AccountId: 011433970860
ContactId: 16276e5f-53fc-40ce-82f1-8602352a3132
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 406970 ms
Total Talk Time (AGENT): 173674 ms
Total Talk Time (CUSTOMER): 93073 ms
Interruptions: 0
Overall Sentiment: AGENT=2.1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/24/16276e5f-53fc-40ce-82f1-8602352a3132_20250124T16:42_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Uh, hi, this is [PII], uh, calling from provider's office to check on claims.
[AGENT][POSITIVE] Oh, I'd love to help you with claims today, and do you mind if I get a good call back number for you?
[CUSTOMER][NEUTRAL] Yeah, that is [PII].
[AGENT][POSITIVE] Thank you I appreciate that. Oh, I'm sorry.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mm, can, uh, can you spell your name, please?
[AGENT][NEUTRAL] Yes, it's [PII] First initial, last name, [PII].
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] My pleasure and what's the policy number we're gonna pull up today?
[CUSTOMER][NEUTRAL] That is 148.
[CUSTOMER][NEUTRAL] 0322.
[AGENT][POSITIVE] Thank you and give me a moment to get that pulled up for you.
[CUSTOMER][NEUTRAL] Mhm. Uh, but before we proceed, I would like to inform you that this call is being recorded for training and quality purpose. So, are you OK with that?
[AGENT][POSITIVE] Absolutely thank you for letting me know.
[AGENT][NEUTRAL] And
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] What is the uh member's first and last name and date of birth, please?
[CUSTOMER][NEUTRAL] Uh, that is [PII].
[CUSTOMER][NEUTRAL] [PII], that's the last name, [PII].
[AGENT][POSITIVE] Perfect, thank you so much and what is the date of service we want to look at for him?
[CUSTOMER][NEUTRAL] [PII] $821 even bill amount.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And would you be able to verify for me the name of the facility on file for this?
[CUSTOMER][NEUTRAL] Uh, that is MD Group Holding.
[AGENT][POSITIVE] Perfect, I believe this is your claim. Just give me one more second.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] All right perfect thank you very much. um I do show the claim here it looks like we received it [PII] and we processed it on [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It looks like the claim number here is going to be 353.
[AGENT][NEUTRAL] 7603.
[AGENT][POSITIVE] And I show hold on I'm so sorry one sec.
[AGENT][NEUTRAL] I'm so sorry. I just had to sneeze, um, I.
[CUSTOMER][NEUTRAL] Uh, OK.
[AGENT][NEGATIVE] I show your claim here was denied. I have two different denial codes. Um, the first one's on that first charge, the 99215, and it just states that office visits are not covered by the above numbered policy. And then the last denial code on here covers the rest of the procedure codes, and it states that the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] I find one just a second.
[AGENT][NEUTRAL] You're fine.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Your doctor's office is not covered under the patient's plan?
[AGENT][NEUTRAL] Um, so those particular procedure codes are not covered in a doctor's office or in a clinic. As far as their whole policy goes, I can take a look at that for you.
[CUSTOMER][NEUTRAL] Mhm so the.
[AGENT][NEUTRAL] Yeah, it does not, I don't show here that they have coverage in a doctor's office or clinic on their policy.
[CUSTOMER][NEUTRAL] So, patient is not having coverage for doctor's office?
[AGENT][NEUTRAL] It does not, um, it doesn't look like it, no I'm pulling up their full policy document for you to.
[AGENT][NEUTRAL] I just wanna make sure I'm giving you all the right information, so one second while I load up their call.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] Oh.
[AGENT][POSITIVE] Are you having a great day so far?
[CUSTOMER][NEUTRAL] Oh yeah.
[AGENT][POSITIVE] Good.
[CUSTOMER][NEUTRAL] Uh, how about you? Are you having?
[AGENT][POSITIVE] I'm having a really good day, um.
[AGENT][NEUTRAL] Really, I don't, it's, I'm kind of tired today, but it's Friday, so it's a great day.
[CUSTOMER][NEUTRAL] Ah yeah, at least it a Friday.
[AGENT][NEUTRAL] Yes, all right, so I'm looking at their full policy document here and they do not have any outpatient benefits in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] For any CPT or just a particular CPTs?
[AGENT][NEUTRAL] Just for any of them so I can list to you where they're covered if you'd like to know their outpatient coverage.
[CUSTOMER][NEUTRAL] Uh, may I know plan name?
[AGENT][NEUTRAL] Yeah, the plan name is Medin M E D L I N K.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Oh, OK, no issues. Can I have call reference number?
[AGENT][NEUTRAL] Oh yes, my name is [PII], and today's date.
[CUSTOMER][POSITIVE] OK. OK, [PII]. Thank you so much. Have a great day.
[AGENT][POSITIVE] Hey my pleasure thank you you take care.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Bye bye.