AccountId: 011433970860
ContactId: 1f98231e-6c8c-4100-8a33-da1aae82c858
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 705880 ms
Total Talk Time (AGENT): 258836 ms
Total Talk Time (CUSTOMER): 188822 ms
Interruptions: 5
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/21/1f98231e-6c8c-4100-8a33-da1aae82c858_20250521T15:16_UTC.wav
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[AGENT][NEUTRAL] Morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can you help me with regarding the claim status?
[AGENT][NEUTRAL] You're needing claim status, is that correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][POSITIVE] Yes, I can help you. And what is your name?
[CUSTOMER][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Our callback number is [PII].
[AGENT][NEUTRAL] That was [PII]. Is that correct, ma'am?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] That is what I said, yes, sir. And how many claims do you have then to check status on?
[CUSTOMER][NEUTRAL] 11 only.
[AGENT][NEUTRAL] Yes, OK. And what is that member's policy number, please?
[CUSTOMER][NEUTRAL] It is D 43,730,860.
[AGENT][NEUTRAL] OK, now [PII], thank you, but that is not an APO policy number. Were you trying to reach APL or 90 degree benefits?
[CUSTOMER][POSITIVE] But actually, I called that number they give you your number. You connected with that.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, [PII], so what is the APO policy number?
[AGENT][NEUTRAL] I can't look up the member's information with the D number. No, so that's not our policy number.
[CUSTOMER][NEUTRAL] It is A D
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] What is the patient's last name then?
[CUSTOMER][NEUTRAL] It is [PII]
[AGENT][NEUTRAL] [PII] and the first name?
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] It is [PII]
[AGENT][NEUTRAL] One moment please while I locate the member's information.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] What.
[AGENT][NEUTRAL] And any information that I do provide for you will be a verification of benefits and not a guarantee of payment. What is the patient's date of birth?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So the correct policy number that you should have for this number is 2,491,540.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And what is the date of service and total bill amount, please?
[CUSTOMER][NEUTRAL] OK. The date of service is [PII] and total bill amount is $997.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And what is the name of the provider group on this claim?
[CUSTOMER][NEUTRAL] It is Leportera.
[AGENT][NEUTRAL] What's the tax ID number?
[CUSTOMER][NEUTRAL] Uh, OK. The, uh, the tax ID number is [PII].
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Alright, give me just a moment then. I'm having to pull some additional information.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK then so this claim was received.
[AGENT][NEUTRAL] The received date is going to be.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] It was processed and denied on [PII].
[AGENT][NEUTRAL] The claim number is 351-0968.
[AGENT][NEUTRAL] And the reasons for the denial is that this policy does not provide a wellness expense benefit.
[AGENT][NEUTRAL] And also the outpatient rider only allows payment for outpatient surgery in an outpatient hospital or physician office. Therefore, no benefits are payable.
[AGENT][NEUTRAL] [PII], are you still there?
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yes, yes, I'm here. Can you repeat that, yes, yes, yes, I'm here.
[AGENT][NEGATIVE] One of the denial reasons states.
[CUSTOMER][NEUTRAL] Yes, I'm here.
[AGENT][NEGATIVE] This policy does not.
[AGENT][POSITIVE] Provide a wellness expense benefit.
[AGENT][NEUTRAL] That is on the 99396.
[AGENT][NEGATIVE] And all of the other codes on the claim were denied stating.
[AGENT][NEUTRAL] The outpatient rider only allows payment for outpatient surgery.
[AGENT][NEUTRAL] In an outpatient hospital or physician's office.
[AGENT][NEGATIVE] Therefore, no benefits are payable.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Therefore, no benefits for payers, correct?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK. Uh, and
[AGENT][NEUTRAL] And if you need a copy of that explanation of benefits then with that remark on it, you should be able to print that by going to our portal which is located at secured.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK. Can you tell me your name?
[AGENT][NEUTRAL] Again, my name is [PII], and you would use my name along with today's date as your call reference number.
[CUSTOMER][NEUTRAL] OK. Uh, [PII], so I'm sorry, but, uh, here in, in my UBD dinner for non-covered charges.
[CUSTOMER][NEUTRAL] With remark code and 130.
[AGENT][NEUTRAL] I'm sorry, what is your question?
[CUSTOMER][NEUTRAL] Uh, can you just tell me why it is not?
[AGENT][NEUTRAL] Yes, sir, it's not covered under this limited benefit plan. The member's policy does not cover wellness and it does not cover as I read the remark on the other.
[CUSTOMER][NEUTRAL] 84.
[CUSTOMER][NEUTRAL] It is under the provider contact or patient?
[AGENT][NEUTRAL] No sir, no sir, I just said that it was under the member's plan. The member's plan does not cover it.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. Thank you so much, uh, [PII].
[AGENT][POSITIVE] Well, you're very welcome. Is there anything else that I can help you with?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, no, thank you. But I didn't give you, can you tell me Cha number?
[AGENT][NEUTRAL] Can I tell you what? The reference number it's my name and today's date.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, your name is correct.
[AGENT][NEUTRAL] That is correct. That is the reference number for our call.
[CUSTOMER][POSITIVE] OK, thanks.
[CUSTOMER][NEGATIVE] Uh, [PII], I'm really sorry, but you just tell me again the reason, please, uh, your sound is lagging.
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEGATIVE] No, sir, you're, there's background noise where you're located that's making it difficult for me to hear you. The reason for the denial says this policy does not provide a wellness expense benefit.
[CUSTOMER][NEUTRAL] Please, uh.
[AGENT][NEUTRAL] And the other codes were denied as the outpatient rider.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Only allows payment.
[AGENT][NEUTRAL] For outpatient surgery.
[AGENT][NEUTRAL] In an outpatient hospital or physician office.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] It was.
[AGENT][NEGATIVE] Therefore, no benefits are payable.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Hang on one second.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEGATIVE] Therefore, no benefits.
[AGENT][NEUTRAL] are payable.
[CUSTOMER][NEUTRAL] For pair, correct?
[AGENT][NEUTRAL] are payable.
[CUSTOMER][NEUTRAL] Payable.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, OK. Thank you so much.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And again, is there anything else that I can help you with today?
[CUSTOMER][POSITIVE] OK. No, thank you so much. Thank you.
[AGENT][POSITIVE] OK. Well, thank you again for calling APL and I hope you have a very nice day, ma'am.