AccountId: 011433970860
ContactId: d399886f-56e0-4bcb-95fb-67475a97a587
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 640340 ms
Total Talk Time (AGENT): 234897 ms
Total Talk Time (CUSTOMER): 208581 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/10/d399886f-56e0-4bcb-95fb-67475a97a587_20250210T21:39_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII] with Northwest Neurobehavioral Health. I'm calling because I'm needing to verify uh and get benefits information for a uh respective patient.
[AGENT][NEUTRAL] All right, [PII] Happy to check on benefits. What is the patient's policy number?
[CUSTOMER][NEUTRAL] Uh, yes, the policy number is 02584657.
[AGENT][POSITIVE] All right, thank you so much. Let me pull that up.
[AGENT][NEUTRAL] And if I could get patient's name and date of birth?
[CUSTOMER][NEGATIVE] Yes, it's [PII], and I'm gonna mispronounce this, [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh [PII], and date of birth is [PII].
[AGENT][POSITIVE] All right, thank you so much. And we're looking for medical coverage, correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK. So member does it looks like have an active medical plan with us. The effective date is [PII]. It is a different policy number. The one they gave you is a dental, not medical.
[CUSTOMER][NEUTRAL] OK. Am I able to get that medical one then?
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] Absolutely.
[AGENT][NEUTRAL] So the uh medical policy number is 02584655.
[CUSTOMER][NEUTRAL] OK, I'm just gonna repeat that to make sure. 02584655.
[AGENT][NEUTRAL] Mhm, that's correct, [PII].
[CUSTOMER][POSITIVE] OK, perfect. You know, it's a surprise how many times I get dental cards instead of medical cards even though we ask for medical ones.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Huh
[CUSTOMER][POSITIVE] All right. Well, thank you for that. Um,
[CUSTOMER][NEUTRAL] OK, yeah, so I will need uh the.
[CUSTOMER][NEUTRAL] Accumulators, of course, and then uh with medical specifically I'm leaving the office and specialist outpatient visit, uh, and rehabilitation, specifically occupational and speech if they're separated.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and is behavioral health included in medical or is that separate in the plans?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, let me take a look here.
[AGENT][NEUTRAL] Mhm. So the patient has what we call a limited benefit plan. It's a hospital indemnity plan, so it's gonna pay just like a set amount.
[AGENT][NEUTRAL] Uh, depending upon what the patient's being seen for. So let's see.
[AGENT][NEUTRAL] As far as like an office visit goes, the patient is allowed 5 a calendar year.
[AGENT][NEUTRAL] And the benefit payment for the office visit is $75 a visit.
[AGENT][NEUTRAL] And let's see we're looking for any sort of.
[AGENT][NEUTRAL] Inpatient, let's see.
[AGENT][NEUTRAL] So it does have like an inpatient and hospital benefit. However, it does say that the term hospital should not be included for any institution.
[AGENT][NEUTRAL] Used by the person as a place of rehabilitation, place of rest, nursing, convalescent home.
[AGENT][NEUTRAL] So I'm not certain that what the patient's needing to be seen for doesn't sound like it might not be covered under that.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, OK, uh, is there coverage for outpatient office?
[AGENT][NEUTRAL] Yeah, so the outpatient like office visit benefit is $75 per visit. So the plan pays just $75 towards the visit. There's no deductible co-pay or anything like that on this.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] There's, OK, so there's no deductible.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Hm, so as far as the rehab, it doesn't list anything besides just the.
[CUSTOMER][NEUTRAL] Hospitalization or inpatient.
[AGENT][NEUTRAL] Yeah, it just says inpatients and like in hospital and under in hospital, it does say rehabilitation is not a covered benefit.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I don't think it would cover any portion of rehabilitation.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Um, what about, uh, like therapy visits? Is any of that covered?
[AGENT][NEUTRAL] Uh, let's see
[AGENT][NEUTRAL] Yeah, I don't show anything under the exclusions, so that would just fall under an office visit under outpatient.
[CUSTOMER][NEUTRAL] $100 is it?
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and the main one that's gonna be complicated potentially is um if there's coverage for diagnostic testing or not.
[AGENT][NEUTRAL] Uh, let's see.
[CUSTOMER][NEUTRAL] And if you, if you're able to look up uh based off of CPT codes I can provide those.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] So, the plan does cover wellness and diagnostic testing.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, it looks like the breakdown on it shows.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] The max it's gonna pay out is 500 and the minimum is 250. So it says diagnostic testing benefit per test. It looks like the benefit amount is $250 per test.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Did you need me to check on anything else for you, [PII]?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] That, oh, is our telehealth visits covered under the same 5 visits outpatient or are they not allowed?
[AGENT][NEUTRAL] Yeah, let's see here.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, I don't see telehealth in the exclusions or anything so I don't see.
[AGENT][NEGATIVE] That should be covered. I don't see why it wouldn't be.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's just hard to tell cause with the uh pandemic officially ending, a lot of places have been verifying the status, so just always have to check.
[AGENT][NEUTRAL] Oh, yeah.
[AGENT][POSITIVE] No worries.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And I did forget to ask with the diagnostic testing, does it require an authorization or no?
[AGENT][NEUTRAL] No pre-op is required, no.
[CUSTOMER][NEUTRAL] OK, perfect. And are there any specific exclusions such as uh like group therapy or anything like that for the plan?
[AGENT][NEUTRAL] Uh, let's see.
[AGENT][NEUTRAL] Not that I see on here, so yeah, I don't see any exclusions on that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Good to know. And then the last question is what is the timely filing limit for any claims?
[AGENT][NEGATIVE] Uh, no timely filing limit.
[CUSTOMER][NEUTRAL] No timely filing limit, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Perfect, I believe that that is.
[CUSTOMER][NEUTRAL] All of the questions that I have.
[AGENT][POSITIVE] OK, sounds good. You're welcome. You have a good rest of your day.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][POSITIVE] Thank you you too bye.
[AGENT][NEUTRAL] Bye-bye.