AccountId: 011433970860
ContactId: 1b4b7a08-dd4b-44f4-89a7-3b405f061904
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 407440 ms
Total Talk Time (AGENT): 218917 ms
Total Talk Time (CUSTOMER): 137268 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/2025/01/02/1b4b7a08-dd4b-44f4-89a7-3b405f061904_20250102T13:39_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I am calling from Pella Medical Center. I need to ask a question in regards to a claim, please.
[AGENT][NEUTRAL] OK, [PII], are you needing claim status?
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] Do you need claim status?
[CUSTOMER][NEUTRAL] Um, I need to ask about a deny a denied claim.
[AGENT][POSITIVE] OK, yes ma'am, I can help you with that. And what is your callback number please, [PII]?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you. And the member's policy number, please?
[CUSTOMER][NEUTRAL] D 43730102
[AGENT][NEUTRAL] OK, now that policy number that is for, uh, excuse me, that is an IMA or a 90 degree benefit is the denial from do they also have a policy with APL?
[CUSTOMER][NEUTRAL] Um, it says American Public Life. Let me, um.
[AGENT][NEUTRAL] OK. Yeah, on their ID card, there would be another number for us also.
[CUSTOMER][NEUTRAL] Oh, OK, let me look on the card one second, sorry about that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK, here we go.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] What would it begin with?
[AGENT][NEUTRAL] Either a 0 or a 1 or 2 possibly.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] There's not any letters in the, at the beginning.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you have the explanation of benefits?
[CUSTOMER][NEUTRAL] Um, yeah, let me get that document too.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yeah, because this um.
[CUSTOMER][NEUTRAL] This card that just has the the the that one beginning with a D um so let me look at the EOB one second.
[AGENT][NEUTRAL] Right, because the EOB from APL will also have it on there.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] 1 2nd.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, let's see, huh.
[CUSTOMER][NEUTRAL] OK, policy number 024572223.
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][POSITIVE] You're welcome thank you.
[AGENT][NEUTRAL] You're welcome. And any information [PII] that I do provide for you would be a verification of benefits and not a guarantee of payment. What is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII]
[AGENT][NEUTRAL] OK, thank you and the date of service and total bill amount?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm. And total bill amount?
[CUSTOMER][NEUTRAL] $1,649 even.
[AGENT][POSITIVE] OK. Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so we've received this claim more than once. The most recent, what is the claim number you're calling about?
[CUSTOMER][NEUTRAL] Well, the, the only one that we have is the one that says it's a duplicate process on [PII], the claim number, yeah, the claim number 3540694. That's the only um EOB that we have.
[AGENT][NEUTRAL] Excuse me.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm. So the original claim.
[AGENT][NEUTRAL] Um, are you gonna need to receipt date or just the claim number?
[CUSTOMER][NEGATIVE] I'm gonna need to receive it because we don't have it at all, the original.
[AGENT][NEUTRAL] OK. The received date was [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Processed and denied on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Claim number is 346.
[AGENT][NEUTRAL] 984 6.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the reason for the denial on here states the outpatient rider only allows payment for outpatient surgery in an outpatient hospital or physician's office. Therefore, no benefits are payable.
[CUSTOMER][NEUTRAL] OK, so again that's, uh, it only covers outpatient surgery.
[AGENT][NEUTRAL] That is what this, this states that this, because this is not a major medical plan.
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] This is a limited benefit plan.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Alright, alright, that's fine.
[AGENT][NEUTRAL] Now, if you've never been given our website either, [PII], I can give you that because you should be able to get a copy of the explanation of benefits for for that claim number I just gave you from there.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] And our our portal website is secured.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, [PII]. [PII], is that correct?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] Yes, ma'am, that is correct. Uh-huh.
[CUSTOMER][NEUTRAL] OK and um is there any, is it a complicated log in or?
[AGENT][NEUTRAL] Yeah, you set up a username and a password. You just answer the questions, you'll set it up under um a medical or dental provider and we'll ask you for the tax ID now when the, when you get to the patient account number, that throws some people, that is the patient account number that you will have for the member, not their APO policy number. It does state provider's patient account number.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But
[CUSTOMER][NEUTRAL] OK, so.
[AGENT][NEUTRAL] Some people do get confused on that.
[CUSTOMER][NEUTRAL] So that wouldn't be the ID number.
[AGENT][NEUTRAL] Not for us. In the in the system for the hospital or the provider, it's whatever number you all have for the number.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so just use
[AGENT][NEUTRAL] So look them up in your patient, yes.
[CUSTOMER][NEUTRAL] Then we use the one that I originally gave you OK.
[AGENT][NEUTRAL] No, no, no, no, no, no, on the claim form that you will submit, there's a patient account number. It starts with an H.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh, the OK, the hospital account number, OK.
[AGENT][NEUTRAL] Yes, the yes, the provider's patient account number for the member, not their ID number for our insurance.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I see, OK, yeah, and that's all different. Well, thank you for explaining that. Alright, thank you for your help. Can I get your name and a reference number please?
[AGENT][NEUTRAL] Mhm, yes.
[AGENT][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] Again, my name is [PII].
[AGENT][NEUTRAL] And my name along with today's date will be your call reference number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Alright thank you so much for your help you have a good day.
[AGENT][POSITIVE] OK. Well, yes, ma'am, you too. And if that's all I can help you with, thank you again for calling APL.
[CUSTOMER][POSITIVE] Thank you bye bye.
[AGENT][NEUTRAL] You