AccountId: 011433970860
ContactId: c50d8b33-cf65-4871-9705-b2c1e1258897
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 641119 ms
Total Talk Time (AGENT): 381944 ms
Total Talk Time (CUSTOMER): 148223 ms
Interruptions: 4
Overall Sentiment: AGENT=0.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/30/c50d8b33-cf65-4871-9705-b2c1e1258897_20250130T17:29_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Uh, what providers I'd like to check if my providers participating with the patient's plan.
[AGENT][NEUTRAL] OK, so you need um eligibility information, is that correct?
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] If the provider is par participating.
[AGENT][NEUTRAL] Part participating, OK, got you.
[AGENT][NEUTRAL] OK, can I have your name please?
[CUSTOMER][NEUTRAL] My name is [PII]. It's [PII]
[AGENT][NEUTRAL] And can I have a callback number, [PII] just in case we get disconnected please.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And can I have the name of the facility or provider you're calling from, please?
[CUSTOMER][NEUTRAL] I hold that's a the choice of the mallet.
[AGENT][NEUTRAL] And what's the policy certificate or member ID please?
[CUSTOMER][NEUTRAL] Policy 02592661.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And you didn't need to obtain any benefits or eligibility you're looking to see which uh plan the uh member participates with, is that right?
[CUSTOMER][NEUTRAL] I wanna check if the provider is participating.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] In the members.
[AGENT][NEUTRAL] OK, just give me one moment, go ahead and verify patient's name and date of birth.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK [PII], just, just, um, just so you know there's a verification of coverage only, not a guarantee of payment so the policy, um.
[AGENT][NEUTRAL] That's active for [PII] with us is a limited medical hospital indemnity plan.
[AGENT][NEUTRAL] Um, so it does not have any kind of, uh, network participation. It is an indemnity plan, so it's not like a major medical plan.
[CUSTOMER][NEUTRAL] So what, what, what does it cover?
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] It only goes hospital services.
[AGENT][NEUTRAL] Uh, let me check and see.
[AGENT][NEUTRAL] Uh, what type of service are you needing to verify for?
[CUSTOMER][NEUTRAL] In office provider.
[AGENT][NEUTRAL] Like an office visit?
[CUSTOMER][NEUTRAL] Uh, therapy.
[AGENT][NEUTRAL] And what kind of therapy?
[CUSTOMER][NEUTRAL] Just give me a moment, sorry, I have uh.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I just know that.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, he's a behavioral health sorry, he's a behavioral doctor.
[AGENT][NEUTRAL] Pardon me?
[CUSTOMER][NEUTRAL] Behavioral.
[AGENT][NEUTRAL] Behavioral health OK and is it an office setting?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Sure, OK, OK, so this policy again, it's limited Medical Hospital indemnity. It does have some additional benefits in addition to the hospitalization and confinement. Um, they do have a wellness and diagnostic testing benefit rider on this plan and the outpatient sickness benefit rider, um, which would cover the patient in the event of, uh, services that are provided in a physician's office, urgent care.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] The
[AGENT][NEUTRAL] A clinic or uh emergency room. They're allowed up to 5 visits per person.
[AGENT][NEUTRAL] Per calendar year.
[AGENT][NEUTRAL] At $75 so it's payable at $75 per visit up to 5 visits.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] For for uh behavioral health provider also or that's all.
[AGENT][NEUTRAL] Now
[AGENT][NEUTRAL] Well, it would be, if it's considered a sickness, um, so in other words, if this, as long as the diagnosis is not an accident and it is not an organic, um, just give me one moment on that mental health and I'll read that to you.
[AGENT][NEUTRAL] Um, also, do you know if your facility participates or your provider, uh, provider's office, do you participate with, uh, multi-plan?
[CUSTOMER][NEUTRAL] I'm not sure that depends on if if the provider participates in multi plan, then APO play the claim. It depends on the participation of multi plan.
[AGENT][NEUTRAL] It does not um what what their card does recommend that they use multi plan providers that may offer them greater savings because this is not a comprehensive major medical plan. It is limited hospital indemnity, so they are encouraged to use the multi plan provider and again in hopes that they could have a greater savings if they're using a multi plan provider as opposed to.
[CUSTOMER][NEUTRAL] Is it provided there's a multiple that's a greater.
[AGENT][NEUTRAL] It should be on their ID card, yes, on their ID card it directs them to use multi uh to search for providers that participate with multi plan again because this is not comprehensive coverage.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, we'll have to um check with multiline further to participate.
[AGENT][NEUTRAL] OK and then um as far as the uh just give me one moment to look at that behavioral health so do you um.
[AGENT][NEUTRAL] Just one moment please.
[AGENT][NEUTRAL] OK, so the um the stipulation under the mental health is that, that it needs to be uh.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Just one moment.
[AGENT][NEUTRAL] That was for the hospitalization just so um it does cover uh some services for mental health as far as the diagnosis. Like I said, as long as it is not um
[AGENT][NEUTRAL] Uh, an illness, uh, I'm sorry, an accident diagnosis. So, um,
[AGENT][NEUTRAL] It will cover uh for.
[AGENT][NEUTRAL] Uh, diagnostic and uh psych psychiatric illnesses such as bipolar disorders, depression, major depressive orders, obsessive compulsive disorders, paranoid or schizophrenic, uh, I'm sorry, psychiatric disorders, and schizophrenic, uh, affective disorders as well as schizophrenia.
[CUSTOMER][NEUTRAL] So again, so it will cover these disorders if if it's not, it will cover any disorders if it except if it's an accident diagnosis.
[AGENT][NEUTRAL] Right, yeah, it's not a, as long as it, so this policy again, it's an outpatient sickness benefit rider. So as long as the condition meets the, uh, you know, meets that illness, it should, it will be covered as long as, again, it's the, the, uh, place of service is a physician's office or urgent care emergency room or clinic. So as long as it's not an accidental diagnosis and it does, uh, again that uh that uh
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] That uh condition is considered an illness or a sickness.
[CUSTOMER][NEUTRAL] So if the condition is an illness or sickness then it's covered.
[AGENT][NEUTRAL] Right then it's covered, yes, and it has to again be in those settings so it's outpatient hospital or that type of facility it will not be covered again this policy is uh.
[CUSTOMER][NEUTRAL] But I'm talking about a physician's office actually.
[AGENT][NEUTRAL] Yeah, mhm. So that physician's office as long as this place of service is a physician office, and again that condition is considered a illness or sickness and not an accident.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so it doesn't so it doesn't depend on any uh like the provider does not need to be participating with the insurance.
[AGENT][NEUTRAL] Right, because it is, yes, it doesn't have to be participating because again this is not a major medical plan, it does not have a network again they're encouraged to use right the multi plan, right, yeah, mhm, yeah, there is no network.
[CUSTOMER][NEUTRAL] So if so the divide doesn't be credential.
[CUSTOMER][NEUTRAL] So as long as the patient just has an illness or sickness, uh, and it's a physician office.
[AGENT][POSITIVE] Right, mhm, is in his office. That's correct.
[CUSTOMER][NEUTRAL] And does the patient have any responsibility of copay or car insurance or deductible or something?
[AGENT][NEUTRAL] Um, well, there is no co-insurance or deductible for this plan. Again, if the if the, uh, service is, uh, covered under the outpatient sickness benefit rider we'll pay that straight benefit payment of $75 and again that's up to 5 visits. So there is no copay or deductible, right? It's a right, $75 is the most, the maximum we can pay. That's right.
[CUSTOMER][NEUTRAL] Oh, so the patient is $75 for any visit?
[AGENT][POSITIVE] It's a, it's a benefit, right.
[CUSTOMER][NEUTRAL] Is the maximum you can pay and 5 visits per rolling year.
[AGENT][NEUTRAL] Up to 5 visits, right.
[CUSTOMER][NEUTRAL] Rolling your accounting.
[AGENT][NEUTRAL] Pardon me?
[CUSTOMER][NEUTRAL] 5 inches for how long?
[CUSTOMER][NEUTRAL] A calendar year?
[AGENT][NEUTRAL] But for the calendar year, yes.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] So it's a $75 payable benefit they're allowed up to 5 visits per person per calendar year.
[CUSTOMER][NEUTRAL] OK, and what's the.
[CUSTOMER][NEUTRAL] Address where we send back on.
[AGENT][NEUTRAL] OK, those claims will be addressed to IMA.
[CUSTOMER][NEUTRAL] That's the [PII]?
[AGENT][NEUTRAL] That's correct in [PII] and payer ID 64556.
[CUSTOMER][NEUTRAL] Yeah,
[CUSTOMER][NEUTRAL] Yes, OK, uh, can I get a reference number?
[AGENT][NEUTRAL] Certainly the call reference number is my name in today's date and my first name is R0.
[CUSTOMER][NEUTRAL] What's your name?
[AGENT][NEUTRAL] X Y.
[AGENT][NEUTRAL] Last initial L like love. So my name and today is state is your call reference number. Did you have any other questions, [PII]?
[CUSTOMER][POSITIVE] Uh thank you, thank you so much for your help and have a good day.
[AGENT][POSITIVE] You too, thank you for calling API. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Bye.