AccountId: 011433970860
ContactId: f6570a63-6fdf-42bb-aa08-10d469b7843f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 418730 ms
Total Talk Time (AGENT): 157438 ms
Total Talk Time (CUSTOMER): 138055 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/03/f6570a63-6fdf-42bb-aa08-10d469b7843f_20250203T19:47_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, I'm calling from a provider's office to see if a patient um has benefits for an outpatient surgery.
[CUSTOMER][NEUTRAL] At a um facility.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I can help you. Um, what's your name?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] And [PII], what's the policy number?
[CUSTOMER][NEUTRAL] It is 02584935.
[AGENT][POSITIVE] And a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. Give me one moment to pull up the file, OK?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Thank you for holding, [PII]. What is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] It is
[CUSTOMER][NEUTRAL] [PII] date of birth is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And we're checking eligibility and you said this is outpatient hospital?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] Oh, I have the information for you. The effective date is [PII].
[AGENT][NEUTRAL] Policy is active at this time?
[AGENT][NEUTRAL] And.
[AGENT][NEUTRAL] Uh, what type of service is it for?
[CUSTOMER][NEUTRAL] Um, so it's, uh, I'm calling from an OBGYN, um, so it's, uh, I have surgery codes, but it'll be, uh, like on campus outpatient hospital for a hysteroscopy with an IUD removal.
[AGENT][NEUTRAL] OK. I don't know if the contraceptive management is, you know, the removal of that is covered or not. And what type of surgery is it?
[CUSTOMER][NEUTRAL] Outpatient like GYN surgery?
[AGENT][NEUTRAL] What's, what's the, the procedure code?
[CUSTOMER][NEUTRAL] The codes it's gonna be um I have.
[CUSTOMER][NEUTRAL] Two, I want you to check and then maybe another one just in case, but 58301 for the IUD removal and then 58555 for the hysteroscopy.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Oh, a hysteroscopy. OK, yeah.
[AGENT][NEUTRAL] Let's see
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] So, under this policy, uh, it's related to an accident or and or sickness, and it's a sickness. Uh, the surgery benefit in a hospital setting is up to $2000 per day.
[AGENT][NEUTRAL] And then under this policy it's a maximum of one day per calendar year, so let me check to verify if there's been any um.
[AGENT][NEUTRAL] Surgeries this year.
[CUSTOMER][NEUTRAL] When you say accident, does that mean?
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Would this qualify as an accident?
[AGENT][NEGATIVE] No, no, no, it's an accident and or sickness, so it's a sickness.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's considered a sickness. It's a medical concern. Yeah, the hysteroscopy.
[CUSTOMER][POSITIVE] OK, got you, got you.
[CUSTOMER][POSITIVE] OK good
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] And I don't show any claims on file for this patient, so, um, up to $2000 per day, a maximum of 1 day per calendar year per covered person.
[CUSTOMER][NEUTRAL] Um, does that mean that that's what the, I don't know if you guys are contracted with us or not. I'm not familiar with this insurance policy. $2000 per day, that's what the insurance company would pay out towards the patient, or.
[AGENT][NEUTRAL] That is the benefit, so that would be correct. Uh, the PPO network of contracted providers is multi-plan. Are you familiar with multi plan?
[CUSTOMER][NEUTRAL] I am, I think so. I, but we usually have like the PHCS multi plan, so I don't know if I'm familiar with this one per se.
[AGENT][NEUTRAL] OK, would you like their phone number to call to verify?
[CUSTOMER][NEUTRAL] No ma'am, I'll um I'll use our resources here but OK, so this doesn't work like she doesn't have like a deductible and an out of pocket and a co-insurance that goes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] No, this is a limited hospital indemnity plan and so it just pays up to a certain dollar amount per day under this policy.
[AGENT][NEUTRAL] One time per calendar year.
[CUSTOMER][NEUTRAL] OK and then um.
[CUSTOMER][NEUTRAL] Did you say that they're so there that would be considered the IUD as well would go towards that?
[AGENT][NEUTRAL] I don't believe the IUD removal is covered, um, you can bill for it, but just know that this is just a verification, not a guarantee of payments. We need to get that actual claim. I know the, the hysteroscopy is.
[CUSTOMER][NEUTRAL] OK, and I have one more code to check just in case it's for hysteroscopic IUD removal, um, that code's 58562.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] But if it's as a result of the IUD removal, it would be the same type of, you know, I don't know if the removal of that is covered.
[CUSTOMER][NEUTRAL] OK, that may not be a cover so you're not able to tell me if there's coverage or not?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Well, it is for the outpatient uh hysteroscopy, but IUD removal is not generally covered under the policy.
[CUSTOMER][NEGATIVE] So the hysteroscopic IUD removal would not be covered.
[AGENT][POSITIVE] Yes, correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Not covered, not covered. Heroscopy covered. OK. And then, um, does any, do any of these codes require prior authorization with this type of plan?
[AGENT][NEUTRAL] Prior office not required.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Any other questions Miss [PII]?
[CUSTOMER][NEUTRAL] I'm just checking. I don't believe so. And then what was your name and then a reference number for this call?
[AGENT][NEUTRAL] OK. OK.
[AGENT][NEUTRAL] You'll use my name in today's date as reference for your call, [PII]
[AGENT][NEUTRAL] First initial last name is [PII].
[CUSTOMER][POSITIVE] Thank you for your help, [PII].
[AGENT][POSITIVE] Oh, you're welcome. Thank you for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] You too.