AccountId: 011433970860
ContactId: 1a0d2b14-fe06-4fa3-9b2d-e4dad9f9ffc3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 416700 ms
Total Talk Time (AGENT): 196929 ms
Total Talk Time (CUSTOMER): 145583 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/10/1a0d2b14-fe06-4fa3-9b2d-e4dad9f9ffc3_20250410T13:18_UTC.wav
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[AGENT][NEUTRAL] For contacting ATL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from provider's office checking on claim status, and this call will be recorded for training and quality purposes.
[AGENT][NEUTRAL] I can help with uh claim status. What is that policy number, please?
[CUSTOMER][NEUTRAL] Uh, yeah, sure. Just providing you that.
[CUSTOMER][NEUTRAL] OK, so the policy number is 19336.
[AGENT][NEUTRAL] 19336.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] It's a group number.
[AGENT][NEUTRAL] Oh, the group number. OK. Um, the, um, policy number may begin with a 01 or 02. Uh, do you, do you have the card there with you or?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I do have a card. So I do have two policies. I will provide it in the hospital benefit card number. It's 1527444 M Mike Lima number 8.
[AGENT][POSITIVE] OK, thank you. Is there um.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Oh, I'm sorry, and the insured's name and the.
[CUSTOMER][NEUTRAL] You can uh
[AGENT][NEUTRAL] Yes, uh-huh.
[CUSTOMER][NEUTRAL] Uh, you can, uh, you can put the number 7 at the end instead of 8.
[AGENT][NEUTRAL] OK, and the insured's name and date of birth, please?
[CUSTOMER][NEUTRAL] It's [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Thank you. While I'm looking that up, if I could have a callback number please, the event that we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] Thank you, [PII], what uh date of service we're looking for for um this patient?
[CUSTOMER][NEUTRAL] Yeah, for now it's for [PII] with the total bill amount of $370 even.
[AGENT][POSITIVE] Thank you. Um,
[AGENT][NEUTRAL] Your claim number is 354.
[AGENT][NEUTRAL] 6951.
[AGENT][NEUTRAL] And it looks like we received that claim.
[AGENT][NEUTRAL] On, um, see if I can find it here.
[AGENT][NEUTRAL] So I'm checking.
[AGENT][NEUTRAL] Um, let me just see when we got it.
[AGENT][NEUTRAL] All right, there's there's a lot of claims here.
[CUSTOMER][NEUTRAL] Uh, uh, can you please check it for [PII]?
[AGENT][NEUTRAL] Uh, yes, that's, that's what I'm doing right now. So we've received your claim on the [PII].
[AGENT][NEUTRAL] And we processed it on [PII].
[AGENT][NEGATIVE] Now, the policy doesn't cover.
[AGENT][NEUTRAL] Um, office visit co-pays.
[AGENT][NEGATIVE] So this was denied.
[CUSTOMER][NEUTRAL] May I know what
[AGENT][NEUTRAL] Yes, uh-huh.
[CUSTOMER][NEUTRAL] May I know the reason?
[AGENT][NEUTRAL] Yes, the policy doesn't cover office visit co-pays. They, they're not covered by this policy.
[AGENT][NEUTRAL] And so that is why.
[CUSTOMER][NEUTRAL] As per, as per member's policy or provider's contract.
[AGENT][NEUTRAL] That is correct. Uh, it's by the member's policy.
[CUSTOMER][NEUTRAL] OK. Can you please provide me the policy name?
[AGENT][NEUTRAL] Uh, this is a secondary gap insurance. It's called APL.
[CUSTOMER][NEUTRAL] Secondary gap.
[CUSTOMER][NEUTRAL] Insurance, right? And what is the
[AGENT][POSITIVE] That's right.
[CUSTOMER][NEUTRAL] Policy number or plan code name?
[AGENT][NEUTRAL] Uh the the policy name is APL.
[CUSTOMER][NEUTRAL] AP uh, OK, is it a PPO HMO or any other APO plan?
[AGENT][NEUTRAL] Uh no, this is a secondary insurance, um, so no, it's not an HMO or PPO.
[CUSTOMER][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] Is there anything else that that any other claims I can look at?
[CUSTOMER][NEUTRAL] Uh, yeah, just give me a moment. Can you please provide me the uh.
[CUSTOMER][NEUTRAL] Reason why the office visits are not covered?
[AGENT][NEUTRAL] Because they're, they're not covered by the policy. The, the policy excludes them. They, they're just not covered by the policy.
[CUSTOMER][NEUTRAL] OK. Uh, actually, I do have claims in which, uh, the CBD code 99212 has been covered previously. It's, it was also an office visit. Uh, may I provide you the date of service and bill amount as in reference?
[AGENT][NEUTRAL] For this individual, yes. And what is that, uh, what is that data service?
[CUSTOMER][NEUTRAL] Yeah, it's
[CUSTOMER][NEUTRAL] [PII] with the total charge amount of $175.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, the claim number for this one, the, the one that you've just given me, uh,
[AGENT][NEUTRAL] That claim number is 35.
[AGENT][NEUTRAL] 306-666.
[AGENT][NEUTRAL] Um, 353-066-6. Now, that claim was denied as having no office visit co-pay. Uh, it's, it's not covered by this policy. Now, it could be covered by his major medical. It's possible that it, it's covered by his major medical, but it's not covered by this policy.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So for the claim of [PII], it was also not covered?
[AGENT][NEUTRAL] It was not covered. No, it's, it's, it's, what, what you may be thinking of is that it may be covered by his major medical policy, but this is a secondary policy. Um, this is his sec, yeah.
[CUSTOMER][POSITIVE] OK, no problem.
[CUSTOMER][NEUTRAL] I got it. Uh, can you please provide me the call reference?
[AGENT][NEUTRAL] Yes, my name is [PII]. The first letter of my last name is [PII]. We use that today's date as a reference.
[CUSTOMER][NEUTRAL] OK, just spell, just spell it out.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] It's [PII]
[AGENT][NEUTRAL] Why?
[CUSTOMER][NEUTRAL] OK, [PII], can you please uh repeat the claim number?
[AGENT][NEUTRAL] The claim number is 353.
[AGENT][NEUTRAL] 0666. That's, that's the one that you, that you thought had been paid.
[CUSTOMER][NEUTRAL] 0666, right?
[AGENT][POSITIVE] That's right.
[CUSTOMER][NEUTRAL] Uh, no, ma'am. Actually, for the claim, uh, for the date of service, [PII]. I need the claim number for that one.
[AGENT][NEUTRAL] OK, for that, uh, November [PII], excuse me just a second here, for that claim, that is uh 3546951.
[CUSTOMER][NEUTRAL] 3546951. It's number 3, number 5, number 46951. Is that correct? Or 33?
[AGENT][NEUTRAL] That's
[AGENT][POSITIVE] That that is correct.
[AGENT][NEUTRAL] It's, it's 354.
[AGENT][NEUTRAL] 6951.
[CUSTOMER][POSITIVE] OK, got it. Thank you so much and have a great day bye for now.
[AGENT][POSITIVE] Thanks for contacting EP