AccountId: 011433970860
ContactId: c167a42f-610b-4b39-903f-d72c90bba403
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 398880 ms
Total Talk Time (AGENT): 164694 ms
Total Talk Time (CUSTOMER): 206813 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/c167a42f-610b-4b39-903f-d72c90bba403_20250121T15:14_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] at Doctor [PII]'s office. Um, I need benefits on this policy, please.
[AGENT][NEUTRAL] OK, may I please have a callback number?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] And may I have the policy number?
[CUSTOMER][NEUTRAL] 02152694 ML 8.
[AGENT][NEUTRAL] May I have the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yes, it's [PII], uh [PII].
[AGENT][POSITIVE] And thank you so much [PII] for verifying the policy. You're calling in for benefits. Is there a specific benefit that you're calling in for?
[CUSTOMER][NEUTRAL] Well, um, patients coming in, the patient had surgery, uh, and now it's a follow-up, but I never knew he had American public life. It's in there, but I don't know the benefits on that.
[AGENT][NEUTRAL] OK. Is this
[CUSTOMER][NEUTRAL] This is a follow up from surgery, yeah.
[AGENT][NEUTRAL] OK, so this is an office setting?
[CUSTOMER][NEUTRAL] Yes, it's an offices he had surgery uh in January on the left knee.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But I don't know if they have any benefits for this year [PII].
[AGENT][NEUTRAL] OK, so he had surgery January of this year or January of last year?
[CUSTOMER][NEUTRAL] Last year, hon. Uh, let me see, appointment. Let me see. Surgery was, yeah, yeah, I can't deal with this sometimes. Uh, let's see. Surgery was [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And that was inpatient or outpatient surgery?
[CUSTOMER][NEUTRAL] I was outpatient, outpatient.
[AGENT][NEUTRAL] OK, I can give you the benefits for this year and last year if that would, that would work.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, uh, this year is fine time.
[AGENT][NEUTRAL] It's just, OK, OK, I'm pulling that up for you now.
[AGENT][NEUTRAL] And will the office visit be billed as well or just?
[CUSTOMER][NEUTRAL] I'm, I'm, I'm just looking at right now uh benefits for an office visit. How does the office visit, yeah, OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, and verification of coverage does not guarantee the payment of the claim.
[AGENT][NEUTRAL] For this policy for the office visit fee, the member does not have that benefit for that co-pay for the visit, but if a procedure or testing or anything is rendered within an office setting, the member has up to $3000 per calendar year in which that will go towards the primary insurance deductible, co-insurance, or co-pay for the procedure.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Oh, OK. So if we do an X-ray.
[CUSTOMER][NEUTRAL] On this patient, I'm just saying, uh, would the X-ray be part of that $3000 deductible?
[AGENT][NEUTRAL] Yes, we just don't cover the office visit fee.
[CUSTOMER][NEUTRAL] Office, OK. So, X-rays they have a benefit of $3000 and that'll pay the deductible and co-insurance, correct?
[AGENT][NEUTRAL] Or the copay, whichever amount that is applied to the member's responsibility.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. I got it, yeah, because his primary insurance this year does have a $3000 deductible. We're probably not gonna bill in any because it's a follow up, but I just need to know the benefits. Um, so would this cover surgery, uh, DME, and physical therapy?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me check that for you.
[AGENT][NEUTRAL] And the surgery is rendered in outpatient facility?
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Outpatient, outpatient, yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So for this member they do have the DME benefits and the outpatient benefits. Now with this policy just to let you know that it does just cover sickness or injury, it will not cover any type of preventative or wellness but for outpatient, the member does have up to that $3000 as well for that calendar year and the DME as well.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, so in other words, it's accident.
[AGENT][NEUTRAL] It's, it's, it's injury, it's gonna be like sickness or injury. So it's not just it's not an accident policy.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Oh, OK. So it's, OK, so it's injury. OK. Oh, so it's
[AGENT][NEUTRAL] We just don't cover anything for preventative or wellness.
[CUSTOMER][NEUTRAL] OK, injury and sickness. OK, so that means
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] That if we do physical therapy on this patient, it will cover up to $3000.
[AGENT][NEUTRAL] Yes, that's the maximum that the member has.
[CUSTOMER][NEUTRAL] Right, right, right, and, and I'll pay $100 I'll pay up to $3000. Do we need authorization for physical? No, OK.
[AGENT][NEUTRAL] No authors required through us if you would get that from the primary if need be.
[CUSTOMER][NEUTRAL] Oh, OK. All right. What's the effective date of this policy?
[AGENT][NEUTRAL] It is showing that the effective date is [PII].
[CUSTOMER][NEUTRAL] [PII], and it's active. Now, here's another question. So for the year [PII], these are the benefits for [PII], because I'm sure he used up the benefits for [PII] when he had his surgery, is that correct?
[AGENT][NEUTRAL] Let me check that for you.
[CUSTOMER][POSITIVE] Thanks, honey.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] So I do see that the member did use their maximum benefits for the year of [PII].
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, so then this benefit is for [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Oh, benefits. Oh, great.
[CUSTOMER][NEUTRAL] 20, yeah, because in in case we do an X-ray, we will gonna collect like $25 for the X-ray, but we shouldn't because this $3000 is part of that.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] It's just it is based off of the primary, so as long as we get that EOB saying that it will apply to the member's deductible coinsurance or co-pay.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] I got you.
[CUSTOMER][NEUTRAL] Oh, OK. OK. And what is your name, please?
[AGENT][NEUTRAL] It is [PII]. Would you like for me to spell that for you?
[CUSTOMER][POSITIVE] Yes, yes, yes, please.
[AGENT][NEUTRAL] It is spelled [PII] and today's date will be the call reference.
[CUSTOMER][POSITIVE] Thank you very much. Have a wonderful day. Thank you.
[AGENT][POSITIVE] You're welcome, thank you for calling American Public Life.