AccountId: 011433970860
ContactId: 22222695-a5dc-4d5c-90df-8028779b7c6f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1122630 ms
Total Talk Time (AGENT): 258979 ms
Total Talk Time (CUSTOMER): 369295 ms
Interruptions: 20
Overall Sentiment: AGENT=1, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/09/22222695-a5dc-4d5c-90df-8028779b7c6f_20250509T14:19_UTC.wav
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[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Calling APPL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] from Community Medical Associates. Uh, to check on a claim status.
[AGENT][NEUTRAL] OK, I can help you with claim status, Ms. [PII]. What is your callback number, ma'am?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and then may I please get the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Hello
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] the.
[AGENT][NEUTRAL] Are you there?
[CUSTOMER][NEUTRAL] [PII]. Yes. The name of the name of the member is [PII]. Date of birth is [PII]. And do you need your ID number?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] D as in Delta 42026474.
[AGENT][NEUTRAL] OK, and then for Ms. [PII], can you please spell her first name and last name for me?
[CUSTOMER][NEUTRAL] In the.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, can you spell it, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, can you spell it in English for me, please?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Or do you have her social?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mm, uh, the first name is [PII] the last name [PII] [PII]
[AGENT][NEUTRAL] OK. Let me look her up real quick.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] is.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] In the.
[AGENT][NEUTRAL] OK, I'm going to need to transfer you now on over to IMA I'm going to give you that phone number just in case the call gets disconnected during the transfer.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] do you want to.
[AGENT][NEUTRAL] You just let me know when you're ready for it.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Yes, yes, sir.
[AGENT][NEUTRAL] OK, it's [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, the same number I have called.
[AGENT][NEUTRAL] And it's gonna be a brief hold while I transfer you on over.
[AGENT][NEUTRAL] OK, do you have the member's social security number?
[CUSTOMER][NEUTRAL] Actually the same number I have called.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] No, you can transfer the call to that department.
[AGENT][NEUTRAL] OK, I'm trying to find um.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] The member for you?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, there is um.
[AGENT][NEUTRAL] But I'm not pulling it up in my system.
[CUSTOMER][NEUTRAL] OK, the SSN number is [PII].
[AGENT][POSITIVE] Thank you, let me try it that way.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] OK and then on what um what kind of service are you, are you checking the claim status for? Is it for um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Medical, dental, which one?
[CUSTOMER][NEUTRAL] Medical.
[AGENT][NEUTRAL] Medical, OK.
[AGENT][POSITIVE] I think I have found her, yay, good deal. Alright, and then what is um the data service and the charge amount?
[CUSTOMER][NEUTRAL] 35 of 2025 for $81 even.
[AGENT][NEUTRAL] OK, I'm gonna put you on a brief hold, Miss [PII], while I search this claim for you and I will be right back.
[CUSTOMER][NEUTRAL] Mm sure.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, thank you for holding for me, Ms. [PII]. Can you please give me the name of the facility you're calling for?
[CUSTOMER][NEUTRAL] Oh, that is.
[CUSTOMER][NEUTRAL] Community Medical Associates.
[AGENT][NEUTRAL] OK, I do have the claim for you. The claim number is
[AGENT][NEUTRAL] 357 7.
[AGENT][NEUTRAL] 581
[CUSTOMER][NEUTRAL] Maybe.
[AGENT][NEUTRAL] The claim has been denied for two reasons. One is vein puncture.
[CUSTOMER][NEUTRAL] Uh, just give me a minute. Just give me a minute. Uh, what's the claim number? 3577?
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes, 357-758-1.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] And the claim has been denied for two reasons. One is veina puncture is not covered by the policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the other reason is
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Really
[AGENT][NEUTRAL] The outpatient rider only allows payment for outpatient surgery in an outpatient hospital or physician's office. Therefore, no benefits are payable.
[CUSTOMER][NEUTRAL] So for outpatient uh visit, one, you guys will pay only for outpatient visit, right?
[AGENT][NEUTRAL] Yeah, outpatient hospital or physician's office?
[CUSTOMER][NEUTRAL] Only physician offices it is covered, right? OK, thank you so.
[AGENT][NEUTRAL] Or an outpatient hospital, yes.
[CUSTOMER][NEUTRAL] Outpatient hospital. So this is, this is the denial reason. And in that case, uh, the previous rep has given the claim status like uh that with the claim number 202503101089.
[CUSTOMER][NEUTRAL] Uh, the claim was denied, uh, like, ma.
[AGENT][NEUTRAL] That is not one of our claim numbers.
[CUSTOMER][NEUTRAL] So this is not your claim number?
[CUSTOMER][NEUTRAL] OK, thank you so much in that, in that case, thank you so much. Um, so this is your claim number. Uh, can I have the receipt and the process the date of the claim?
[AGENT][NEUTRAL] No, ma'am.
[AGENT][POSITIVE] Yes, ma'am. Let me look that up for you real quick.
[CUSTOMER][NEUTRAL] Yeah, sure, sure.
[AGENT][NEUTRAL] OK, we received the claim on [PII] and processed it on [PII].
[CUSTOMER][NEUTRAL] And denied as non, uh, in that case, can I get the copy of UB to my fax number?
[AGENT][NEUTRAL] Yes, what is your fax number?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and what was the first part? I got the [PII]. What was the first three digits?
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold, Ms. [PII], while I get that claim ready for you and then I'll be right back.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding for me, [PII]. I have that fax on its way to you now.
[AGENT][NEUTRAL] Are you there, [PII]?
[CUSTOMER][POSITIVE] Uh, yeah, thank you so much for your help. Actually, I have one more claim for the same number. Could you help me with that too?
[AGENT][NEUTRAL] Yes ma'am, what is the date of service and the charge amount?
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] [PII] for $28 even.
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold while I look this one up and I'll be right back with you, ma'am.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] [PII], what is the name of the facility for this claim?
[CUSTOMER][NEUTRAL] Oh, personal name us.
[CUSTOMER][NEUTRAL] Community Medical Associate same facility.
[AGENT][NEUTRAL] OK, alright. I'm gonna put you back on hold. I'm gonna keep searching.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you [PII] for holding for me. So I have found the claim.
[AGENT][NEUTRAL] The claim number is 357.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 5041.
[AGENT][NEUTRAL] The claim has been denied because vana puncture is a non-covered service.
[CUSTOMER][NEUTRAL] You know.
[CUSTOMER][NEUTRAL] Can I have received in the office today?
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] This one was received on [PII] and processed on [PII].
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Oh, what is the received today?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] [PII] and processed on [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So received invo on same day right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Under this claim number, OK, this is, uh, only your claim number. Uh, can I get a caller reference number for the number?
[AGENT][NEUTRAL] Yes, you can use my name [PII] and today's date.
[CUSTOMER][NEUTRAL] And I do need a copy of this UB to the same fax number. You are on hold.
[AGENT][POSITIVE] OK, I'm gonna put you on a quick hold and I'll get that ready for you. I'll be right back.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding for me, Ms. [PII]. I've got that fax on its way to you now.
[CUSTOMER][POSITIVE] Hm thank you so much for your assistance. Have a great day.
[AGENT][POSITIVE] You too and you have a wonderful weekend. Is that everything I can help you with today?
[CUSTOMER][POSITIVE] Yeah, yeah. Thank you so much. Have a great day.
[AGENT][POSITIVE] You're welcome. Thank you for calling APL, Ms. [PII]. Bye-bye, ma'am.