AccountId: 011433970860
ContactId: f02d0bbc-d017-4bc3-86d0-eeb1fb1c1e77
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 955530 ms
Total Talk Time (AGENT): 450921 ms
Total Talk Time (CUSTOMER): 424242 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/25/f02d0bbc-d017-4bc3-86d0-eeb1fb1c1e77_20250225T16:04_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] in the care team. I've got, is this claim support?
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK good I've got uh Ms. [PII] on the other line and she is calling from Piedmont reproductive.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, she's very, uh, she doesn't take my answers. I told, OK, she's just wanting benefits for infertility on this policy number.
[CUSTOMER][NEUTRAL] 2554963
[AGENT][NEUTRAL] OK, so she's wanting benefits for infertility?
[CUSTOMER][NEGATIVE] She's wanting me to tell her, yes, yes, and she's wanting me to tell her that infertility, artificial insemination and all this stuff, she gave me a whole list of procedure codes and I keep telling her that this policy covers $75 for treatment in an office and I told her that this policy only covers.
[CUSTOMER][NEUTRAL] Um, MRI, CT, and colonoscopy for diagnostic tests, and she won't let up. um, so I'm transferring her and we've been IMing each other in our health chat.
[CUSTOMER][POSITIVE] So I'm transferring her to you for further help.
[AGENT][NEUTRAL] Oh God.
[CUSTOMER][NEUTRAL] So you can basically tell her the same thing I've told her.
[AGENT][NEUTRAL] OK, um, give me just a second because some of our policies actually have an exclusion for.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Reproductive health.
[CUSTOMER][NEUTRAL] OK, and let me give you her callback number. She was adamant that I give you the call back number so that if we get disconnected you can call her back, which I've already had to do one time because the first time she called the line was really staticky, so I hung up and called her back, but the number is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII] and she's extension [PII].
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] OK, so just to let you know under the limitations and exclusions um.
[AGENT][NEUTRAL] There is a limitation that says due to so we do not cover basically any losses in the policy or riders.
[AGENT][NEUTRAL] Um, due to hernia, adenoids, tonsils, varicose veins, appendix, disorder of the reproductive organs, or elective sterilization within 6 months after the effective date unless due to an emergency.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I'm not sure when this policy was effective, but that is there and then I'm trying.
[CUSTOMER][NEUTRAL] The effective date of this policy is [PII].
[AGENT][NEUTRAL] OK, so
[AGENT][NEUTRAL] So yeah, I mean.
[AGENT][NEUTRAL] It's gonna be completely based on how they bill are they.
[AGENT][NEUTRAL] Billing it as a sickness or they, you know.
[CUSTOMER][NEUTRAL] I did tell her
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEGATIVE] I did tell her that we will have to get the itemized statement with procedure codes and diagnosis codes to be able to review it further and that wasn't good enough for her.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Lord, like I don't understand what else she wants.
[CUSTOMER][NEUTRAL] Just keeps going on.
[CUSTOMER][NEUTRAL] Well, I'll tell you what, we're gonna have to have a margarita after this.
[AGENT][NEGATIVE] [PII], don't, don't tip me with a good time now.
[CUSTOMER][NEUTRAL] I know, right?
[AGENT][NEUTRAL] So, I mean, you've given her everything.
[CUSTOMER][NEUTRAL] OK, yeah.
[CUSTOMER][NEUTRAL] I know you I maybe just hearing it repeated again.
[CUSTOMER][NEUTRAL] Will finally make it sink in. I don't know.
[AGENT][POSITIVE] OK, I'll I'll see what I can do.
[CUSTOMER][NEUTRAL] OK, thanks, [PII]. All right. Bye-bye.
[AGENT][POSITIVE] Thank you, [PII].
[AGENT][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Um, [PII], can I have the initial of your last name, please?
[AGENT][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] Yeah, so, um, Pauly transferred me over to you and um this is for infertility benefits. I just need to get the benefits for infertility.
[AGENT][NEUTRAL] OK, so this is a hospital indemnity plan so um unless there are exclusions or limitations in the policy that strictly prohibit that, um, the benefits will be based on whether it is deemed um an accident or a sickness and for this.
[CUSTOMER][NEUTRAL] OK. Um, for, yeah, for infertility, I just need to get if diagnostic testing for infertility and infertility treatment is covered. So those two parts. First is diagnostic testing, and the second part in fertility treatment like AI, IVF, cryopreservation. So those are the two things that I wanna get. I want to know if this is covered on the patient's policy.
[AGENT][NEUTRAL] OK, so for diagnostic we'll address that first.
[AGENT][NEUTRAL] Um, let's see.
[CUSTOMER][NEUTRAL] And then we are in network.
[AGENT][NEUTRAL] You are OK, OK.
[CUSTOMER][NEUTRAL] And the place of service is specialist office, but we don't bill for the office visit, we bill for the professional fee.
[AGENT][NEUTRAL] Got you, OK.
[CUSTOMER][NEUTRAL] And the type of policy you said it's a limited hospital indemnity plan?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, give me just one moment.
[CUSTOMER][NEUTRAL] Uh, do you go by CPT codes? Cause I have CPT codes.
[AGENT][NEUTRAL] No ma'am.
[AGENT][NEUTRAL] OK, so I was trying to see if she had anything else that we might be able to look at as well as far as uh policies, but this is her only one that would even consider this particular type of treatment.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Um, [PII], can, can I give you my phone number? Can you, if ever we get disconnected, can you give me a call back, please?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Uh, my phone number is [PII] extension 599.
[AGENT][POSITIVE] OK perfect I got it down.
[CUSTOMER][NEUTRAL] Can, can you, can you please repeat my phone number? I just wanna make sure.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so under um the diagnostic testing um the diagnostic tests that are covered are MRI, CT and colonoscopy, but it's the only diagnostic.
[CUSTOMER][NEUTRAL] OK, so those are
[CUSTOMER][NEUTRAL] OK, so those are the only diagnostic procedures that that would only be covered for diagnostic testing for this patient's plan, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. So what about um for
[CUSTOMER][NEUTRAL] Uh, the treatment, infertility treatment.
[AGENT][NEGATIVE] So this policy does not.
[AGENT][NEUTRAL] Indicate coverage specific to infertility treatment. Um, I did review the effective date and any limitations and exclusions. The only time that um reproductive health or the treatment of is excluded is if it's within 6 months of their effective date. This policy is a year and a half old, so it is not within.
[AGENT][NEUTRAL] The 6 months, so they're any treatment that they obtain would be considered um possibly under the outpatient sickness router um because it does not mention specific infertility treatment.
[CUSTOMER][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] I'm sorry, ma'am. So it would, what, what's the 6 month again? I'm sorry, what's that?
[AGENT][NEUTRAL] The exclusions listed in the policy, um, if she were to be.
[AGENT][NEUTRAL] I don't know, seeking assistance with reproductive issues, which I'm assuming she is because she's at an infertility clinic, um, that is only so disorder of reproductive organs or any type of sterilization within 6 months after the effective date unless it's due to an emergency would be excluded. However,
[AGENT][NEUTRAL] This is past her 6 months time frame for that, so we would look at her, excuse me, we would look at her.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh goodness, I don't know why I'm sorry, I keep getting choked up. Um, we would look at her office visits or the treatment under the outpatient sickness rider which pays up to 5 visits per year at $75. There is a possibility that as far as the um.
[AGENT][NEUTRAL] As the.
[AGENT][NEUTRAL] Surgery goes, um, for like obtaining her eggs and all of that. There is a possibility that that would be covered, but without having
[AGENT][NEUTRAL] Like the bill, I, I wouldn't be able to tell you yes or no. It is a possibility, but I, I don't know. She does have a surgical rider, but it has to do be specific to a sickness or an injury.
[AGENT][NEUTRAL] So that's all gonna have to do with like coding and all of that.
[CUSTOMER][NEUTRAL] So, so it would, so it would, so it would only be covered if it's in relation to sickness and injury?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, so what about, um, is it, um, I just wanna know like direct to the point specifically cause like, you know, other insurances have direct like if you look under infertility, it says covered or not. So what about for like AI, IVF cryopreservation, genetic uh pre-implantation, genetic testing, etc. Is there a specific section for infertility on this member's policy if it's covered or not for infertility treatments like the one that I mentioned, AI, etc.
[AGENT][NEUTRAL] No ma'am.
[AGENT][NEGATIVE] No, ma'am, they're not.
[AGENT][NEUTRAL] Because it's an indemnity plan, it, it, it's just based off of whether it's a sickness or an injury and what type of treatment is incurred because of that. And so it does go into like how a sickness and an injury is defined, but it does not specifically limit disorders of the reproductive organs unless it's within 6 months of the effective date.
[CUSTOMER][NEUTRAL] So, infertility
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] But this one, ma'am, there's no coverage for infertility, right?
[AGENT][NEUTRAL] There could be that it does not exclude it.
[AGENT][NEUTRAL] But there is no section specific to infertility or fertility treatments. There is, there's nothing in here that I'm gonna be able to say, OK, and I go to that section and I say OK, this is what we cover and this is what we don't that policy doesn't list it out that way.
[CUSTOMER][NEUTRAL] So no specific section for infertility, correct?
[AGENT][POSITIVE] Yeah, that's correct.
[CUSTOMER][NEUTRAL] And, and you said, you said that this type of policy, the limited hospital indemnity plan, this only would cover specifically for sickness and injury, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Um, OK. And, um, [PII].
[CUSTOMER][NEUTRAL] Does this patient have like uh
[CUSTOMER][NEUTRAL] Individual deductibles, stuff like that.
[AGENT][NEGATIVE] No, not for this policy they do not.
[CUSTOMER][NEUTRAL] So no deductible, no out of pocket?
[AGENT][NEUTRAL] No ma'am.
[CUSTOMER][NEUTRAL] Oh, so for this policy, OK, again, for this policy, member doesn't have any deductible or no out of pocket as well, correct?
[AGENT][NEUTRAL] That's correct, they just have a limit to the.
[AGENT][NEUTRAL] Dollar amount APL will pay per visit or per test or per day of confinement, etc. that that's where the limitation is at.
[CUSTOMER][NEUTRAL] Can I have the effective date of the policy?
[AGENT][NEUTRAL] Sure, it is [PII].
[CUSTOMER][NEUTRAL] Can I have the office visit for a specialist for work?
[AGENT][NEUTRAL] Um, it's going to be $75 per visit.
[AGENT][NEUTRAL] For outpatient sickness.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Specialist office visit in our credit? Um $75 correct?
[AGENT][NEUTRAL] Yes, that's the maximum benefit payment.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Is [PII] the subscriber of the policy?
[AGENT][NEUTRAL] Uh, yes, she is, she is the primary.
[CUSTOMER][NEUTRAL] Does she have like a spouse or husband listed on the policy?
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] No, it looks like it's an individual policy.
[CUSTOMER][NEUTRAL] OK, so basically, cause for diagnostic testing, um, the codes that I provided to for a while ago for diagnostic testing, basically we have like ultrasound, blood work, semen analysis, etc. So basically, this is not covered for diagnostic testing because the one, the ones that you said that would only be covered is CT MRI and colonoscopy only, right? For diagnostic testing.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And then for the treatment, infertility treatment, you said there is no section as well for infertility on this patient's plan, and this is a limited hospital indemnity plan which only covers sickness and injury, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] So basically, there's no infertility coverage for the patient.
[AGENT][NEUTRAL] It depends on how you bill if it is billed.
[AGENT][NEGATIVE] As a sickness.
[AGENT][NEUTRAL] Then there is a possibility that any treatment she received would be covered, but I can't give you guarantees on the payment because I don't know what that bill looks like. I know that you have codes that you intend on using, um, but you know sometimes that doesn't always happen, so.
[CUSTOMER][NEUTRAL] OK, but
[CUSTOMER][NEUTRAL] But again, but yeah, but then again, you said that this type of policy would normally cover sickness and injury only, correct? Due to sickness and injury.
[AGENT][NEUTRAL] Yes, do you have a diagnosis code that you?
[CUSTOMER][NEUTRAL] No. I don't have diagnosis code. I have, uh, I have CPD codes for diagnostic testing and for infertility treatment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so just I can't again I can't guarantee payment. I don't know what the bill is gonna look like. I don't know what the diagnosis codes are gonna be used.
[CUSTOMER][NEUTRAL] But, uh, but again, but again, you said that this policy limited hospital indemnity plan is basically for sickness and injury due to sickness and injury only, correct?
[AGENT][NEUTRAL] Yes, it is.
[CUSTOMER][NEUTRAL] And then you don't see any section, there's no section specifically for infertility on this patient's plan.
[AGENT][NEUTRAL] No, no, there's not.
[AGENT][NEUTRAL] I mean just in my personal opinion.
[CUSTOMER][NEUTRAL] Um, can you please spell out your first?
[AGENT][NEGATIVE] Infertility seems to be sickness, in my opinion.
[AGENT][NEUTRAL] But again without the bill I wouldn't be able to confirm if that would be covered under her sickness benefits.
[CUSTOMER][NEUTRAL] Um, how, uh, I'm not sure if it is sickness, ma'am, because this is like for a patient to diagnose first the patient, um, like for pregnancy to have a child. So I'm not sure if it, I don't know if it's considered sickness. I don't think so.
[AGENT][NEUTRAL] I mean, if you're reproductive, well, the only reason I state that is because if your reproductive organs are not working, then your body is sick, you know what I'm saying? Like something is wrong with it.
[CUSTOMER][NEUTRAL] But then again, ma'am, OK. Yeah, but I just, but I just want, but I just wanna clarify that you don't see any infertility section on this patient's policy, correct?
[AGENT][NEUTRAL] No, there's not an infertility section in this policy, no ma'am.
[CUSTOMER][NEUTRAL] OK. Can you please spell out your first name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the initial to your last name?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And can I have the reference number for the call, please?
[AGENT][NEUTRAL] It would be my name with today's date.
[CUSTOMER][NEUTRAL] Uh, you don't give out any numbers or digits for the reference number?
[AGENT][NEUTRAL] No, we do not.
[CUSTOMER][NEUTRAL] So it's only your name and today's date.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] OK thank you.