AccountId: 011433970860
ContactId: fc072667-2e29-446a-a960-f3b3b395dedf
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 379440 ms
Total Talk Time (AGENT): 164031 ms
Total Talk Time (CUSTOMER): 164317 ms
Interruptions: 1
Overall Sentiment: AGENT=0.9, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/30/fc072667-2e29-446a-a960-f3b3b395dedf_20250430T22:42_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, hi, I'm calling from IHS radiology, um, from a provider facility just to get help with, uh, eligibility and benefits for a patient.
[AGENT][NEUTRAL] Yeah, I can check eligibility benefits for you. Um, what was your name?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Could you spell that for me?
[CUSTOMER][NEUTRAL] Yeah, [PII]
[AGENT][POSITIVE] OK, thank you.
[AGENT][POSITIVE] And then, can I get a good call back number from you in case we're disconnected please?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] Thank you. And then do you have that policy number?
[CUSTOMER][NEUTRAL] Uh yes, I do. It's going to be.
[CUSTOMER][NEUTRAL] 02595600.
[AGENT][NEUTRAL] OK and uh what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Perfect, thank you for verifying that. So this policy is active. Effective date was [PII], and this is a limited indemnity medical plan, so it is designed or uh essentially pays a set dollar amount per covered procedure or office visits. What kinds of benefits were we needing to check?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, I just wanted to verify if a CT of the neck is covered.
[AGENT][POSITIVE] I'm so sorry.
[CUSTOMER][NEUTRAL] Is a covered benefit for the.
[AGENT][NEUTRAL] Did you, I'm sorry, did you say a CT scan?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let me check that. Give me just a moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, of course I will let you know verification of coverage is not a guarantee of payment for claims. Uh, so this member does have a medical imaging test benefit that does include a CT scan. That benefit pays $100 per day. That is a maximum of 1 day per calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so $1 I'm sorry, 1 $100 is the limited pay, uh, uh, for the patient, correct?
[AGENT][NEUTRAL] Correct, that is the um.
[CUSTOMER][NEUTRAL] Or that's as far as what you pay.
[AGENT][NEUTRAL] That's the benefit amount. Yes, that is the total benefit amount we would pay for a medical imaging test.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Where is this, uh, being uh excuse me, where was this being taken place?
[CUSTOMER][NEUTRAL] Um, it would be in a facility. Uh, did you need like an MPI or anything to?
[AGENT][NEUTRAL] No, uh, the reason I ask is that there would be, uh, additional benefits if it was in like an emergency room or an urgent care facility or a physician's office.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Uh, it would just be outpatient office setting in a lab, um, in a, in a imaging facility, sorry.
[AGENT][NEUTRAL] OK, OK, no, you're OK, um, so yeah, there's not a benefit for that kind of facility unfortunately.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Oh, so they, they still, it, it wouldn't be covered here.
[AGENT][NEUTRAL] No, no, no, no, it would. I'm sorry. Um, I don't mean to be confusing. Uh, there's additional benefits if they were being seen at a, you know, physician's office, uh, urgent care or emergency room.
[CUSTOMER][NEUTRAL] Oh,
[AGENT][NEUTRAL] So it could potentially have stacked yeah.
[CUSTOMER][NEUTRAL] OK, I see what you're saying. I apologize.
[CUSTOMER][NEUTRAL] OK. Uh, so can I, am I able to give the CPT code to you to confirm um for that just because it looks like the patient.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] Oh, it just, it looks like the patient was coming in for another procedure, um, or another imaging exam.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And it wasn't, it's not being covered um by this insurance. It wasn't two of the imagings weren't covered here.
[AGENT][NEUTRAL] Did you, you filed the claims with us and they denied?
[CUSTOMER][NEUTRAL] Um, it looks like our off reps called over to the, to this line, and they were told on the line that, uh, the insurance doesn't cover the um ultrasounds and it looks like it was a um.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] What is this other one?
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] This one looks like it's a.
[CUSTOMER][NEUTRAL] It's a NM uh for the gastric NT study.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So I can tell you that of course as this is a limited indemnity medical plan, it is very limited and very specific as to what is and is not covered. So specifically for the under the medical imaging test, under the diagnostic testing benefit, it lists out MRI, CAT scan, um, CT, PET scan, um, and that's, and, uh, excuse me, radioactive iodine uptake test. Those are the only.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Tests that would be covered under the this benefit.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Unless it required um an advanced study or a follow up test.
[CUSTOMER][NEUTRAL] I see. OK. Uh.
[CUSTOMER][POSITIVE] OK, that makes sense to me. OK, awesome. Um, and then I, so I think I believe I have everything then, so just $100 per day.
[CUSTOMER][NEUTRAL] Um, and then it's the active date and do you mind if I grab your name again?
[AGENT][NEUTRAL] Sure, it's [PII]. And was there anything else I could help you with?
[CUSTOMER][NEUTRAL] Um, no, just, just if you happen to have any reference number. Oh, sorry, I, I did have one more question.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Uh, just to confirm i[PII] there's any authorization required for this exam.
[AGENT][NEUTRAL] No, no authorization is required.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, awesome, yeah, and then just see.
[AGENT][NEUTRAL] And then a reference number?
[AGENT][NEUTRAL] Sure, that would just be my first name, last initial and today's date and so my last initial is A.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] OK awesome thank you so much for explaining that to me.
[AGENT][POSITIVE] Of course, yeah, thanks for giving us a call. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] You too thank you bye bye.
[AGENT][POSITIVE] Thank you. Bye-bye.