AccountId: 011433970860
ContactId: 01470a6e-5caf-4a24-ab38-6aebc340a7a9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 380700 ms
Total Talk Time (AGENT): 139575 ms
Total Talk Time (CUSTOMER): 74498 ms
Interruptions: 1
Overall Sentiment: AGENT=1.1, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/12/01470a6e-5caf-4a24-ab38-6aebc340a7a9_20250612T21:18_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling for the provider to check on additional information on a claim that has been denied.
[CUSTOMER][NEUTRAL] Please note, this call will be monitored and recorded for quality and training purposes.
[AGENT][NEUTRAL] OK, well I'll be more than happy to help you with the claim clarity um, [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Yes. The callback number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And it's a direct line.
[CUSTOMER][NEUTRAL] And the policy number is 024.
[CUSTOMER][NEUTRAL] 559
[CUSTOMER][NEUTRAL] 26
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII]. With the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and may I have the date of service and the total bills for the claim?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] For $450.33.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] That would be Jenny Stewart Medical Center.
[AGENT][NEUTRAL] Thank you for that and again just for the call, all the information provided is a verification of benefits, not a guarantee of payment. Hold on one moment, the claim just came up.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So I'm showing the claim was received on [PII] I'm sorry, [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 3600279.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because the outpatient rider only allows for outpatient surgery.
[AGENT][NEUTRAL] In an outpatient hospital or physician office?
[AGENT][NEGATIVE] Therefore, no benefits are payable.
[CUSTOMER][NEUTRAL] Just a moment, I'm taking it down.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the outpatient surgery is only allowed in outpatient hospital or physician's office. Is that right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Let me
[CUSTOMER][NEUTRAL] And for this claim, uh, can you confirm the place of service on this one?
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Um, 99214 is the office, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then the other one is for the
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] I'm not sure. 99214 is an office, um, and let me see.
[AGENT][NEUTRAL] And it said an outpatient facility or a physician office. Um, if you like, I can, I can definitely send this back to claims to reprocess if it was processed correctly, they'll let you know. Um, if not, they'll go ahead and reprocess and give a correct decision. um.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Was it a surge, the surgery was in the physician's office, correct?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Yes, please do.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, I'll go ahead and send this over. I do apologize for that if it is processing correctly, um, but claims is going to take another look at it and if it is correct, they'll let you know. If not, we'll go ahead and correct it.
[CUSTOMER][POSITIVE] Yes, thank you.
[AGENT][POSITIVE] You're very welcome. Was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] Yes, the turnaround time, please.
[AGENT][NEUTRAL] Um, so it's 7 to 15 business days from the day that we receive it.
[AGENT][NEUTRAL] So it'll be 7 to 15 that's at the most. Hopefully it will not be that long, um, because it's already been processed.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes. And is there a separate ticket number for this one or just the car reference number?
[AGENT][NEUTRAL] Um, just a call reference number. It will be my name and today's date.
[CUSTOMER][NEUTRAL] Can I have your last name initial?
[AGENT][NEUTRAL] Sure, it's [PII].
[AGENT][NEUTRAL] And my name is [PII].
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're very welcome. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] Yes. Thank you for your.
[CUSTOMER][NEUTRAL] Nothing else that's it.
[AGENT][POSITIVE] All right, well, thanks so much for calling APL. I hope you have a good day.
[CUSTOMER][NEUTRAL] You too. Bye.
[AGENT][POSITIVE] Thank you, bye bye