AccountId: 011433970860
ContactId: 26475571-049d-4bb5-96c8-99e915de83c0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 540929 ms
Total Talk Time (AGENT): 202385 ms
Total Talk Time (CUSTOMER): 228294 ms
Interruptions: 9
Overall Sentiment: AGENT=0.9, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/13/26475571-049d-4bb5-96c8-99e915de83c0_20250513T20:41_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Hi, this is [PII]. I'm calling from Health Texas Provider Network to check on a claim status, and I'm really sorry, your name is?
[AGENT][NEUTRAL] [PII] and your name again? I'm sorry, I didn't understand you either.
[CUSTOMER][NEUTRAL] Bye bye
[CUSTOMER][NEUTRAL] Sure. My name is [PII] spelled as [PII]. Initial of my last name is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Thank you. And the initial to my last name is [PII].
[AGENT][NEUTRAL] And [PII], you said that you need to check the status on one claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] That is correct, yeah. Yeah.
[AGENT][NEUTRAL] Is that correct?
[AGENT][NEUTRAL] Yes, I can help you with that. And [PII], what is your callback number, please?
[CUSTOMER][NEUTRAL] Callback number is [PII].
[AGENT][NEUTRAL] Thank you. And what is the member's policy number, please?
[CUSTOMER][NEUTRAL] Uh, it is 25315.
[AGENT][NEUTRAL] OK, that's not a policy number, that would be a group number. There should be another number on the member's ID card.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] that would be a great
[CUSTOMER][NEUTRAL] And I don't know all the numbers.
[CUSTOMER][NEUTRAL] Um, I do not have any other, uh, number apart from this one.
[CUSTOMER][NEUTRAL] Is it, it starts with Z as in Zulu?
[AGENT][NEUTRAL] What is that number again?
[AGENT][NEUTRAL] I'm sorry, does it start with what, [PII]?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Uh, how, like, what is the number of
[CUSTOMER][NEUTRAL] What are the numbers of uh
[CUSTOMER][NEUTRAL] Includes in this member ID.
[CUSTOMER][NEUTRAL] Is it it starts with the numbers.
[AGENT][NEUTRAL] OK, do you have a
[AGENT][NEUTRAL] Z as in zebra? No, sir, it would not. What is that? Give me that first number you gave me again and I'll have to try to look it up.
[CUSTOMER][NEUTRAL] Yeah. OK.
[CUSTOMER][NEUTRAL] Sure. It is 25315.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][POSITIVE] Thank you one moment.
[AGENT][NEUTRAL] And uh what is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII] and the date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And any information [PII], that I do provide for you today will be a verification of benefits and not a guarantee of payment. Uh, what is her date of birth?
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] OK, so the correct policy number, [PII], that you should have for this number is 02.
[CUSTOMER][NEUTRAL] That you should have for this number is 02.
[AGENT][NEUTRAL] 457337
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh one moment.
[CUSTOMER][NEUTRAL] Yeah, at least I.
[AGENT][NEUTRAL] What is the date of service and total bill amount for her place?
[CUSTOMER][POSITIVE] Thank
[CUSTOMER][NEUTRAL] Day of service is [PII] with a bail amount of $421.90.
[AGENT][NEUTRAL] 4431.90. Is that correct?
[CUSTOMER][NEUTRAL] 421, 421.90.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And again, [PII], any information provided will be a verification of benefits and not a guarantee of payment.
[CUSTOMER][NEUTRAL] To make some complication.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So just one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, [PII] said this claim was received. It was received on [PII].
[CUSTOMER][NEUTRAL] The [PII].
[AGENT][NEGATIVE] It was processed and denied on the same day.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] The claim number is 35,799,970.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] 9
[AGENT][NEUTRAL] And the reason for the denial states policy provides no benefits for the treatment of conditions other than a sickness or injury as defined by the policy.
[CUSTOMER][NEUTRAL] And the
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] And a sickness or injury?
[CUSTOMER][NEUTRAL] OK. So it is not covered under the patient's plan, right?
[AGENT][POSITIVE] Yes, sir, that is correct.
[CUSTOMER][NEUTRAL] So, OK, what is specifically is not covered? It is the procedure code or the diagnosis code?
[AGENT][NEUTRAL] There's one code on this claim.
[CUSTOMER][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Oh, I'm sorry, yeah. So it is the procedure code, right?
[AGENT][NEGATIVE] And that is not covered under this policy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, so the
[CUSTOMER][NEUTRAL] The procedure is not covered in the patient's policy, right?
[AGENT][NEUTRAL] Yes, policy provides no benefits for the treatment of conditions other than sickness or injury as defined by the policy.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] 008376.
[AGENT][NEUTRAL] And if you need a copy of this explanation of benefits, you can print it now that you have the claim number, [PII], you should be able to print it from our portal by going to [PII].
[CUSTOMER][NEUTRAL] I don't.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm. OK. So for this one, it was in IS policy provides no benefit apart from sickness and what else.
[CUSTOMER][NEGATIVE] Illness.
[AGENT][NEUTRAL] Policy provides no benefits for the treatment of conditions.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Other than sickness or injury?
[AGENT][NEUTRAL] As defined by the policy.
[CUSTOMER][NEUTRAL] That's behind the back.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] We're not.
[CUSTOMER][NEUTRAL] They
[CUSTOMER][NEUTRAL] So total goes to the patient responsibility like the bill amount?
[AGENT][NEUTRAL] We do not determine patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] be up to the.
[CUSTOMER][NEUTRAL] OK. But uh uh we have uh UOB.
[CUSTOMER][NEUTRAL] Received and it was stating that we have received your claim. However, it is pending due to benefit renewal information from your employer group.
[AGENT][POSITIVE] Correct. And now that it was.
[CUSTOMER][NEUTRAL] Once the information received, we'll continue. Uh-huh.
[AGENT][NEGATIVE] Right, and it was continued and then it was denied for the reason that I read to you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So is there any possibility like if you can send us the EUB, the latest one?
[AGENT][NEUTRAL] Yes, sir. I, yes, sir. If you go to that website that I just gave you with the claim number that I just gave to you, you should be able to print the explanation of benefits that has that remark that I read to you.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I just with the claim that I just.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it here.
[CUSTOMER][NEUTRAL] OK, so what will the call reference for this one?
[AGENT][NEUTRAL] It would be my name along with today's date.
[CUSTOMER][NEUTRAL] It would be
[CUSTOMER][POSITIVE] OK. Thank you so much, [PII] for helping me out. I appreciate it. Mhm.
[AGENT][POSITIVE] OK. Well, you're welcome. Absolutely, [PII]. It was my pleasure. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No, that's it for myself.
[AGENT][POSITIVE] OK, well then, thank you again for calling APL and I hope you have a nice rest of your day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You too. Bye-bye, [PII].
[AGENT][POSITIVE] Thank you. Uh-huh. Bye-bye.
[CUSTOMER][POSITIVE] Thank you.