AccountId: 011433970860
ContactId: 13a003e2-75ac-4798-8a3c-4061eb59d12f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 313570 ms
Total Talk Time (AGENT): 115493 ms
Total Talk Time (CUSTOMER): 113963 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/31/13a003e2-75ac-4798-8a3c-4061eb59d12f_20241231T19:46_UTC.wav
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[AGENT][NEUTRAL] APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling from a provider's office. I wanted to see if you could tell me how a couple of medical claims processed for one of our patients if it's a limited indemnity plan and patient responsibility.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I can help you, [PII]. We do not determine patients responsibility, but I can give you the status of the claim. Do you have the policy number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, I do, um, the policy number that well.
[CUSTOMER][NEUTRAL] I'm probably gonna have to give you because the only number I have is for benefits and a card.
[CUSTOMER][NEUTRAL] And I don't have the um.
[CUSTOMER][NEUTRAL] Other number unless I can give you, can you try 02344576?
[AGENT][NEUTRAL] Yeah, that's our policy number. What's a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] My direct line is [PII].
[AGENT][POSITIVE] Thank you one moment.
[AGENT][NEUTRAL] What is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient is [PII]. His date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you and what's the date of service?
[CUSTOMER][NEUTRAL] I have two dates that are exactly the same different amounts. The first one is [PII]. We submitted a claim for $1,067.50.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The next one?
[CUSTOMER][NEUTRAL] The second one is [PII] for $634 even.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. OK, thanks.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For the charge of 106,750, what are the procedure codes on that claim?
[CUSTOMER][NEUTRAL] Um, the first one is 93,880.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And the other one is 93308.
[AGENT][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] All right, so.
[AGENT][NEUTRAL] So for the $1,0067.50 claim.
[AGENT][NEGATIVE] It says the medical test for this state of service is not a covered diagnostic test. Therefore, no benefits, no benefit is payable for this claim.
[AGENT][NEUTRAL] Uh, what type of test was it, [PII]?
[CUSTOMER][NEUTRAL] Um, let me see here, it looks like.
[CUSTOMER][NEUTRAL] It looks like what it was cardiology for a.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] My myocardial infarcation.
[AGENT][NEUTRAL] OK, under this, this limited policy there are certain diagnostic tests that are covered that's not a covered one, so there was no payment made on that one for that reason.
[CUSTOMER][NEUTRAL] OK, now would this be patient responsibility?
[AGENT][NEUTRAL] We do not determine patient's responsibility. Our position is to process it according to the patient's policy, and that being it's, it's not a covered item under the patient's policy. So then it would be, you know.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, we can end up billing the patient.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] however you all choose whatever your processes are internally.
[AGENT][NEUTRAL] And then for the $634 charge.
[AGENT][NEGATIVE] This was not covered as well. The denial remark code says.
[AGENT][NEUTRAL] Uh, the policy provides no benefits for charges made by a doctor for inpatient visits. So that was an inpatient visit. Uh, policy states not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] That it is not covered.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I do have the claim numbers if you.
[CUSTOMER][NEUTRAL] Alright, do you give?
[CUSTOMER][NEUTRAL] I, I do have those. I just wanna see if you can give me a call reference. I just wanted to make sure these processed correctly.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, my name and today's date you'll use as your reference, [PII], and did you have any other questions?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] No, thank you so much. I appreciate your help.
[AGENT][POSITIVE] You're welcome. Thank you for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] You too bye bye.