AccountId: 011433970860
ContactId: dd65ee3e-787c-4c0f-83ca-7f0a8d233f61
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 925440 ms
Total Talk Time (AGENT): 396144 ms
Total Talk Time (CUSTOMER): 382488 ms
Interruptions: 4
Overall Sentiment: AGENT=0, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/05/dd65ee3e-787c-4c0f-83ca-7f0a8d233f61_20250605T18:28_UTC.wav
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[AGENT][NEUTRAL] APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name's [PII]. I am with a provider's office and I'm trying to verify benefits for mental health services.
[AGENT][NEUTRAL] OK, let's take a look, [PII]. Do we have a policy or certificate number?
[CUSTOMER][NEUTRAL] Um, 02617356.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then I need to verify please the patient name and date of birth.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] All right, so that number that you gave me, [PII], that policy number, is their dental. Do you want the medical one?
[CUSTOMER][POSITIVE] Would love it thank you.
[AGENT][NEUTRAL] Yeah, no worries, uh, 02.
[CUSTOMER][NEUTRAL] I know I was, I saw dental on there and I was like, does this cover medical? I don't know.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] People just like to here just use this, you know, it's like OK.
[AGENT][NEUTRAL] Right, right, yeah.
[AGENT][NEUTRAL] All right, so it's uh
[CUSTOMER][NEUTRAL] OK, and I'm sorry, you said it was 02?
[AGENT][NEUTRAL] Yeah, and then 617-351.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, OK, so it's just the difference is the one on the end. 617351, OK.
[AGENT][NEUTRAL] Mhm, yeah.
[AGENT][NEUTRAL] Um, let's see here.
[AGENT][NEUTRAL] So the act or the effective date on here is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it's a limited benefit policy, so let me see what it says in regards to any sort of, there's anything in here for mental health.
[CUSTOMER][NEGATIVE] It looks like someone else called last month or something and it looks like it they wrote that it only pays $50 max for 4 visits.
[AGENT][NEUTRAL] OK, yeah, if it's gonna be like an office setting.
[CUSTOMER][NEUTRAL] Uh huh
[AGENT][NEUTRAL] OK. Yeah.
[CUSTOMER][NEUTRAL] But since they didn't change the policy number, I'm wondering if that's the dental or the medical.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So let me just see. So it does state on here, physician office visit, it's $50 per day, maximum of 4 days per calendar year per covered person.
[CUSTOMER][NEUTRAL] $50 max.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Per day
[CUSTOMER][NEUTRAL] 4 day max.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And that's for any provider, right?
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Um, it that would also include mental health or?
[AGENT][NEUTRAL] Yeah, so it just says um health examinations, diagnosis, and or treatment. And it says face to face contact between a physician and patient is not required. You can do telemedicine. So, yeah, it, it doesn't say anything. I'll check exclusions just to make sure if there's anything.
[CUSTOMER][NEUTRAL] Yeah, I just wonder when it comes, you know, to limited policies sometimes they don't cover it all, you know.
[AGENT][NEUTRAL] No, that's true, yeah. Let's see.
[CUSTOMER][NEUTRAL] And since you said that she's the she's the spouse on the policy, right?
[AGENT][NEUTRAL] Mhm, yeah.
[CUSTOMER][NEUTRAL] I see a [PII] is the policy holder.
[AGENT][NEUTRAL] Mhm, yeah, he's a sub subscriber, correct.
[AGENT][NEUTRAL] Um, OK.
[AGENT][NEUTRAL] So under exclusions, it does list serious mental illness without demonstratable organic disease. It does say alcohol and drug addiction treatment.
[AGENT][NEUTRAL] Those are the only things, excuse me, that I see under exclusions.
[CUSTOMER][NEUTRAL] Well, I guess it depends then what is her diagnosis?
[AGENT][NEUTRAL] Yeah, it would depend it may.
[CUSTOMER][NEUTRAL] We even have a diagnosis yet.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So uh I haven't given her one yet.
[CUSTOMER][NEUTRAL] So it excludes mental it OK excludes.
[CUSTOMER][NEUTRAL] Serious mental illness.
[AGENT][NEUTRAL] Right, it says it, yeah.
[CUSTOMER][NEUTRAL] Right diagnosis.
[AGENT][NEUTRAL] It's a serious mental illness without demonstratable organic disease.
[CUSTOMER][NEUTRAL] What does that mean?
[AGENT][NEUTRAL] That's what I was just thinking myself.
[AGENT][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] Demonstrate.
[CUSTOMER][NEUTRAL] You're making me have to spell demonstratable what?
[AGENT][NEUTRAL] Uh, let's see.
[CUSTOMER][POSITIVE] My English teacher would be laughing. You're telling her to spell demonstrable, OK.
[AGENT][NEUTRAL] Alright, organic disease.
[CUSTOMER][NEUTRAL] Organic.
[CUSTOMER][NEUTRAL] Disease. I'll write it down. I don't know what that means.
[CUSTOMER][POSITIVE] OK, I love it I love it, gotta love these limited policies I'm telling you.
[AGENT][NEGATIVE] I mean, and half the time, I'll be honest with you, [PII], when they call, they, they don't even know what they have, you know what I mean? Like.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, you gotta wonder how much they're paying per month for a policy that only pays a max of $50 for only limit of 4 visits per year. That's, I mean really.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I should try to look up some sorry ACA plans.
[AGENT][NEUTRAL] Yeah, it looks like, so it looks like that means basically a mental health condition that causes some sort of significant functional impairment. That's what they mean by that.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEGATIVE] Significant impairment, so like delusions or?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Or I guess if you had severe anxiety to the point where you couldn't drive or, you know, it's like impairing your, that's the way I'm understanding it, like day to day activities, you know.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, but they haven't even diagnosed her yet, so I can't even tell you what it is. Could be just depression, which would not fall into that.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You know,
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That's not considered um serious mental illness.
[CUSTOMER][NEUTRAL] But you know, schizophrenia or bipolar disorder is considered, you know, serious mental illness.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So yeah, I mean, I would just put that, you know, if the benefits are gonna pay, it looks like it's a max of the $50 per visit. It's, it's not gonna pay anything additional.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and do you have a filing deadline for claims?
[AGENT][NEUTRAL] No, we don't have a timely filing limit, and then I don't know if you need the payer ID or the mailing address.
[CUSTOMER][NEUTRAL] I do also to on uh does she have any RX coverage?
[AGENT][NEUTRAL] Mhm. It does actually have a bin number, group number and RX coverage. Let's see.
[CUSTOMER][NEUTRAL] Oh that's good because usually I mean it's like no you know they pay we might pay them back something, you know, OK.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] So these always read, yeah, these and these always read different to me. It's an outpatient prescription drug benefit. It states on the scheduled benefits. It's $10 a day.
[CUSTOMER][POSITIVE] And I was like oh that's good.
[AGENT][NEUTRAL] And then it says the max, yeah.
[CUSTOMER][NEUTRAL] $10 a day.
[AGENT][NEUTRAL] It does it per day, which has always been.
[CUSTOMER][NEUTRAL] What if you take one pill per day?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Or what if you take 2 pills per day?
[AGENT][NEUTRAL] We'll pay the outpatient prescription drug benefit per day when a covered person has a written prescription filled or refilled. The prescription must be ordered by a physician and dispensed by a pharmacist. OK. Um, the purpose of this benefit does not include experimental drugs, immunizations, OK.
[AGENT][NEUTRAL] Doesn't really give much more information than that, just that it's $10 per day and that it's a maximum of, there's a day limit to let me go back sorry, [PII].
[CUSTOMER][NEUTRAL] Ah, Chico, that's weird. So I'm wondering.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] You know, um,
[AGENT][NEUTRAL] Yeah, it says $10 per day maximum of 15 days.
[CUSTOMER][NEUTRAL] Does it really pay?
[CUSTOMER][NEUTRAL] So it only pays for 15 days.
[AGENT][NEUTRAL] Yeah, so it's more, it seems more like a
[CUSTOMER][NEUTRAL] That sounds like something may be given on the unit, not a prescription because how could you do.
[AGENT][NEUTRAL] Not
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Just 15 days.
[CUSTOMER][NEUTRAL] Unless it's
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] If the doctor gives them a prescription today that's considered a day.
[CUSTOMER][NEUTRAL] But it doesn't limit the number of.
[CUSTOMER][NEUTRAL] I mean that's just weird. Does it go through a certain company like Express Scrips, Caremark, Medco?
[AGENT][NEUTRAL] Um, so looks like prescriptions go through, um,
[AGENT][NEUTRAL] Is it listed as Lucy RX. It's a new company.
[CUSTOMER][NEUTRAL] Oh OK
[CUSTOMER][POSITIVE] My goodness gracious alive.
[AGENT][NEUTRAL] And then benefits in a card, so.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][POSITIVE] It's Lucy like I love Lucy.
[AGENT][NEUTRAL] Yeah, L U C Y RX and their customer service number is [PII], and then they have a pharmacy help desk also.
[CUSTOMER][NEUTRAL] I'll put that on there. We're gonna have to probably figure out what we're doing on these no authorizations required, is that correct?
[AGENT][NEUTRAL] No, they don't require pre-op.
[CUSTOMER][NEUTRAL] Does does she have any um hospital benefits?
[AGENT][NEUTRAL] Oh, let's see.
[CUSTOMER][NEUTRAL] And y'all don't use any kind of network.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So there is a hospital admission benefit. It's $500 for the first day, one day.
[AGENT][NEUTRAL] And then each day after that pays $50 per day and it's a maximum of 30 days.
[CUSTOMER][NEUTRAL] OK, so inpatient.
[CUSTOMER][NEUTRAL] First day is $500 max, right?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 5
[CUSTOMER][NEGATIVE] Wow you can't even understand what the
[CUSTOMER][NEUTRAL] Max
[CUSTOMER][NEUTRAL] And then um for days.
[CUSTOMER][NEUTRAL] 2 through what was the maximum amount of days?
[AGENT][NEUTRAL] Uh, 30.
[CUSTOMER][NEUTRAL] 30
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Only
[CUSTOMER][NEUTRAL] Pays
[CUSTOMER][NEUTRAL] $50 right?
[AGENT][NEUTRAL] Mhm, mhm.
[CUSTOMER][NEUTRAL] $50.
[CUSTOMER][NEUTRAL] Um, 30 day.
[CUSTOMER][NEUTRAL] Hospital
[CUSTOMER][NEUTRAL] Max
[CUSTOMER][NEUTRAL] Per year.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, all right, interesting.
[CUSTOMER][NEUTRAL] Um, is there a group number?
[AGENT][NEUTRAL] Yeah, let's take a look.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Group number is 70,070.
[CUSTOMER][NEUTRAL] 70,070 OK and.
[AGENT][NEUTRAL] Yeah, and it's Carrollton Staffing.
[CUSTOMER][NEGATIVE] Oh wow this is actually out of uh.
[AGENT][NEUTRAL] Staffing agency, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, no, that's, I guess understandable Carrollton staffing.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Carrington Staffing care.
[AGENT][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Oh see.
[CUSTOMER][NEUTRAL] OK, [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] And then [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh, [PII], oh, like the [PII], OK.
[AGENT][NEUTRAL] [PII], yeah.
[CUSTOMER][NEUTRAL] Carlton staffing.
[CUSTOMER][NEGATIVE] If I could only do the [PII], yeah, I can't dance worth a darn.
[CUSTOMER][NEUTRAL] Um, doesn't mean I don't try, but you know.
[CUSTOMER][NEUTRAL] Could probably get me a million dollars just trying to tape that and go oh my goodness, oh that's so crazy like at her try. Well, the operative word is try, right? Um, yeah, what's the address for claims?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] Uh, claims mailing address is going to go to [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that's in [PII]. [PII],
[CUSTOMER][POSITIVE] Oh, that's all right honey.
[CUSTOMER][NEUTRAL] I got that one. Aetna goes through [PII], so that's the only reason why I know.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then zip is [PII].
[AGENT][NEUTRAL] And payer ID, yeah.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Her ID is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Awesome [PII] and you said the effective date was [PII], right?
[AGENT][NEUTRAL] Uh, [PII]. Sorry about that.
[CUSTOMER][NEUTRAL] 0 [PII] of [PII], OK, and I'm sorry, what was your name again?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] With the [PII] or without the [PII]?
[AGENT][NEUTRAL] With an [PII] at the end.
[CUSTOMER][NEUTRAL] OK, um, is there a reference number for the call?
[AGENT][NEUTRAL] Yeah, absolutely. You can use my name with my last initial and then just today's date. The initial to my last name is [PII], and then today's date.
[CUSTOMER][POSITIVE] Alrighty Miss [PII], very interesting, OK.
[AGENT][POSITIVE] Alright have a good day, [PII].
[CUSTOMER][POSITIVE] All right thanks so much you too alright bye bye.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Bye bye.