AccountId: 011433970860
ContactId: eb089646-fe35-4db9-b00b-00635690d7a0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 362839 ms
Total Talk Time (AGENT): 160718 ms
Total Talk Time (CUSTOMER): 107398 ms
Interruptions: 3
Overall Sentiment: AGENT=0.9, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/eb089646-fe35-4db9-b00b-00635690d7a0_20250416T16:16_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. How are you?
[AGENT][POSITIVE] I'm great, thanks for asking. How are you doing, [PII]?
[CUSTOMER][NEUTRAL] Good, I needed to verify benefit coverage for a member, please.
[AGENT][NEUTRAL] Sure, I can assist you with that, [PII]. Can I have a callback number for you and that policy number?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Policy number is 02493162.
[AGENT][NEUTRAL] Could you verify this patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII]. Date of birth [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][POSITIVE] And I apologize. I forgot your name just that fast.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] You're calling to verify benefits eligibility for what place of service?
[CUSTOMER][NEUTRAL] Medical office visit.
[AGENT][NEUTRAL] So this policy does not cover office visits unfortunately.
[CUSTOMER][NEUTRAL] Specialist
[AGENT][NEUTRAL] It only covers the treatment received in the office.
[CUSTOMER][NEUTRAL] This, this is an office, a uh a specialist office is a medical office.
[AGENT][NEUTRAL] Right, and her policy does not cover office visits. It only covers the treatment received in the office and outpatient services. Office visits is not considered as an outpatient services. It's considered as an office visit, place of service 11. If it's not place of service 1922, or 23 is not considered as outpatient.
[CUSTOMER][NEUTRAL] OK, hold on. So, uh uh uh office, OK, so office visit code 11 is not covered under this policy?
[AGENT][NEUTRAL] Yes, that is correct. She does not have benefits for office visits. However, the treatment received in the office is covered under the policy, which will fall under her outpatient benefits.
[CUSTOMER][NEUTRAL] So for anything out, out of the scope of the office visit, you guys pick up like diagnostic testing.
[AGENT][NEUTRAL] Right, any, yes, anything that's considered as treatment received in the office.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And how much do you guys cover a year?
[AGENT][NEUTRAL] Give me one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] So she has office visit benefits of $3000 per calendar year and this is not a guaranteed benefits just a disclaimer of the policy's coverage.
[AGENT][NEUTRAL] It looks like you called about in January.
[CUSTOMER][NEUTRAL] Yeah, she's calling again because she doesn't, she does, she wants her policy to cover her co-pay. Her office did a co-pay and she's, and we're trying to explain to her that from the last time we verified benefits.
[AGENT][NEUTRAL] Hm
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Did she call us?
[AGENT][NEUTRAL] Did she come here to American Public Life?
[CUSTOMER][NEUTRAL] I'm not sure if she called you, but.
[CUSTOMER][NEUTRAL] I'm not sure if she called, but I know we probably called prior to this phone call, and we're just verifying the information we got versus.
[CUSTOMER][NEUTRAL] Other information she's in question of.
[CUSTOMER][NEUTRAL] So, I told her I would call again and confirm her coverage.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] And dictate it back to her.
[AGENT][NEUTRAL] She should give us a call so someone can explain her policy to her well she did call. She called [PII]. We told her that her policy doesn't cover all of this.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] I don't know. I guess when they tell them that they have a gap insurance policy and it covers deductible copay and co-insurance, they forget to tell them that it covers co-pay, deductible co-pay and co-insurance for services covered under the policy.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, but unfortunately office visits are not covered, so she can give us a call and someone would greatly be able to tell her that office visits are not covered.
[CUSTOMER][NEUTRAL] OK, so you do not cover, oh.
[CUSTOMER][NEUTRAL] So you do not cover her office visit co-pay, correct?
[AGENT][NEUTRAL] That's correct. She office visits are not covered under the policy. Only when it's considered only, the only time it is covered is when she goes in for treatment received in the office like a CTT uh ultrasound or X-ray or something that's taking place in the office for the treatment that is covered but not the 99.
[AGENT][NEUTRAL] Well, what is the code for office visit like 99.
[CUSTOMER][NEUTRAL] Whatever gets applied to the 99213 or 992,040. Yeah.
[AGENT][NEGATIVE] 99214. Yes, those are not covered. No, unfortunately, they are not covered.
[CUSTOMER][NEUTRAL] OK, and has she utilized any of this max coverage of 3000 per calendar year or she still has funds available?
[AGENT][NEUTRAL] For 2025, she has utilized.
[AGENT][NEUTRAL] $783.42 of her benefits.
[CUSTOMER][POSITIVE] OK, thank you very much I appreciate your help.
[AGENT][POSITIVE] You're welcome, [PII]. Thanks for calling APL. Have a good day. Goodbye.
[CUSTOMER][NEUTRAL] You too bye.