AccountId: 011433970860
ContactId: 03779a2c-54e9-41c6-800b-4d5ff62d377c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 336809 ms
Total Talk Time (AGENT): 140405 ms
Total Talk Time (CUSTOMER): 97297 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/04/03779a2c-54e9-41c6-800b-4d5ff62d377c_20250604T15:21_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], I need to first off verify eligibility on a patient and then see if you guys have received a claim from us.
[AGENT][NEUTRAL] OK, um, well, I can definitely help you with the eligibility and the claim. May I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure, sure, it's [PII].
[AGENT][NEUTRAL] Thank you and the member's policy number?
[CUSTOMER][NEUTRAL] It is 123-5013.
[AGENT][NEUTRAL] Thank you. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment.
[AGENT][NEUTRAL] And let me see, I am showing that the policy is active. It's been effective since [PII].
[CUSTOMER][NEUTRAL] OK, and you guys do show secondary payer correct?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, can you tell me if you have received a claim from us um for data service [PII], the bill amount is 260.
[AGENT][NEUTRAL] And I'm sorry, this isn't secondary, this is a hospital indemnity policy. They may have other insurance. It's not like um the gap policy that we have, so this we could be a secondary.
[CUSTOMER][NEUTRAL] Well, I do show that they have Blue Cross as primary, um, but yeah.
[AGENT][POSITIVE] OK, good. OK.
[AGENT][NEUTRAL] Because some, because we can't see it on our end so I'm like, I don't know, they might.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what was the total bill for the claim?
[CUSTOMER][NEUTRAL] 260.
[AGENT][NEUTRAL] 260.
[AGENT][NEUTRAL] And that was [PII]?
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Uh huh, the family doctors.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Alright, and yes, we do have a claim on file. Did you need the claim status for it?
[CUSTOMER][NEUTRAL] Yes, please, can you start with the claim number, hon?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm. Claim number is 352.
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] 666 2.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And we received it on [PII].
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] It was processed on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let me see what the decision was.
[AGENT][NEUTRAL] It was denied because the claim submission received is noted as an accident or injury, but the policy only covers sickness.
[CUSTOMER][NEUTRAL] Let me see what they had. Hold on one second.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] It's an office visit for pain in the left hip.
[CUSTOMER][NEUTRAL] Uh, looks like it is um.
[CUSTOMER][NEUTRAL] Maybe that's X-rays that they did. So you're saying that this is a result of um.
[CUSTOMER][NEUTRAL] An injury?
[AGENT][NEUTRAL] Well, no, so what we're saying is the policy only covers sickness, but what we received says that it's an accident or injury.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] To see if I can pull up the um OK, do you have a claim for [PII]?
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] And that one is for 565.
[AGENT][NEUTRAL] [PII], you said 565?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Yeah, I just found it. Hold on one moment it's coming up now.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] OK, so this one is um claim number 358.
[AGENT][NEUTRAL] 4881.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm, OK.
[AGENT][NEUTRAL] We received it on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it was processed on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and it was denied because the maximum benefit, um, for the outpatient rider has been met for the calendar year.
[CUSTOMER][NEUTRAL] OK, it has been met.
[CUSTOMER][POSITIVE] Alrighty, if you can provide me Miss [PII] with a reference number, I would appreciate it.
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alrighty thank you so much I appreciate it enjoy the rest of your day hon.
[AGENT][POSITIVE] Yeah, you also, and thanks for calling APL. Bye-bye.
[CUSTOMER][POSITIVE] No problem bye bye.