AccountId: 011433970860
ContactId: 16914602-b102-47bd-886d-3f491daa21a7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 685559 ms
Total Talk Time (AGENT): 163129 ms
Total Talk Time (CUSTOMER): 141822 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/14/16914602-b102-47bd-886d-3f491daa21a7_20250214T18:19_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] How may I assist you? Uh, hi, my name is [PII] calling from provider's office to check on a claim status. Can you please help me with that?
[AGENT][NEUTRAL] Uh sure, yes, I can assist you with claim status, Ms. [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Uh yes, it's [PII], a direct line.
[AGENT][NEUTRAL] OK, and may I have the name of the facility or provider you're calling from?
[CUSTOMER][NEUTRAL] you're calling from? Uh, yes, sure. The facility name is Medical University Hospital Authority.
[AGENT][NEUTRAL] OK, thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Mhm. The policy number. Uh yeah, sure.
[CUSTOMER][NEUTRAL] The policy number is 02454122.
[AGENT][NEUTRAL] All right. What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Um. Patient's name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you, and may I have the date of service and the amount of the claim?
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Servicing the amount of
[CUSTOMER][NEUTRAL] Uh yeah, sure. The date of service is [PII] for the bill amount $106 event.
[AGENT][NEUTRAL] OK, let me see if I can find this claim for you. In the future, you can check claim status online through our website at [PII] and that's just optional.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] OK, let me pull this be one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm still waiting on the UB to pull up maybe one more minute.
[CUSTOMER][POSITIVE] Uh, uh, yes, sure. Take your time.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK, so we processed the claim [PII] and the claim was denied. The reason for this denial is that benefit payable under the certificate are limited to those on the schedule of benefits. This is not a cover loss under the plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh under the plan.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] It's an uncovered service.
[CUSTOMER][NEUTRAL] May I know what type of plan does the member has?
[AGENT][NEUTRAL] This is a secondary supplemental plan to the major medical.
[AGENT][NEUTRAL] Did you go there, Ms. [PII]?
[CUSTOMER][NEUTRAL] Uh yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] National medical plan.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Uh, I'm so sorry, but can you please repeat the dinner reason for me again?
[AGENT][NEUTRAL] Uh, well, basically, it's a non-cover service under the member's plan.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] I want to know why.
[CUSTOMER][NEUTRAL] It's not covered?
[AGENT][NEGATIVE] It's just not covered under the member's plan.
[AGENT][NEUTRAL] It's not a cover service on the members plan.
[CUSTOMER][NEUTRAL] And may I know if
[CUSTOMER][NEUTRAL] Clinical services are not covered or why it was not covered under the patient plan?
[AGENT][NEUTRAL] OK. Let me look at the claim itself and tell you because when it says non-cover under the member's plans, it means that it's not a procedure or it's not a facility or it's not just, it's not covered, it's just not covered. So, um, I'll have to look at the codes and I'll have to look at the information. Um bear with me just a second. I'll have to put you on hold, OK?
[CUSTOMER][NEUTRAL] Cover
[CUSTOMER][POSITIVE] OK, yeah, sure, take your time.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for me Miss [PII].
[AGENT][NEUTRAL] OK, so based on the procedure code and diagnosis code, it looks like this was a uh clinic visit for an assessment or management of a patient. That is in uh considered like an office visit or a clinic visit, which is not covered under the member's plan.
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Management
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Not covered under the membership.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEGATIVE] So this one will only cover procedures but not like this. Mhm.
[CUSTOMER][NEUTRAL] And so the claim is
[CUSTOMER][NEUTRAL] All right. And so the claim is fully patient responsibility?
[AGENT][NEUTRAL] Uh, it's up to the provider's discretion. We're not the major medical, so it is denied by us because it's not payable under the member's plan.
[AGENT][NEUTRAL] So it's up to the provider's discretion.
[CUSTOMER][NEUTRAL] on
[AGENT][NEUTRAL] But usually they go back to the major medical.
[CUSTOMER][POSITIVE] Up to the providers with special.
[CUSTOMER][NEUTRAL] And dramatic.
[CUSTOMER][NEUTRAL] What?
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] All right. OK. Thank you so much for the information. It was a great help. And can you please provide me your call reference number?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will. Do you need the spelling of my name or any other information, Miss [PII]?
[CUSTOMER][NEUTRAL] Uh, yes. Can you please spell your name for me?
[AGENT][NEUTRAL] Sure. That's [PII]. Last initial [PII].
[CUSTOMER][NEUTRAL] Mhm. yeah.
[CUSTOMER][POSITIVE] Mhm. Sure, I understand [PII]. All right. OK, thank you so much for the information and assist stays. It was a great help and have a wonderful day and a happy weekend.
[AGENT][NEUTRAL] And
[AGENT][POSITIVE] You as well, Miss [PII]. Thank you for calling APL. Have a good weekend.
[CUSTOMER][POSITIVE] Mhm. You too have a great day. Bye-bye.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] OK.