AccountId: 011433970860
ContactId: 25e47ee3-9389-4c0a-b8d7-5e50d9357fdb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 670750 ms
Total Talk Time (AGENT): 205068 ms
Total Talk Time (CUSTOMER): 196031 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/25e47ee3-9389-4c0a-b8d7-5e50d9357fdb_20250429T17:09_UTC.wav
--------------------------------------------
[CUSTOMER][POSITIVE] Wow
[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, yes, I'm calling to check claim status.
[AGENT][NEUTRAL] OK. Do you have the, can I get your name and a good callback number?
[CUSTOMER][NEUTRAL] Sure, it's [PII], and it's [PII].
[AGENT][NEUTRAL] OK, thank you, [PII]. Do you have a uh policy number of the patient?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Uh, yes, let me get that information.
[CUSTOMER][NEUTRAL] So that's 02, excuse me, 02576313.
[AGENT][NEUTRAL] And the patient name and date of birth?
[CUSTOMER][NEUTRAL] It's for [PII] and it's [PII].
[AGENT][NEUTRAL] And we were wanting claim status. Is that correct?
[CUSTOMER][NEUTRAL] I'm following up on a corrected claim that was sent to you guys and that was sent.
[CUSTOMER][NEUTRAL] Actually, no, it's not a corrected claim, just regular claim status. I'm sorry.
[AGENT][NEUTRAL] OK, what was that date of service and bill charges?
[CUSTOMER][NEUTRAL] Uh, [PII] and it's for 4,904 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] And what was the provider name?
[CUSTOMER][NEUTRAL] Glendora digestive disease?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me see 3.
[AGENT][NEUTRAL] OK, looks like we received it on 327-25.
[AGENT][NEUTRAL] Also 328, 25, and let's see.
[AGENT][NEGATIVE] Uh, it looks like we had denied it as only the largest surgical procedure is payable when two or more procedures are performed on the same day.
[CUSTOMER][NEUTRAL] Mm and why is that?
[AGENT][NEUTRAL] According to their policy.
[CUSTOMER][NEUTRAL] So you guys only pay one procedure I've been there with two different sites, excuse me.
[AGENT][NEUTRAL] Uh, yes, I think they just have one surgical benefit. Let me pull up the policy real quick.
[CUSTOMER][POSITIVE] OK, thank you, uh huh.
[AGENT][NEUTRAL] It was two separate sites on the body or was it in the same incision?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] No, two different sites, and I have here when we called to check benefits it says here that the plan will pay up to $2000 for procedure.
[CUSTOMER][NEUTRAL] What would be the allowable amount for each procedure?
[AGENT][NEUTRAL] There's not allowed. This is a hospital indemnity plan, so it just pays a dollar amount.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let me look at those surgical benefits. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, if 2 or more surgical procedures are performed at the same time through the same or different incisions, only one benefit, the largest will be payable.
[CUSTOMER][NEUTRAL] So, different sizes, only one can be paid.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that's because this is what the patient plan has, right?
[AGENT][NEUTRAL] Yes, it's a limited hospital indemnity plan.
[AGENT][NEUTRAL] A supplemental policy.
[CUSTOMER][NEUTRAL] OK, so who would be responsible? OK, who would be responsible for the other procedure? Is it a write-off or will the patient be responsible?
[AGENT][NEUTRAL] We don't
[AGENT][NEUTRAL] We don't determine patient responsibility because this is a supplemental policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so what about the 453-85? How much did you guys allow for that or paid?
[CUSTOMER][NEGATIVE] Because we haven't received payment for.
[CUSTOMER][NEUTRAL] For no procedure.
[AGENT][NEUTRAL] I have the 4,904 total bill charges, is that two different.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Right. Yes, it's two different procedures. Uh-huh.
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] Yeah, so that we didn't pay anything on it. So it's because we paid on a diff
[CUSTOMER][NEUTRAL] But you said
[AGENT][NEUTRAL] We paid on a different surgery for a different provider that was a larger build amount.
[CUSTOMER][NEUTRAL] For the same date of service?
[AGENT][POSITIVE] Yes, correct.
[CUSTOMER][NEGATIVE] OK, so I'm confused, so you guys are not gonna pay at all? I thought you paid only the higher code.
[AGENT][NEUTRAL] The higher charges. So I'll read it again. If two or more surgical procedures are performed at the same time, through the same or different incisions, only one benefit, the largest, will be payable. So whatever provider charges the largest amount, that's what we will pay out of this policy.
[CUSTOMER][NEUTRAL] And that, yeah, and that would be us though because the other fee would be coming from the doctor's office and they're not gonna charge more than than the facility fee.
[AGENT][NEUTRAL] OK, I can get you to our claims department and they could explain it further.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK. Hold on one moment.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] er ing
[CUSTOMER][POSITIVE] Yeah, thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hi, [PII], this is [PII] on the care team. I've got a provider on the line that's having trouble understanding the claim denial on this policy.
[CUSTOMER][NEUTRAL] OK, what is the policy number?
[AGENT][NEUTRAL] Policy number is 358-084-1.
[AGENT][NEUTRAL] Oh, I'm sorry, that's the claim. Let me give you the policy. 257.
[AGENT][NEUTRAL] 631-3. Sorry.
[CUSTOMER][NEUTRAL] For Regelo compost compost.
[AGENT][NEUTRAL] Yeah, yeah, it's he's the um patient, and then I'll give you the claim number.
[CUSTOMER][NEUTRAL] OK, what's the claim number?
[AGENT][NEUTRAL] 358-084-1.
[CUSTOMER][NEUTRAL] It's for [PII] for $4,904.
[AGENT][NEUTRAL] Yeah, I read her the denial code or denial reason verbatim that I also read from the plan policy, the language that says, you know, the surgery can be performed, um, we'll only pay the largest of the two, etc. but she's just not wanting to, um, listen.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, let me see what we got here. Give me a moment.
[AGENT][NEUTRAL] Yes, they had 2 surgeries on the same day, but we paid.
[AGENT][NEUTRAL] I guess the, we pay the.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] This claim is for the facility, not the surgeon.
[AGENT][NEUTRAL] OK, so then did we deny it wrong then?
[CUSTOMER][NEUTRAL] Mm, so the surgeon's bill, let me see where we got the surgeon's bill for this one.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEGATIVE] Yeah, we pay the surgeon's bill. This is for the facility, so it actually should have been denied based off the facility, not the surgery.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Yeah, it was processed incorrectly cause the surgeon's bill has already been paid. This is just for the surgery being being performed at this facility.
[AGENT][NEUTRAL] OK, um, do we send out correct?
[CUSTOMER][NEUTRAL] So the examiner, yeah, it'll need to be reprocessed, yeah.
[AGENT][NEUTRAL] Explanation.
[AGENT][NEUTRAL] OK. Uh, do you mind explaining that to her?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] I'll get her on the line and
[CUSTOMER][NEUTRAL] And what's her name?
[AGENT][NEUTRAL] Her name's uh [PII] um and then I've got her callback number too if you want that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And [PII].
[CUSTOMER][NEUTRAL] Yeah, I'll explain to her because the outpatient benefit does not cover, the outpatient benefit only covers for emergency room or urgent care physician's office. It doesn't cover any outpatient facility under the outpatient benefit under this policy.
[AGENT][NEUTRAL] OK, OK, I'm gonna introduce you and then I'll release her.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, I've got uh [PII] on the line. She's from our claim support services and she's gonna be able to help you on this claim, OK?
[CUSTOMER][POSITIVE] Thank you. I appreciate your help.
[AGENT][POSITIVE] Thank you.