AccountId: 011433970860
ContactId: c8565f3b-0e5b-468e-80db-17c112e94480
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 431279 ms
Total Talk Time (AGENT): 146410 ms
Total Talk Time (CUSTOMER): 161471 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/c8565f3b-0e5b-468e-80db-17c112e94480_20250103T13:58_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hi, can you hear me OK?
[AGENT][POSITIVE] Yes, I can.
[CUSTOMER][NEUTRAL] Hello. OK, so, um, I'm getting treatment here at uh U Health in [PII] and it requires a CT scan every 90 days.
[CUSTOMER][NEUTRAL] And um they're gonna do this one at 84 days instead of 90 just because it falls on the schedule that way but I think that my coverage only permits uh.
[CUSTOMER][NEUTRAL] Payment of things of of for the same cause if it's separated by 90 days.
[AGENT][NEUTRAL] OK, so what is your name and your policy number and I can check that for you.
[CUSTOMER][NEUTRAL] Hold on.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Z A Y D N [PII].
[AGENT][NEUTRAL] What's your policy number, [PII]?
[CUSTOMER][NEUTRAL] Oh, I don't have it. Can you look it up by the phone number?
[AGENT][NEUTRAL] OK, and what's your social?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and what's a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure, [PII].
[AGENT][POSITIVE] OK, thank you, give me one moment.
[AGENT][NEUTRAL] And what type of policy do you have?
[CUSTOMER][NEUTRAL] Um, the card is blue, green, and white. It's supplemental too.
[AGENT][NEUTRAL] Mhm, what's the name of the policy on the card? Is that a Metlink policy?
[CUSTOMER][NEUTRAL] Yes, it is.
[AGENT][NEUTRAL] OK. Do you, do you have the card?
[CUSTOMER][NEUTRAL] Um, let me see if I can find it, OK?
[AGENT][NEUTRAL] OK, that's OK. What's your full, your uh mailing address?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you. I think I've located it.
[CUSTOMER][POSITIVE] Alright, I'm looking forward as well.
[CUSTOMER][NEGATIVE] I did find it, it's not a Met link oh it is Metlink.
[CUSTOMER][NEUTRAL] It says with [PII] assignment.
[AGENT][NEUTRAL] OK. Is it 225-3301?
[CUSTOMER][NEUTRAL] I had found the group number.
[CUSTOMER][NEUTRAL] 22, yes, it is.
[AGENT][NEUTRAL] OK, great. And give me your date of birth again.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, do you have an email address on file that you can verify?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, spell that, spell that out for me if you don't mind.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, so that's [PII], which is your [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII] Yeah.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] Yeah, I just wanna repeat it back to you to make sure I've written it down correctly.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] I, I didn't hear you. Please, one more time.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] That's correct.
[AGENT][POSITIVE] OK thanks.
[AGENT][NEUTRAL] OK, and I believe that you're referring to the outpatient benefit that's per occurrence.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me pull up your policy real quick.
[CUSTOMER][NEUTRAL] It's for
[CUSTOMER][NEUTRAL] Yeah, scanning and imaging.
[CUSTOMER][NEUTRAL] Let me.
[AGENT][NEUTRAL] So you are correct. Um, the outpatient benefit is up to $250 per covered person per occurrence.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And that is separated by 90 days.
[AGENT][NEUTRAL] Correct. If it's for the same or related condition.
[CUSTOMER][NEUTRAL] Yes, it is.
[AGENT][NEUTRAL] It has to be separated by.
[AGENT][NEUTRAL] 90 calendar days, that is correct.
[CUSTOMER][NEUTRAL] OK, so if it's 84 days they'll deny the claim?
[CUSTOMER][NEUTRAL] Do they ever make an exception?
[AGENT][NEUTRAL] It has to be 90, separated by 90, so yes, it would be denied.
[AGENT][NEUTRAL] If it's for the same or related condition.
[CUSTOMER][NEUTRAL] Well, what
[CUSTOMER][NEUTRAL] Yeah, what was the last payment that uh was made the claim that was actually processed and paid.
[AGENT][NEUTRAL] What is the condition?
[CUSTOMER][NEUTRAL] For the same one I had a scan on November it's for for yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I do I do.
[CUSTOMER][NEUTRAL] But yeah
[AGENT][NEUTRAL] OK, so it looks like your last service date was [PII].
[CUSTOMER][NEUTRAL] OK, was that covered?
[AGENT][NEGATIVE] No, we denied it because it was within the 90 days.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Prior to that, um, I'm showing a data service of [PII].
[AGENT][NEUTRAL] 24.
[CUSTOMER][NEUTRAL] Was that paid or denied?
[AGENT][NEUTRAL] Yeah, we did pay something on that. We pay the 250, which is your maximum outpatient benefit.
[CUSTOMER][NEUTRAL] OK, so December was denied because it was.
[CUSTOMER][NEUTRAL] How many days apart was that?
[AGENT][NEUTRAL] So [PII] and then we received a claim for date of service [PII].
[CUSTOMER][NEUTRAL] Oh, because it was less than 90 days, it was 84 days again.
[AGENT][POSITIVE] Correct, correct.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] We can is there any way maybe they'll to to ask and make an exception or to file up is there anything that they might do on it?
[AGENT][NEUTRAL] No, that's per, that's per your policy. No exception can be made.
[AGENT][NEUTRAL] Because it's per your policy?
[CUSTOMER][NEUTRAL] September [PII] [PII].
[CUSTOMER][NEUTRAL] When was the last scan? It was [PII].
[CUSTOMER][NEUTRAL] So since that was denied, I can get one in February and it's not gonna get denied, in other words.
[AGENT][NEUTRAL] Correct, because it's beyond 90 days from [PII].
[CUSTOMER][POSITIVE] OK, alright, uh, thank you. I, I understand that. OK, thank you.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] OK, all right. Any other questions [PII] I could help out with today?
[CUSTOMER][POSITIVE] No, that was it. Thank you.
[AGENT][POSITIVE] OK, thank you for calling APL have a good day.