AccountId: 011433970860
ContactId: ddd2a84d-a918-45e7-902d-edd975fcaf82
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 388779 ms
Total Talk Time (AGENT): 128151 ms
Total Talk Time (CUSTOMER): 134812 ms
Interruptions: 0
Overall Sentiment: AGENT=1.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/04/ddd2a84d-a918-45e7-902d-edd975fcaf82_20250304T15:18_UTC.wav
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[AGENT][POSITIVE] And thank you for calling API. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. Um, yeah. Could you help me check the eligibility and benefits for a member office visit and I have some CPT codes. I need to know if it requires authorization.
[AGENT][POSITIVE] Um, yes, sir. I can assist you with benefits. Um, first, I'll need your name and a good callback number.
[CUSTOMER][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] And callback number is [PII].
[CUSTOMER][NEUTRAL] [PII] is [PII].
[AGENT][POSITIVE] Thank
[AGENT][NEUTRAL] OK, [PII]. And please spell your name, please.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, [PII]. Now, could I get the policy number, please?
[CUSTOMER][NEUTRAL] D for David, 41203498.
[AGENT][NEUTRAL] OK, that's not one of our policy numbers. Do you have the member's social?
[CUSTOMER][NEUTRAL] Um, no, this is the only.
[CUSTOMER][NEUTRAL] Number I have here.
[AGENT][NEUTRAL] OK, I could try to look them up by name and date of birth. What's the last name?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] [PII], spells like [PII].
[CUSTOMER][NEUTRAL] [PII]. [PII].
[AGENT][NEUTRAL] And the first name, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you. One moment, please.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And please verify her date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, I found her in our system. Um, I have her policy number here if you need that information.
[CUSTOMER][NEUTRAL] Tell me.
[AGENT][NEUTRAL] The policy number is 025.
[AGENT][NEUTRAL] 85501.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mhm. No problem. And I'm showing the effect and just let me advise you that verification of coverage does not guarantee payment of claims. The effective date on this policy was [PII] and the policy is still active. And let's see for office visits.
[AGENT][NEUTRAL] OK one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] One moment please. I'm waiting for her benefits to come up.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, for office visits, we cover up to $75 per visit and she gets um 5 visits per calendar year.
[CUSTOMER][NEUTRAL] So, no co-pay. The plan only pays $75. And uh after that, it's patient's responsibility.
[AGENT][NEUTRAL] Yes sir.
[AGENT][POSITIVE] Yes sir, that's correct.
[CUSTOMER][NEUTRAL] $75. Only up to how many visits?
[AGENT][NEUTRAL] 5 per calendar year.
[CUSTOMER][NEGATIVE] And no deductible, right? No deductible, no co-pay plan pays $75 only.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Limited to 5 visits.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] This doesn't require referral?
[AGENT][NEGATIVE] No, it doesn't.
[CUSTOMER][NEUTRAL] OK. And um if
[CUSTOMER][NEUTRAL] Could you look up some CPT codes for me if it requires authorization or if you prefer the description I can tell you.
[AGENT][NEUTRAL] Well, no, no codes um require author authorization under this policy.
[CUSTOMER][NEGATIVE] Oh no, no
[AGENT][NEUTRAL] Because we go by the place of service. And again, for office visits and services provided in office, we cover up to $75 per visit.
[AGENT][NEUTRAL] And there's a limit of 5 visits per calendar year.
[CUSTOMER][NEUTRAL] All right, so let me um.
[CUSTOMER][NEUTRAL] Double-check if I understood it right. So no authorization required for any type of procedure, but the plan only pays $75. The rest is gonna be patient responsibility, limited to 5 visits, right?
[AGENT][NEUTRAL] Right, 5 visits per calendar year and all 5 visits are available. She hasn't used any this year yet.
[CUSTOMER][NEUTRAL] And [PII], what's your last name initial?
[AGENT][NEUTRAL] It's [PII] like [PII]. Is there anything else that I can assist you with?
[CUSTOMER][NEUTRAL] Uh, no, I'll take the reference number and also this doesn't require ala para, right?
[AGENT][NEUTRAL] Please repeat that question.
[CUSTOMER][NEUTRAL] Referral, does it require a referral?
[AGENT][NEGATIVE] No, it doesn't.
[AGENT][NEUTRAL] And the reference number is my name and today's date.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh, can I have a direct phone number so I can have it noted here? Because I was transferred like 3 times now. I mean, what's the phone number for this department?
[AGENT][NEUTRAL] Um, well, for the claims department, you would have to contact the [PII] number and just select the option for claims department.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][POSITIVE] All right. Thank you for your help.
[AGENT][NEUTRAL] OK. Is there anything else that I can assist you with, [PII]?
[CUSTOMER][POSITIVE] Oh, that is all I needed.
[AGENT][POSITIVE] OK. Well, I thank you again for calling APL. You have a great rest of your day. Mm bye.
[CUSTOMER][NEUTRAL] Mhm.