AccountId: 011433970860
ContactId: dbc31c27-3d6b-4437-b408-fd03cb2235b2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 418299 ms
Total Talk Time (AGENT): 154097 ms
Total Talk Time (CUSTOMER): 152712 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/02/dbc31c27-3d6b-4437-b408-fd03cb2235b2_20250402T12:54_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] [PII], hey, this is [PII] calling by Augusta Surgical Group. I just need to verify this patient's benefits and eligibility on her APL plan.
[AGENT][NEUTRAL] OK, I can help with that, [PII]. What is your callback number please?
[CUSTOMER][NEUTRAL] Um, it's [PII] and my direct extension is [PII].
[AGENT][POSITIVE] Thank you very much. What is the policy number please?
[CUSTOMER][NEUTRAL] Um, policy number is, um, there's a policy slash cert number and then there's a medical ID number. Do you need the policy or the medical?
[AGENT][POSITIVE] Uh, policy, thank you.
[CUSTOMER][NEUTRAL] Um, policy, OK, uh, 02311714.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Um, yes, her name is [PII] and last name is [PII] Date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you very much for that information, [PII]. You're calling to verify eligibility and benefits. Give me one moment please.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And I'm so sorry this policy shows that it termed as of [PII]. Um, if you would bear with me, let me check to see if there's an active policy, please. One moment, thank you.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] [PII] of
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] T
[AGENT][POSITIVE] OK, and thank you so much for your patience. Um, it showed that the member does have an active policy.
[AGENT][NEUTRAL] And let me provide that policy number to you, please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, it is 2586493.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this policy shows as effective as of [PII] and it currently shows as active.
[AGENT][NEUTRAL] And what benefit would this be for please?
[CUSTOMER][NEUTRAL] Um, medical office benefit and we're a specialist group.
[AGENT][NEUTRAL] O
[AGENT][POSITIVE] OK, yes ma'am thank you one moment.
[AGENT][NEUTRAL] OK. Please note verification of benefits provided does not guarantee payment. We pay up to the benefit of $75 max for the visit that could be with the PCP or specialist. Again, we will pay $75 for the visit.
[CUSTOMER][NEUTRAL] So it's 75 not 35?
[AGENT][NEUTRAL] Yes, ma'am, $75.
[CUSTOMER][NEUTRAL] $300. OK, maximum paid toward a visit. OK, paid to visit.
[AGENT][NEUTRAL] Yes ma'am, and the member is allowed 5 visits per year.
[CUSTOMER][NEUTRAL] and how
[CUSTOMER][NEUTRAL] OK, 5 visits per year. Has she used all those 5 up yet?
[AGENT][NEUTRAL] Let me check.
[CUSTOMER][NEUTRAL] per year.
[AGENT][NEUTRAL] Excuse me.
[AGENT][NEUTRAL] Currently she has not.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] So she still has all 5 left or
[AGENT][NEUTRAL] I'm currently it shows that she has 5 left currently.
[CUSTOMER][NEUTRAL] So 5 left. OK, so 5 left. OK. And does she have any sur, OK, currently, OK, and does she have any surgical benefits on this plan or is it just limited to office only?
[AGENT][NEUTRAL] Currently.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] Uh, she does have surgical benefits. Um, give me one moment.
[AGENT][NEUTRAL] Let me get that for you.
[AGENT][NEUTRAL] bear with me please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, the surgical benefit rates we will pay up to $2000 for the calendar year.
[AGENT][NEUTRAL] And that's surgery and anesthesia. So that combination we pay up to $2000 for the calendar year and if you like, I can check to see what has been used towards that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, give me 1 2nd.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, currently she has used $99.75.
[CUSTOMER][NEUTRAL] That that's been met or remaining.
[AGENT][NEUTRAL] That has been used.
[CUSTOMER][NEUTRAL] Used OK. U. OK, 15 minutes. OK, alright. And um when you say it um covers surgery and anesthesia, is surgery means the surgeon or the facility or either or whichever claim hits first, I guess.
[AGENT][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] If, if the surgery, it does not, she doesn't have any outpatient facility benefits. It covers the surgery, surgeon and the anesthesiologist.
[CUSTOMER][NEUTRAL] Sergeant, OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] Facility benefits.
[CUSTOMER][NEUTRAL] Ok, no outpatient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, surgery and um OK and.
[CUSTOMER][NEUTRAL] Do we still submit the claims to the IMA being it's a different policy number or is that still the same policy but just a different ID number?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] It would be sent to the same, yes ma'am, same uh IMA.
[CUSTOMER][NEUTRAL] Same
[CUSTOMER][NEUTRAL] Same IMA right, and this policy being it's a limited benefit plan, it doesn't require any referrals or for a visit in the office, does it?
[AGENT][NEGATIVE] No, ma'am, it does not.
[CUSTOMER][NEUTRAL] No referrals required, OK.
[CUSTOMER][POSITIVE] Alright, that should cover everything I need, and if I can just get a call reference from my Miss [PII] today for today.
[AGENT][NEUTRAL] OK, we do not use call reference numbers. You can use my name and today's date. My last initial is [PII].
[CUSTOMER][POSITIVE] OK, well thank you again for all your help today.
[AGENT][POSITIVE] You're welcome, Miss [PII], and thank you for calling APL. You have a great week.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][POSITIVE] You too, thank you so much bye bye.
[AGENT][NEUTRAL] Yes, ma'am, bye.