AccountId: 011433970860
ContactId: d6f89b23-c1ed-4356-9365-f3ca7830c581
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 735119 ms
Total Talk Time (AGENT): 276583 ms
Total Talk Time (CUSTOMER): 228789 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/11/d6f89b23-c1ed-4356-9365-f3ca7830c581_20250311T18:58_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII].
[CUSTOMER][NEUTRAL] I'm checking medical eligibility.
[CUSTOMER][NEUTRAL] For a patient
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All right, well, I can definitely help you with the eligibility. May I have your name and a good contact number?
[CUSTOMER][NEUTRAL] I'm [PII]. My last name starts with an [PII]
[CUSTOMER][NEUTRAL] My number is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Her OK, let me go back.
[CUSTOMER][NEUTRAL] Clothes.
[CUSTOMER][NEUTRAL] The ID number?
[AGENT][NEUTRAL] Yes, ma'am. It should start with a 0.
[CUSTOMER][NEUTRAL] Oh this this.
[CUSTOMER][NEUTRAL] 02495934
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], date of birth is [PII]. Do you need her social security number?
[AGENT][NEUTRAL] Uh, no, ma'am. Um, that was the policy number. So I'm in her policy and thank you for verifying. Um, so all the information provided is a verification of benefits, not a guarantee of payment. I am showing that the policy is active. It's been effective since [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And her deductibles.
[AGENT][NEUTRAL] Deductible, let me see if this policy has one. Hold on one moment.
[AGENT][NEUTRAL] Uh, so this is a hospital indemnity policy. So this policy doesn't have a deductible. It's just a list of covered charges and what we would apply to those services is a limited medical policy.
[CUSTOMER][NEUTRAL] OK, so is it a co-insurance on there?
[AGENT][NEUTRAL] Um, no, ma'am.
[CUSTOMER][NEUTRAL] So what's on there?
[AGENT][NEUTRAL] So for like example, there's a daily hospital confinement benefit. So if she's in the hospital, we will pay up to $100 per day. Um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] If there's an admission that turns into a confinement, um, or, or the first occurrence confinement, the policy will pay up to $1500 intensive care.
[AGENT][NEUTRAL] We would pay up to $400 and then um
[AGENT][NEUTRAL] There's an outpatient sickness rider, wellness and diagnosis, so it's not like a major insurance, it's just a list of services that we would pay towards.
[CUSTOMER][NEUTRAL] OK, so the outpatient, that's the one I'm looking for. So is it a 20, 10% on the outpatient?
[CUSTOMER][NEUTRAL] Co-insurance
[AGENT][NEUTRAL] 10% on the hold on one second.
[AGENT][NEUTRAL] Let me pull up the benefits. Do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] No, that's fine.
[AGENT][NEUTRAL] Alright, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Mhm, I'm here.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So for the outpatient um benefits, it's up to $75 per visit. The policy would pay up to 5 times per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, it is a procedure.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] An injection
[CUSTOMER][NEUTRAL] So would that be considered um like a 10%?
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Co-insurance, do you show anything like that?
[AGENT][NEUTRAL] If it's a proced like a surgical procedure?
[CUSTOMER][NEUTRAL] Um, they don't really, it's imaging, it's really, um, nuclear imaging.
[CUSTOMER][NEUTRAL] It's really not a
[AGENT][NEUTRAL] Is it in office?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] It's um it's in the hospital, it's called outpatient. So it's not in a doctor's office, it's an outpatient.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. So the outpatient sickness rider wouldn't really help cause that's
[CUSTOMER][NEUTRAL] At the hospital.
[AGENT][NEUTRAL] That's like an office visit or ER or urgent care, like a visit, um.
[CUSTOMER][NEUTRAL] Mhm, yeah, and, and this is just considered an outpatient.
[AGENT][NEUTRAL] Procedure.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, not like a visit to an urgent care or a physician office, like a visit, not a procedure. So there really wouldn't be, let me see if there.
[CUSTOMER][NEUTRAL] It would be, yeah, it's just that.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] There is like a list of different like surgeries that will be covered under the policy, but
[AGENT][NEUTRAL] Is this considered like a
[CUSTOMER][NEUTRAL] Like what?
[AGENT][NEUTRAL] Like a hysterectomy.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Circumcisions, it's broken down into body parts.
[AGENT][NEUTRAL] Um, so that's the nuclear, go ahead.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] It's like a um a stress test.
[CUSTOMER][NEUTRAL] More like a stress test. Do you see any um
[CUSTOMER][NEUTRAL] Anything on her like that?
[AGENT][NEUTRAL] Mhm. So this so because the pilot.
[CUSTOMER][NEUTRAL] Uh, let me go back let me go back to the.
[CUSTOMER][NEUTRAL] Let me go back to uh.
[CUSTOMER][NEUTRAL] Well, so you don't have CPT codes or anything. It's like imaging. Do you have anything on there like uh
[AGENT][NEUTRAL] I understand what you're saying to me.
[AGENT][NEUTRAL] The policy just doesn't have any coverage for. This is a limited medical policy, so it's not like a Blue Cross Blue Shield or Cigna that covers tests like that. It just has like, um, an example of a test, this will cover, let me see, like a, like a wellness test or diagnostic testing, but like nuclear testing like
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's what this is, diagnostic.
[CUSTOMER][NEUTRAL] It would be diagnostic.
[AGENT][NEUTRAL] Well
[CUSTOMER][NEUTRAL] It would be considered diagnostic.
[AGENT][NEUTRAL] OK, so the best thing to do would be to just submit the information for us to process the claim.
[AGENT][NEUTRAL] What I'm trying to explain to you is this it.
[CUSTOMER][NEUTRAL] So what does it say for diagnostics?
[AGENT][NEUTRAL] That's what I was trying to explain to you. So it lists MRI, CT scan, and colonoscopy. So it's certain.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, test that this covers, nuclear testing is not one of them. It's just those three.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So what is the MRI?
[AGENT][NEUTRAL] An MRI like a, like the imaging test, like a
[CUSTOMER][NEUTRAL] No, no, no, yeah, how is it a co-insurance? It's a what is it?
[AGENT][NEUTRAL] The, what is the benefit?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one second, let me get it for you.
[AGENT][NEUTRAL] So for diagnostic tests in the policy would pay $250 per test.
[CUSTOMER][NEUTRAL] OK, OK, and then um let me see what else is on here.
[CUSTOMER][NEUTRAL] It's like a it's like a muscle image. So it would pay 200 and.
[AGENT][NEUTRAL] 50.
[CUSTOMER][NEUTRAL] I'm gonna put this in the file. 250.
[CUSTOMER][NEUTRAL] I'll put this in the files so they'll have it.
[AGENT][NEUTRAL] But it's only 250 towards those three types of tests.
[AGENT][NEUTRAL] Not any diagnostic tests, just those three.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And OK, so I'm gonna put this note in the file then.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] So we'll have it
[CUSTOMER][NEUTRAL] That it covers specific. So, are there any other testing that it would cover?
[AGENT][NEUTRAL] Uh, in terms of like.
[CUSTOMER][NEUTRAL] Oh, do they group it?
[CUSTOMER][NEUTRAL] Do they group it as imaging?
[AGENT][NEUTRAL] It's diagnostic testing and then it's a wellness exam or test.
[CUSTOMER][NEUTRAL] OK, so diagnostic I'm gonna put that in the file then. I'll put diagnostic testing.
[CUSTOMER][NEUTRAL] That it covers.
[CUSTOMER][NEUTRAL] And then I'll call and let her know.
[AGENT][NEUTRAL] Diagnostic testing, only MRI, CTs, and colonoscopy.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][POSITIVE] Sweet cheese in Collin.
[CUSTOMER][NEUTRAL] OK, I'm gonna put that in the file.
[CUSTOMER][POSITIVE] OK, that sounds great. So,
[CUSTOMER][NEUTRAL] [PII], and do I have a reference code? Do you guys give a reference code?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, so there's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] OK, will do. I'm gonna put all this in her account then and then I'll call her and let her know.
[AGENT][NEUTRAL] All right, well, was there anything else I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] No, I just have to verify that there is insurance and um in my system it says a 10% co-insurance.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] But you don't have a 10% co-insurance showing. It's just a flat 250 for uh those three particular uh tests, the MRI, the CT, and the colonoscopy. OK, sounds good. Colonoscopy.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] If it's uh annually, it's free, correct?
[CUSTOMER][NEUTRAL] That would be a wellness or your wellness is 250.
[AGENT][NEUTRAL] Mhm. So the colonoscopies, I'm not showing where it's free annually.
[AGENT][NEUTRAL] But the wellness testing, um, let me see if there's anything under wellness testing.
[AGENT][NEUTRAL] Um, a routine exam or preventative testing.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, that's all covered under wellness.
[CUSTOMER][NEUTRAL] Under Wellness, OK, that sounds good. I'll put a note in the file and then I'm gonna call her and let her know.
[AGENT][POSITIVE] Alrighty. Well, thank you so much for calling APO Ms. [PII]. I hope you have a great day.
[CUSTOMER][POSITIVE] Thank you. You as well. Bye now.
[AGENT][POSITIVE] Thank you. Bye bye.