AccountId: 011433970860
ContactId: 231c96bf-0f65-405a-9b6a-3c4eb8d475c9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 763919 ms
Total Talk Time (AGENT): 157245 ms
Total Talk Time (CUSTOMER): 280750 ms
Interruptions: 4
Overall Sentiment: AGENT=0.7, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/231c96bf-0f65-405a-9b6a-3c4eb8d475c9_20250207T16:12_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII]. I'm calling from the provider office and I'm looking for the claim status. Can you please help me out with this?
[AGENT][NEUTRAL] Sure, I can assist you with claim status, Ms. [PII], and may I have a callback number just in case we get, we get disconnected?
[CUSTOMER][NEUTRAL] Yeah, sure. The callback number [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Thank you. And you're calling from Ms. [PII]?
[CUSTOMER][NEUTRAL] Provider of Johns Hopkins University, Maryland.
[AGENT][NEUTRAL] I'm sorry, you said Doctor [PII]?
[CUSTOMER][NEUTRAL] Johns Hopkins University.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK. Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] The policy number is 01699768M as in Mary L as in Lima 8.
[AGENT][POSITIVE] Mm thank you.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah, my patient name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] And may I know your name, please?
[AGENT][NEUTRAL] All right. My name is [PII].
[CUSTOMER][NEUTRAL] I'm.
[CUSTOMER][POSITIVE] OK. Thank you so much, sir.
[AGENT][NEUTRAL] You're welcome. And may I have um the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Date of service [PII], amount of $1,293.25.
[AGENT][NEUTRAL] OK, and that was [PII]. Let's see.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK. And for future, you can check claim status online through our website at [PII] and that's just optional. And one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, let me pull the COB bear with me.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][POSITIVE] It's OK. Take your time.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] I I.
[AGENT][NEUTRAL] I'm still waiting on the EOB, bear with me.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, you see that.
[CUSTOMER][NEUTRAL] E H G.
[CUSTOMER][NEUTRAL] No
[AGENT][NEUTRAL] OK. So it looks like we processed this claim on [PII] and the claim was denied. The reason for this denial is that office visits are not covered by the policy and service rendered in office is not covered by the policy.
[CUSTOMER][NEUTRAL] you know
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That.
[CUSTOMER][NEUTRAL] OK, is not covered under the patient plan, right? OK, allow me a moment. And what about the other code, the code 31575.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] OK, for 31579, it is being denied because the services was rendered.
[CUSTOMER][NEUTRAL] And uh in the office, so that is not covered, right?
[AGENT][NEUTRAL] Mhm. And it's not covered. Correct. Mhm.
[CUSTOMER][NEUTRAL] Services is performed.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, allow me a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Can you please provide me the claim number first?
[AGENT][NEUTRAL] Sure, the claim number is 3,532,680.
[CUSTOMER][NEUTRAL] 353-268-0. OK. Give me a moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] 3157.
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] OK, so the office visit is not covered under the patient plan, right?
[AGENT][NEUTRAL] Correct. Office visits or any office procedures are not covered under the member's plan.
[CUSTOMER][NEUTRAL] like
[CUSTOMER][NEUTRAL] OK. Any procedure which was rendered in office, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] But, I, I found the claim of the date of service [PII], and that is the office visit and let me check once which is paid here and that was under in [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. So that was not performed the office. Give me a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hospital.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. But these services are performed in the hospital. That is why it was paid, right?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Yeah, the reason it was paid is because it was a hospital. It was not an office setting. We do not cover office.
[CUSTOMER][NEUTRAL] OK, OK, so thank you so much. And uh as of now we don't receive the copy of EUB. Can you please help me out with the copy of EB? Can you fax that to you?
[AGENT][NEUTRAL] For this member. Mhm.
[AGENT][NEUTRAL] Mhm. Sure, go ahead with the fax number.
[CUSTOMER][NEUTRAL] Yeah, it's 410.
[CUSTOMER][NEUTRAL] 367,230
[AGENT][NEUTRAL] I'm sorry, 410367. What is the last four?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] 2394.
[AGENT][NEUTRAL] 2394. Again, that's 4103672394 for the fax number.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and to your attention, Ms. [PII]?
[CUSTOMER][NEUTRAL] Yeah, that's my attention.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK. Do you mind holding for me while I send this out to you while I got you on the line?
[CUSTOMER][NEUTRAL] Yeah, please.
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][NEGATIVE] You are on hold.
[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 Ms. [PII]. OK, I went ahead and send that over to you. It should be there in a few minutes. Is there anything else I'm gonna help you with [PII]y?
[CUSTOMER][NEUTRAL] Uh, no, that's all. And uh I'm ready for the call reference number.
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will.
[CUSTOMER][POSITIVE] OK, thank you so much for that. You have a wonderful day, so that's all for this call.
[AGENT][NEUTRAL] Mhm
[AGENT][POSITIVE] OK, thank you for calling APR. Have a good day. Bye bye Miss [PII].
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] I