AccountId: 011433970860
ContactId: f0ffa430-be4f-46f0-9d75-1f8176182e1a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 487160 ms
Total Talk Time (AGENT): 207174 ms
Total Talk Time (CUSTOMER): 197511 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/12/f0ffa430-be4f-46f0-9d75-1f8176182e1a_20250312T20:27_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is. How may I help you?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Hey, um, my name is [PII]. Um, I'm calling about, let's see here, our, um, my policy number is 02013247.
[AGENT][NEUTRAL] OK, Miss [PII], let me pull up your policy real quick.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome and real quick can I get your callback number just in case we lose the call I can call you back.
[CUSTOMER][NEUTRAL] A
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][POSITIVE] Thank you, ma'am. And how can I help you today?
[CUSTOMER][NEUTRAL] Um, I was calling, um, I, um, this last open enrollment, I added my kiddo to the policy. Um, and, um, he is currently, uh, receiving some, uh, uh, like feeding therapy that his pediatrician, uh, referred us out to.
[CUSTOMER][NEUTRAL] Um, and so the, the therapy office reached out to y'all and y'all told them that that would not be uh covered under our plan. um, but like it is covered like through Blue Cross, it's applied to our deductible and so I told them I was like, no, I was like they've covered like physical therapy for me and like some other, other things like that in the past so I don't know why this specific therapy wouldn't be covered. Um, can you help me with that?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The
[AGENT][POSITIVE] Right, I can help you with your benefits, Miss [PII], um.
[AGENT][NEUTRAL] OK, first, let's verify your policy. Can you please give me your date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, ma'am. And then can you also verify your address, phone number and email address that we have on the policy for you?
[CUSTOMER][NEUTRAL] Yeah, um, uh, my address is [PII], uh, and my email address is [PII].
[AGENT][NEUTRAL] OK, it looks like I might have your work email address.
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] Yes ma'am, and then the phone number that you gave me, Miss [PII], is that a good number to call you back on if the call is disconnected?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, perfect. Thank you so much. Alright, looking at your policy, I show that you have, OK, it's in just a minute. This is a supplemental insurance policy that does help with deductible co-pay or co-insurance for accident or sickness.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Look looking at the policy, let's see, let me pull up your policy certificate.
[AGENT][NEUTRAL] It does cover physical therapy, but it does not cover phys uh physician office visit fee.
[CUSTOMER][NEUTRAL] OK. So it's, um, it's a, it's not like, not necessarily physical therapy. It's a feeding therapy um for him to work with him on his swallowing and gag reflex and things like that. So, I mean, it is medical. Um, so, uh,
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I mean, is is that would that should be covered correct?
[AGENT][NEUTRAL] Well, it depends um because the policy is specific about it being for accident or sickness.
[AGENT][NEUTRAL] Um, let me read you what it defines as far as did he get in an accident?
[AGENT][NEUTRAL] And is that why he's having trouble swallowing?
[CUSTOMER][NEUTRAL] No, I mean, he's a, he's a.
[CUSTOMER][NEUTRAL] He's a baby, so I mean, it's, I mean, I guess it could be considered like a, a developmental thing.
[AGENT][NEUTRAL] Oh OK.
[AGENT][NEUTRAL] OK, so let's, um, let's go ahead and see what your policy reads as far as the uh definition of sickness.
[AGENT][NEUTRAL] Since it's not an accident and I'm trying to pull it in now for you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][MIXED] It's loading, it's taking its time, but it's loading.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] I'll find what it says for definition of sickness.
[AGENT][NEUTRAL] So if it's done in an office, this, this policy goes by facility too so if it's done in a physician's office, physician's office does not include, it's not included in an outpatient facility under the policy.
[AGENT][NEUTRAL] Um, so your outpatient benefit would not be able to be used in a physician's office.
[AGENT][NEUTRAL] And let me look what it says about sickness, the definition.
[CUSTOMER][NEUTRAL] So the
[CUSTOMER][NEUTRAL] The therapy is not at the doctor's office. It is in a different location. It like it's at a, at a therapy office. So his pediatrician uh referred us to that facility.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, um, the facility since it doesn't cover office visits, would have to be an ER urgent care center, MRI imaging center, or an ambulatory center.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, OK, well, um, what I'll do is I guess I will probably submit.
[CUSTOMER][NEUTRAL] Uh, I'll, I'll try to just submit the claims myself rather than having the office do it and see if it's processed, um, because I know that like claims have been processed for other things that I've used that weren't like an urgent care or doctor's office, um, so the, you know, that the policy has paid on after Blue Cross made their initial payment so I'll I'll just try to do it that way.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, that, that sounds fine. And, and at least if it might pay something if you, um, submit it, and the only you won't know until you submit it and we get the diagnosis codes and procedure codes that are on your claim so that would help.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK very good well I will um I'll get that sent over to you as soon as they process.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, sounds perfect and remember that you'll need to send your EOB and your itemized statement with your diagnosis and procedure codes along with your claim form.
[CUSTOMER][POSITIVE] OK very good I appreciate it.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] No problem at all, Ms. [PII]. I'm glad I was able to help you. Is there anything else I can do to help you today?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] That should be it.
[AGENT][POSITIVE] OK, well, you have a wonderful day and thank you for calling APL.
[CUSTOMER][NEUTRAL] Uh huh you too.
[AGENT][NEUTRAL] Bye bye, ma'am.
[CUSTOMER][NEUTRAL] Bye bye.