AccountId: 011433970860
ContactId: cf557120-0ee4-4980-bf3c-4d884a59da12
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 416859 ms
Total Talk Time (AGENT): 228872 ms
Total Talk Time (CUSTOMER): 149576 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/cf557120-0ee4-4980-bf3c-4d884a59da12_20250428T17:23_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] I'd like to verify benefits and eligibility.
[AGENT][NEUTRAL] OK, yeah, I can check eligibility benefits for you. Uh, what was your name please?
[CUSTOMER][NEUTRAL] [PII] Would you repeat your name, please?
[AGENT][NEUTRAL] Sure, it's [PII] and [PII], can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you and then do you have that policy number?
[CUSTOMER][NEUTRAL] 02356134
[AGENT][NEUTRAL] OK, and what was the name and date of birth for the member, please?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Perfect, thank you for verifying that. Uh, so this policy is active. Effective date was [PII], and this is a secondary medical policy, so it is designed to help with co-pay, deductible and co-insurance after major medical pays, and are we needing to check, uh, inpatient or outpatient benefits.
[CUSTOMER][NEUTRAL] Outpatient mental health in an office setting.
[AGENT][NEUTRAL] OK, and of course I will let you know verification of coverage is not a guarantee of payment for claims. So for this policy office visits themselves are not going to be covered. However, treatment received in office could be, uh, the outpatient benefit is $1500 max per calendar year. If you'll give me one moment, I'll see if any of that has been used.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, none has been used before this year.
[CUSTOMER][NEUTRAL] OK, so you said that the office visit itself would not be covered, but she has a max of 1500. So how does that work? If she currently has a primary insurance.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Is that's for their outpatient benefits?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] OK, so if it's considered uh if it's an office visit, she won't have any coverage?
[AGENT][NEUTRAL] Correct, however, if she receives treatment in office, that could be. So for example, if she was seen just simply for like a consultation or something like that, uh, there would be no benefits payable.
[CUSTOMER][NEUTRAL] OK, so if she received any individual therapy or see a doctor, will you cover any of that?
[AGENT][NEUTRAL] If a treatment is received, so if she receives any sort of treatment like, you know, um X-rays or something like that, if it were simply a consultation, uh, and the only billable thing would be the visit itself, then that would not be covered.
[CUSTOMER][NEUTRAL] OK, you said if it was a consultation?
[AGENT][NEUTRAL] Right, just as an example, um, so if there was nothing else billable but the visit itself, then that would not be covered.
[CUSTOMER][NEUTRAL] OK, so you're stating that any type of therapy or seeing any type of physician, she would not be covered.
[AGENT][NEUTRAL] For that office visit, uh, correct, if it was just that.
[CUSTOMER][NEUTRAL] OK, could you verify um certain CPT codes to tell me if you will cover it or is it just based off of general benefits?
[AGENT][NEUTRAL] Right, so I don't have a way to check individual CPT codes. The only way to know 100% unfortunately is just to file the claim.
[CUSTOMER][NEUTRAL] OK, and depending on how the claim is processed, would you possibly cover 100% of it, or does it depend? Would you pay a certain percentage for each claim and to maximum is 1500 or how would that work?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, yes, so again it's uh to go towards, um, co-pay deductible and co-insurance until it reaches that $1500 calendar year maximum.
[CUSTOMER][NEUTRAL] OK, so she has a primary insurance and if it leaves her with a certain amount for her deductible, her first claim, if it is submitted to you all, you will cover it 100%.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Up to that $1500 yes, until it reaches that maximum, yes.
[CUSTOMER][NEUTRAL] 1500.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, um, so necessarily visit limits don't apply just that $1500 max.
[AGENT][POSITIVE] Correct, um, again, as there's, I'm sorry.
[CUSTOMER][NEUTRAL] There's no
[CUSTOMER][NEUTRAL] There's no specific visit limits. It's just until she maxed out that 1500, is that correct?
[AGENT][NEUTRAL] Correct, yes, as treatment received in office is the only thing that would be covered, uh, as far as um in office.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, are there any additional benefits on this policy like family benefits or is this just individual only with a $1500 max?
[AGENT][NEUTRAL] Um, so that is going to be per covered member, um, and she, let's see, there are two other members, so [PII], uh, her spouse is the prime or excuse me, the policy holder, and then there's a dependent, uh, [PII].
[AGENT][NEUTRAL] But that would be for each that 1500 each, yes.
[CUSTOMER][NEUTRAL] OK, so they have to.
[CUSTOMER][NEUTRAL] OK, OK, um.
[CUSTOMER][NEUTRAL] And I think that is it, and you stated that this is just for treatment only.
[AGENT][NEUTRAL] Yes, uh, as far as office visits are concerned, they do of course have other benefits such as, you know, hospital emergency room, diagnostic testing, um, outpatient treatment, and, uh, hospital facilities, but as far as in office, um, it's only going to be treatment received in office that would be covered.
[CUSTOMER][NEUTRAL] OK, so in regards to mental health benefits, particularly what type of treatment are you speaking of?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So mental health, that's one of those things that's a bit difficult is that such a, it's very broad and this policy is a little bit um kind of on the same way. So the only thing that I see particularly or specifically mentioning um mental health is outpatient treatment uh for a mental or emotional disorder, and that would be in a hospital outpatient facility. So that's the only thing specifying mental health. So again, if it was going to be something like therapy.
[CUSTOMER][NEUTRAL] With this policy.
[CUSTOMER][NEUTRAL] Right, right.
[AGENT][NEUTRAL] Um, that's not going to be a covered benefit under this policy.
[CUSTOMER][NEUTRAL] OK, so specifically for a hospital outpatient.
[AGENT][NEUTRAL] Right.
[CUSTOMER][POSITIVE] OK, OK, thank you so much, [PII], and a call reference number?
[AGENT][NEUTRAL] Yeah, of course.
[AGENT][NEUTRAL] That would just be my first name, last initial, and today's date and so my last initial is [PII] Did you have any other questions for me, [PII]?
[CUSTOMER][POSITIVE] No, that is all. Thank you.
[AGENT][POSITIVE] Alright, yeah, thanks for giving us a call. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][NEUTRAL] OK.