AccountId: 011433970860
ContactId: ffc30049-f998-4cdd-a5cd-c78aba703201
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 617000 ms
Total Talk Time (AGENT): 142295 ms
Total Talk Time (CUSTOMER): 306514 ms
Interruptions: 3
Overall Sentiment: AGENT=0.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/14/ffc30049-f998-4cdd-a5cd-c78aba703201_20250314T12:19_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh yes, Ms. [PII]. Uh, what's the first line of your last name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Thank you, ma'am. Um, I have a couple of questions about a patient's policy, please.
[AGENT][NEUTRAL] OK, what is your name?
[CUSTOMER][NEUTRAL] My name is [PII] and I'm calling from a provider's office.
[AGENT][NEUTRAL] And the first initial of your last name, [PII]?
[CUSTOMER][NEUTRAL] [PII],
[AGENT][NEUTRAL] OK, and did you say you're checking claim status or benefit information?
[CUSTOMER][NEUTRAL] Uh, benefits.
[AGENT][NEUTRAL] OK, is this for service in a doctor's office?
[CUSTOMER][NEUTRAL] A specialist office visit.
[AGENT][NEUTRAL] OK, and what's the policy number and a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] Um, let me grab the insurance card because that number looks small.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Well I'm getting that my phone number is [PII].
[CUSTOMER][NEUTRAL] Actually,
[CUSTOMER][NEUTRAL] OK, that's
[CUSTOMER][NEUTRAL] OK, so I'm guessing.
[CUSTOMER][NEUTRAL] From the card.
[CUSTOMER][NEUTRAL] The outpatient benefits certification number?
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK. 02488919 ML [PII].
[AGENT][NEUTRAL] And what's the patient's name and date of birth?
[CUSTOMER][NEUTRAL] I don't know what that number is.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Alright, thanks for verifying that information. So I have the eligibility date, um, showing it's [PII].
[AGENT][NEUTRAL] Uh, this policy is active at this time and then the office visit is not covered under this policy.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] What kind of
[CUSTOMER][NEUTRAL] Plan is this?
[AGENT][NEUTRAL] To supplemental met link plan secondary to the major medical policy.
[CUSTOMER][NEUTRAL] OK, so it's so the patient has.
[CUSTOMER][NEUTRAL] A commercial insurance and you guys would be secondary.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK. Um, all right. Um,
[CUSTOMER][NEUTRAL] The specialist office visit is not covered.
[CUSTOMER][NEUTRAL] All right, let me.
[CUSTOMER][NEGATIVE] doesn't wanna.
[CUSTOMER][NEGATIVE] Wait for it to feed into the what the heck?
[CUSTOMER][NEUTRAL] OK. What, where did my insurances go?
[CUSTOMER][NEUTRAL] Oh shoot, that's the.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And when did you say the effective date was? I'm sorry.
[AGENT][NEUTRAL] Any other questions?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Alright, OK.
[AGENT][NEUTRAL] Any other questions?
[CUSTOMER][NEUTRAL] All right. So that's active. Uh, yes, ma'am. Um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let me.
[CUSTOMER][NEUTRAL] OK, that needs to go up front, OK.
[CUSTOMER][NEUTRAL] Alright, so let me save an exit and maybe that'll feed in now. OK, so um.
[CUSTOMER][NEUTRAL] What about um chemotherapy?
[CUSTOMER][NEUTRAL] Radiation therapy and injections. Would those be covered in the specialist office setting?
[AGENT][NEUTRAL] Yeah, treatment in the office, the physician visit fee is not covered under this plan.
[CUSTOMER][NEUTRAL] So if patient had chemotherapy, radiation therapy, uh, those would not be covered?
[AGENT][NEUTRAL] When performed in a doctor's office or specialist office, no. Outpatient facility, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So does she have, um, can anything be done in the specialist office setting then? Like MRIs, PET scans?
[AGENT][NEUTRAL] Treatment in the office. Treatment in the office is not covered, and then the office visit copay is not covered under this policy.
[CUSTOMER][NEUTRAL] OK, so she pretty much has no specialist office.
[CUSTOMER][POSITIVE] Um, benefits at all.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Oh, OK, so then we.
[CUSTOMER][NEUTRAL] Even though it's a secondary um.
[CUSTOMER][NEGATIVE] So no no labs, no scans.
[CUSTOMER][NEUTRAL] So even though there's coverage, she's, there's no cover, she has a policy, but there's no active uh.
[CUSTOMER][NEGATIVE] No office benefits at all.
[AGENT][NEUTRAL] So this policy covers inpatient if they were admitted and then outpatient, outpatient like emergency room, surgery in a hospital or facility or an ambulatory surgical center, diagnostic testing in a diagnostic facility. So it's the place of service that's not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um,
[CUSTOMER][NEUTRAL] Secondary plan.
[CUSTOMER][NEUTRAL] Does not
[CUSTOMER][NEUTRAL] Cover.
[CUSTOMER][NEUTRAL] Specialist office.
[CUSTOMER][NEUTRAL] And services done.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Office OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Oh covers hospital.
[CUSTOMER][NEUTRAL] Um, and other outpatient facilities.
[AGENT][NEUTRAL] You know, just outpatient services and office services are not covered, mhm.
[CUSTOMER][NEUTRAL] Outpatient services.
[CUSTOMER][NEUTRAL] I'm writing outpatient facilities. I'm writing this down so that's why I'm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm sorry if I have if I'm having you kind of repeat yourself, um.
[AGENT][NEUTRAL] Yeah, I figured that out.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You're documenting as you go. I do the same thing. I do the same thing.
[CUSTOMER][POSITIVE] Good, thank you. Yes, because, because the patient presented the secondary insurance, so we have, and before I.
[CUSTOMER][NEUTRAL] If I don't load it, I gotta say why, um, kind of explain why, you know, that makes sense.
[AGENT][NEUTRAL] Mhm. Yeah. Right, right. Yes, it does.
[CUSTOMER][POSITIVE] And I wanna make sure I wore it the way.
[CUSTOMER][POSITIVE] The best way for everybody to to understand it.
[AGENT][NEUTRAL] To understand it. Mhm.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so plan any specialist office and services done in the office are not covered, only covers hospital and outpatient facilities.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] So you guys only cover hospital and outpatient facilities.
[CUSTOMER][NEUTRAL] Does not cover specialist office and services done in the specialist office.
[AGENT][NEUTRAL] Yeah, so the easiest way to say it is that out, the policy covers inpatient and outpatient services only. Outpatient under the policy is, you know, hospital, emergency room, diagnostic testing and a diagnostic facility. So just outpatient services are covered, but service in a physician's office, whether it's primary care or specialist, is not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] So PCP specialist office.
[CUSTOMER][NEUTRAL] And services done in there.
[CUSTOMER][NEGATIVE] Are not covered.
[AGENT][NEUTRAL] Any service in a PCP or specialist office is not covered.
[CUSTOMER][NEUTRAL] Any service, OK.
[CUSTOMER][NEUTRAL] Alright, so PCP specialists and services done in office are not covered in an outpatient services are covered.
[CUSTOMER][NEUTRAL] OK, so inpatient would be hospital.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Covered outpatient services mhm mhm.
[CUSTOMER][NEUTRAL] Right, OK.
[CUSTOMER][NEUTRAL] Um, and patient.
[CUSTOMER][NEUTRAL] Hospital ER.
[CUSTOMER][NEUTRAL] In like in like a walk-in.
[AGENT][NEUTRAL] Referring to urgent care?
[CUSTOMER][NEUTRAL] Would a walk-in be covered?
[AGENT][NEUTRAL] Urgent care?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Urgent care is covered, that's under outpatient, so because that's not a PCP office.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Right, OK, check here.
[CUSTOMER][NEUTRAL] OK, and then outpatient.
[CUSTOMER][NEUTRAL] Would be like quest.
[CUSTOMER][NEUTRAL] Um, a radiology center.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah, I'm just making sure all my ducks are in a row just to so they, so there's no questions as to why.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] This was not loaded um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right, Ms. [PII], um,
[CUSTOMER][NEUTRAL] May I please have a reference number?
[AGENT][NEUTRAL] My name and today's date.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] That's easy.
[CUSTOMER][NEUTRAL] You are 3:14.
[CUSTOMER][POSITIVE] All right, thank you so much, Ms. [PII]. I appreciate your help.
[AGENT][POSITIVE] Oh, no worries and thank you for calling APL and have a good day, [PII], OK?
[CUSTOMER][POSITIVE] Thanks you as well.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] Bye.