 for the office visit if if that if that is being charged as well.
[CUSTOMER][NEUTRAL] So would the risk be patient responsibility or would it be an adjustment?
[AGENT][NEUTRAL] Well, we're not going to adjust it. So it's, you're very likely want to get in touch with the, with the insured regarding that and to see if he has another insurance. But, but like I said, our contractual obligation is just this. So, um, it's not an adjustment, it's just a limited benefits.
[CUSTOMER][NEUTRAL] Because we're a network
[AGENT][NEUTRAL] It's just the, the bottom line, the flat rate that we're going to pay, so it's not an adjustment, it's not, uh, you know, because you're in or out of network or anything like that. It's just that it's, it's only going to pay this amount no matter what.
[CUSTOMER][NEUTRAL] OK, can I get a, um, let's see, can I get a call reference please?
[AGENT][NEUTRAL] My name is [PII]. The first letter of my last name is [PII], and we're gonna use that in today's date as a reference. Is there anything else at all that I can help with?
[CUSTOMER][POSITIVE] No, I think we're good thank you.
[AGENT][POSITIVE] OK, thank you for contacting API have a good day.