AccountId: 011433970860
ContactId: 024cba6d-021f-48c7-b516-381ec6944856
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 604400 ms
Total Talk Time (AGENT): 249666 ms
Total Talk Time (CUSTOMER): 159565 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/10/024cba6d-021f-48c7-b516-381ec6944856_20250310T16:17_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII] and I'm calling from the provider's office and I was calling um in regards to a claim.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with your claim status, and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] It's 01954452.
[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] Um, [PII] [PII].
[AGENT][NEUTRAL] Thank you for that. And all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bills for the claim?
[CUSTOMER][NEUTRAL] Yes, it is [PII] for $1,134.
[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] Uh, Summit Medical Center.
[AGENT][NEUTRAL] OK, so I'm showing we received the claim twice. Um, did you want the the original or both?
[CUSTOMER][NEUTRAL] Well, I know the the first one denied because you needed the primary EOB and I had called, um, and so I faxed the primary EOB to you guys um on [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] And it looks like we got some kind of a denial on [PII].
[CUSTOMER][NEUTRAL] Stating not not covered under the patient's plan, so I was just wondering if this is if you guys.
[CUSTOMER][NEGATIVE] Don't cover the copay.
[AGENT][NEUTRAL] was later pay. OK, hold on one second. So this major pay, OK, sorry, I'm trying to get everything together. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then the second one.
[AGENT][NEUTRAL] OK, so the first one denied because it showed that primary paid everything and we asked for an explanation of benefits showing, um, I'm sorry, saying that primary, we can only apply if primary applies and we ask for the explanation of benefits. So that's what was sent in in.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEGATIVE] February and then this one was denied.
[AGENT][NEUTRAL] 6430.
[AGENT][NEUTRAL] Not a covered loss.
[CUSTOMER][NEGATIVE] It's a copay basically her insurance company processed it and paid what they were gonna pay, um, but they left a $50 copay.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Do you guys, that's what um.
[AGENT][NEUTRAL] So our payments do go towards the copay, the deductible, and the co-insurance of covered charges after primary. What I'm hesitating about is I'm trying to pull up the documents to see, because it just says facility here, so I can see what it was for because secondary has its own.
[AGENT][NEUTRAL] Set of coverage too. So I'm trying to see if primary, yes, applied, but if it's something that's not covered on the secondary policy, we still wouldn't apply. So I'm just trying to see what it was, so I can look on the policy and see.
[AGENT][NEUTRAL] What the claims examiner saw.
[CUSTOMER][NEUTRAL] It was an
[CUSTOMER][NEUTRAL] It was an office visit it's an office visit.
[CUSTOMER][NEUTRAL] Basically, the, she came in to the wound care clinic. The wound care clinic is in the hospital, it's an off-site.
[CUSTOMER][NEUTRAL] Wound care clinic
[CUSTOMER][NEUTRAL] On the facility side. It's like,
[CUSTOMER][NEUTRAL] If that makes sense
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's OK, it's coming up now.
[AGENT][NEUTRAL] And it was page 2.
[AGENT][NEUTRAL] So why isn't it, do you mind if I place you on just a brief hold? I'm just looking at these documents.
[CUSTOMER][NEUTRAL] Yeah, that's fine.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][POSITIVE] OK thanks.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, wait a minute. The first one is asking for the explanation of benefits saying that primary, we can't apply unless primary applies, OK. So then they brought, they sent this in.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Benefits payable under the certificate are limited to those outlined on the schedule of benefits.
[AGENT][NEUTRAL] Cause I gotta be able to explain it.
[AGENT][NEGATIVE] So what are we saying? Office visits are not covered. I, I don't know why I didn't go to PI EFT for.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh, it did. It was all those lines. Oh yeah, OK.
[AGENT][NEUTRAL] So I'll put this over here.
[AGENT][NEUTRAL] And it's a fertility charge, and they have the office treatment rider.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] That's something different. I clicked on the wrong thing.
[AGENT][NEUTRAL] 126.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 126 was the second one. I need 099.
[AGENT][NEGATIVE] Why would they put that on there? That's not why that wasn't covered.
[AGENT][NEUTRAL] It's not covered because office visits aren't covered. Now that's why she feels like for the second one.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. So I'm just looking at the claim and the documents and the denial reasons. So, this is coming over as a facility charge. Um, so the patient has the OK, go ahead.
[CUSTOMER][NEUTRAL] And it
[CUSTOMER][NEUTRAL] Yeah, it kinda, well it is a facility charge, it's an outpatient facility like the wound care she.
[CUSTOMER][NEUTRAL] Came to the wound care clinic. It's an, it's an outpatient facility that, like I said, the wound care clinics at the facility.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Does she not, do you not
[AGENT][NEUTRAL] So the policy for in terms of like outpatient facilities, it would cover if it's like a surgery in an outpatient facility or like diagnostic testing in an outpatient facility, but
[CUSTOMER][NEUTRAL] But not for an office visit.
[AGENT][NEUTRAL] Right, so the, the policy itself doesn't cover office visits at all. Um, it could cover the treatment in the office, but this what was sent over was for the facility charge, not the treatment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, it's, it was, I guess she came in for, you know, came into the wound care clinic and they just did like an office visit.
[AGENT][NEUTRAL] Yes, so that's why it's saying it's not um a covered, I guess a covered charge because the facility charge itself is not covered on the policy.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, OK, I will that's what I thought but I just wanted to make sure. OK, thank you so much I appreciate your help.
[AGENT][POSITIVE] Well, sure, that's what we're here for. You're welcome, [PII]. Was there anything else I can help you with? OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] What do you
[CUSTOMER][NEUTRAL] Um, do you have a reference number?
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name in today's date, and that's [PII] my [PII] [PII].
[CUSTOMER][NEUTRAL] So that in case.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and then today's day is the [PII], OK.
[CUSTOMER][POSITIVE] OK, thank you so much [PII] have a good day.
[AGENT][POSITIVE] You also thanks for calling APL. Bye-bye.
[CUSTOMER][POSITIVE] Thanks bye bye.