AccountId: 011433970860
ContactId: e3f8229b-00ef-4f5b-8e0e-f6861af3ab48
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1443479 ms
Total Talk Time (AGENT): 294593 ms
Total Talk Time (CUSTOMER): 368483 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/e3f8229b-00ef-4f5b-8e0e-f6861af3ab48_20250408T14:16_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] My name is [PII]. Last name initial [PII], calling from the provider's office to know the patient eligibility and benefits.
[AGENT][POSITIVE] Yes, I can help you with eligibility and benefits. And you said your first name was what again?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] OK, [PII], do you have that policy number on you?
[CUSTOMER][NEUTRAL] Yes, I have.
[CUSTOMER][NEUTRAL] The policy number is
[CUSTOMER][NEUTRAL] 026
[CUSTOMER][NEUTRAL] 06091.
[AGENT][POSITIVE] OK perfect thank you and then what's a good call back number in case our call gets dropped?
[CUSTOMER][NEUTRAL] [PII] direct line.
[AGENT][POSITIVE] Perfect. Thank you.
[AGENT][NEUTRAL] OK, and the patient's first and last name and date of birth, please?
[CUSTOMER][NEUTRAL] Patient's first name, [PII], last name [PII], and the date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] The
[AGENT][NEUTRAL] OK, give me just one second.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So it looks like patient's policy is currently active. The effective date is [PII].
[AGENT][NEUTRAL] And let's see.
[CUSTOMER][NEUTRAL] May I know the plan name and plan type?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Just one sec.
[CUSTOMER][NEUTRAL] Hello
[AGENT][NEUTRAL] So it looks like this.
[AGENT][NEUTRAL] This policy is hospital indemnity plan.
[AGENT][NEUTRAL] And then you wanted to know benefits as well?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You said the plan name is Hospital indemnity plan?
[AGENT][POSITIVE] Yes, correct.
[CUSTOMER][NEUTRAL] Mhm. Plant type?
[AGENT][NEUTRAL] It's called an HI so it's hospital indemnity plan.
[CUSTOMER][NEUTRAL] On
[AGENT][NEUTRAL] That's what type of policy they have.
[CUSTOMER][NEUTRAL] Hospital indemnity plan.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then are you looking for inpatient, outpatient?
[AGENT][NEUTRAL] Benefits today?
[CUSTOMER][NEUTRAL] Outpatient, outpatient, ma'am.
[AGENT][NEUTRAL] Outpatient.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Place of service, place of service specialist office.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I need benefits for specialist office visit, and I have two CPT codes. I need benefits for that codes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, just one moment while I look into her policy.
[AGENT][NEUTRAL] OK, so it looks like patient has an outpatient sickness rider, which the benefit amount is $75 per visit and maximum visits per calendar year or $5 per adult.
[CUSTOMER][NEUTRAL] Hello
[CUSTOMER][NEUTRAL] Maximum 5 visits for plan year.
[AGENT][NEUTRAL] Yes, so maximum visits per calendar year are 5.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] May I know how many visits are used and how many visits are remaining?
[AGENT][NEUTRAL] Let me check for you.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] you
[AGENT][NEUTRAL] OK, so it looks like no benefits were used for this year.
[CUSTOMER][NEGATIVE] Nothing was, nothing has been used.
[AGENT][NEGATIVE] No, nothing has been used.
[CUSTOMER][NEUTRAL] OK, ma'am. You gave me office visit benefits, specialist office visit. Then what about the CPT codes 99213 and 93,000?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] What was that?
[CUSTOMER][NEUTRAL] Need benefits for these two quotes, ma'am. 99213 and 93,000.
[AGENT][NEUTRAL] OK, just one moment.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] C1.
[CUSTOMER][NEUTRAL] 07
[CUSTOMER][NEUTRAL] Like
[AGENT][NEUTRAL] OK, can I put you on a brief hold really quick while I look these codes up?
[CUSTOMER][POSITIVE] Take your time.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Hey [PII], thank you for holding.
[AGENT][NEUTRAL] So I'm not finding those numbers that you gave me, but the outpatient sickness benefit is a maximum per visit is $75.
[CUSTOMER][NEUTRAL] Mhm. Yes.
[CUSTOMER][NEUTRAL] OK, ma'am. Then what about the benefits for diagnostic testing and EKG EKG and diagnostic testing?
[AGENT][NEUTRAL] So it looks like the maximum benefit for diagnostic testing and wellness exam.
[CUSTOMER][NEGATIVE] But it's not.
[AGENT][NEUTRAL] Is $250 per calendar year per covered person.
[CUSTOMER][NEUTRAL] 7
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] EKG and diagnos EKG, ma'am.
[AGENT][NEUTRAL] OK. Just one second.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Electrocardiogram, EKG or ECG that is 93,000 is an elec electrocardiogram. ECG or EKG I need benefits for that.
[CUSTOMER][NEUTRAL] But uh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm looking for you, just one moment.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Wouldn't
[AGENT][NEUTRAL] OK, so it looks like EKG.
[CUSTOMER][NEUTRAL] I need accurate information, ma'am, because
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so an EKG is not covered under this policy, only CT scans, MRI's, and colonoscopies.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEGATIVE] EKG is not covered. EKG is not covered. Only MRI, CT scan are, are covered.
[AGENT][NEGATIVE] Not covered.
[AGENT][NEUTRAL] Yes, only CT scans, MRI's, and colonoscopies are covered.
[CUSTOMER][NEUTRAL] Only MRIs, CT scan.
[CUSTOMER][NEUTRAL] Colonoscopy are covered.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, correct.
[AGENT][NEUTRAL] But they do have that diagnostic testing benefit for the $250 per calendar year per covered person.
[CUSTOMER][NEUTRAL] Just wait a second caller knows.
[AGENT][NEUTRAL] OK. Go ahead.
[CUSTOMER][NEUTRAL] I recovered.
[CUSTOMER][NEUTRAL] But they said maximum $250 for diagnostic testing?
[AGENT][POSITIVE] Yes, that is correct per calendar year per covered person.
[CUSTOMER][NEUTRAL] You mean
[CUSTOMER][NEUTRAL] Maximum insurance will pay to $50 per uh
[AGENT][NEUTRAL] Yes, uh, that's per calendar year. Mhm.
[CUSTOMER][NEUTRAL] Uh, could you explain in a single in a, in a single visit $250 or
[AGENT][NEUTRAL] $250 for diagnostic testing and a wellness exam is $250 per calendar year per covered person. Correct.
[CUSTOMER][NEUTRAL] G for golf
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Mm just wait a second, ma'am.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] 07553.
[CUSTOMER][NEUTRAL] What is that, ma'am, maximum 250 means, uh, that is the limit amount for that, uh, services, $250.
[AGENT][NEUTRAL] Yes. So they have diagnostic testing benefits.
[AGENT][NEUTRAL] And wellness exam.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that is per calendar year.
[AGENT][NEUTRAL] Per covered person.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] $250.
[CUSTOMER][NEUTRAL] OK, ma'am.
[CUSTOMER][NEUTRAL] May I know PCP referrals and authorizations required are not required?
[AGENT][NEUTRAL] I'm sorry, what was that?
[CUSTOMER][NEUTRAL] May I know the
[CUSTOMER][NEUTRAL] Authorizations and referrals required are not required.
[AGENT][NEUTRAL] Authorization is not required, no.
[CUSTOMER][NEUTRAL] Referrals, PC referrals.
[AGENT][NEUTRAL] Yes, authorization is not required.
[CUSTOMER][NEUTRAL] Yes, ma'am. PCP referral, ma'am.
[AGENT][NEUTRAL] Uh, referrals are not required. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, may I know the benefits, you said the EKG and uh ECG is not covered?
[AGENT][NEUTRAL] Yes, EK EKG is not covered, only CT.
[AGENT][NEUTRAL] MRI and colonoscopies.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Uh, you said diagnostic testing and wellness exams, uh, $250 maximum for a covered person.
[CUSTOMER][NEUTRAL] For plan year.
[AGENT][POSITIVE] Yes, that is correct. per calendar year per covered person.
[CUSTOMER][NEUTRAL] May I know how much um, may I know, may I know how much amount you there still?
[CUSTOMER][NEUTRAL] And how much remaining?
[AGENT][NEGATIVE] The patient has not used any benefits as of this year.
[AGENT][NEGATIVE] No benefits have been used.
[CUSTOMER][NEUTRAL] Is there any deductibles and out of pockets?
[CUSTOMER][NEUTRAL] Is there any dates and out of pockets in this plan?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Call reference number?
[AGENT][NEUTRAL] Yes, the reference number would be my first name, which is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] H A L E Y.
[AGENT][NEUTRAL] Last initial, which is [PII] mhm.
[CUSTOMER][NEUTRAL] Last name [PII]?
[CUSTOMER][NEUTRAL] OK. Thank you for giving me. OK, you said the reference number is your name and the date?
[AGENT][NEUTRAL] And then
[AGENT][NEUTRAL] Yeah, and
[AGENT][NEUTRAL] Yes, and it would be, yes, today's date.
[CUSTOMER][POSITIVE] Thank you for giving me this information. Have a nice day. Nice to talk to you. Bye.
[AGENT][POSITIVE] OK, yes, it's been a pleasure speaking with you. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] We
[CUSTOMER][NEUTRAL] Uh, one more question, ma'am. Ma'am, I have a question in this benefits.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] We took benefits on [PII], ma'am, for the same patient.
[CUSTOMER][NEUTRAL] We took benefits on [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For the same patient.
[CUSTOMER][NEUTRAL] For office visit, I mean, for specialist office visit and the EKG.
[CUSTOMER][NEUTRAL] Services
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] OK. Yes, the benefits are the same. Correct.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, ma'am. Uh, benefits are the same.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um, but we got a denial claim, ma'am. Denial claim with the stating.
[CUSTOMER][NEUTRAL] Remark code. We are waiting information to confirm eligibility from benefits in your card.
[CUSTOMER][NEUTRAL] Upon receipt of this information, we will continue processing your claim. If you have any questions, please call benefits.
[CUSTOMER][NEUTRAL] What does that mean, uh, this patient is active from from [PII], the date of service is [PII].
[CUSTOMER][NEUTRAL] They, they denied this claim with the stating this reason.
[CUSTOMER][NEUTRAL] We are waiting, awaiting, we are awaiting information to confirm eligibility from benefits in your card. Upon receipt of this information, we will continue processing your claim.
[AGENT][NEUTRAL] So the policy is active and that just means we're pending additional information.
[CUSTOMER][NEUTRAL] From the patient.
[AGENT][NEUTRAL] Let me see, do you have a claim number for that?
[CUSTOMER][NEUTRAL] I just.
[CUSTOMER][NEUTRAL] Yes, I have. Yes.
[CUSTOMER][NEUTRAL] Can I give?
[AGENT][NEUTRAL] Yes, you can give me the card number.
[CUSTOMER][NEUTRAL] I have everything, claim number.
[CUSTOMER][NEUTRAL] Claim number 3581287.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Date of service [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Procedure codes 99213 and 93,000.
[AGENT][NEUTRAL] OK, so I see the remark code and
[AGENT][NEUTRAL] As soon as we receive additional information, this claim will be processed.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] As soon as you receive the additional information, is it from the patient?
[AGENT][NEUTRAL] I'm not allowed to disclose that, no.
[CUSTOMER][NEUTRAL] Uh, just to confirm, ma'am, uh, is it from the patient or from the provider? Additional information.
[CUSTOMER][NEUTRAL] This is for eligibility confirmation from the patient.
[AGENT][NEUTRAL] No, neither.
[AGENT][NEUTRAL] Are there any other questions?
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You mean, uh, you will be reprocess the claim again?
[CUSTOMER][NEUTRAL] Like
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] As soon as the information is received.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] We are awaiting additional information and the claim will process.
[AGENT][NEUTRAL] As soon as we, we get that information. Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] We have
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Uh, no, ma'am.
[AGENT][NEUTRAL] That's it.
[CUSTOMER][POSITIVE] Uh, thank you for giving me this information. Have a nice day. Nice to talk to you. Bye.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Of course. Yes, thank you for calling EPL. Have a good day.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Bye.