AccountId: 011433970860
ContactId: 2e3659eb-17d8-46fd-9ac0-b66bf0388c90
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 680890 ms
Total Talk Time (AGENT): 210138 ms
Total Talk Time (CUSTOMER): 136936 ms
Interruptions: 2
Overall Sentiment: AGENT=1.3, CUSTOMER=1.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/19/2e3659eb-17d8-46fd-9ac0-b66bf0388c90_20250619T14:35_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello, good morning. This is [PII] from Prisma Health. I just wanted to get information for this one claim I have.
[AGENT][NEUTRAL] OK, you're needing claim status, [PII], is that correct?
[CUSTOMER][POSITIVE] That is right.
[AGENT][POSITIVE] Yes, ma'am. I can help you with that. And what is your callback number?
[CUSTOMER][NEUTRAL] Oh, my direct line is [PII].
[AGENT][POSITIVE] Thank you and the member's policy number please.
[CUSTOMER][NEUTRAL] All right. And before I provide that, please be aware that this call is being recorded for quality assurance and training purposes. Uh, the member ID is 01867894.
[AGENT][NEUTRAL] Thank you, one moment, [PII], while I get the member's information pulled up.
[CUSTOMER][POSITIVE] All right. Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] And then the information again that I do provide for you today, [PII] will be a verification of benefits and not a guarantee of payment. What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] OK. So this is for [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Thank you and what is the um date of service and total bill amount for him, please?
[CUSTOMER][NEUTRAL] Yes, this is for the date range from [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the total charge is $508.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] OK. I'm sorry, your first name is [PII]?
[AGENT][POSITIVE] That is correct and you will also be using my name along with today's date as your call reference number if you need one.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And just the um initial to your last name?
[AGENT][NEUTRAL] [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so just give me a few moments please to look through some information here.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[AGENT][POSITIVE] Perfect
[AGENT][NEUTRAL] OK, so you said that on this range that you gave me, is that a total bill amount? Was this for an inpatient stay? What is this exactly for?
[CUSTOMER][NEUTRAL] Um, hold on, let me check. This don't give me the information, but I do have here, uh, a claim number. Will that, will that work?
[AGENT][NEUTRAL] Yes, ma'am. What is the claim number you have?
[CUSTOMER][NEUTRAL] Uh yes. The claim number we have here is 3489207.
[AGENT][NEUTRAL] You said 348-9207. Is that correct?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK. It said that claim number is not even associated with this number.
[AGENT][NEUTRAL] I'm not sure.
[CUSTOMER][POSITIVE] Oh, OK. Mm. All right. I'm sorry about that.
[CUSTOMER][NEUTRAL] Hold on.
[AGENT][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hold on, ma'am. I'm sorry. Let me gather information here.
[AGENT][NEUTRAL] 3489 yeah.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, wait just a moment. OK, I, I'm so sorry. I overlooked something. I apologize about that, [PII]. One moment.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] OK, and how can I help you with that claim, [PII]?
[AGENT][POSITIVE] I have it pulled up. How can I help you with that?
[CUSTOMER][NEUTRAL] All right. So,
[AGENT][NEGATIVE] This was denied.
[CUSTOMER][NEUTRAL] OK, sir.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the reason for the denial on here.
[AGENT][NEUTRAL] On each of the codes.
[AGENT][NEUTRAL] State covered diagnostic benefits.
[AGENT][NEUTRAL] are limited to MRI.
[AGENT][NEUTRAL] CT
[AGENT][NEUTRAL] Colonoscopy and other diagnostic testing is not covered under the policy. Therefore, no benefits are payable for this data service.
[AGENT][NEUTRAL] This is not major medical insurance. This is a limited benefit plan.
[AGENT][NEUTRAL] This is a hospital indemnity limited benefit plan that
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] He had with us.
[CUSTOMER][NEUTRAL] I need to
[AGENT][NEUTRAL] Uh-huh
[CUSTOMER][NEUTRAL] Mhm. OK. So, yeah, it's limited, so not covered under this policy. Um, OK, it's not denied for any medical records. It's just that it's not covered, right?
[AGENT][NEUTRAL] Correct. This particular service and test is not covered under this member's plan.
[AGENT][NEUTRAL] So the, again, I'll read it to you. Covered diagnostic benefits are limited to an MRI, CT, and a colonoscopy.
[CUSTOMER][NEUTRAL] OK, I.
[AGENT][NEUTRAL] Other diagnostic testing is not covered under the policy. Therefore, no benefits are payable for this data service.
[CUSTOMER][POSITIVE] OK, perfect. By any chance, if somehow they
[AGENT][NEUTRAL] Yes ma'am. And if you
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Uh, if for some reason, just in case they, uh, they attempt or try to appeal it, uh, what is the time frame?
[AGENT][NEUTRAL] An appeal must have been filed within 180 days from the date of the decision.
[CUSTOMER][NEUTRAL] And uh what is the date of the decision? I'm sorry.
[AGENT][NEUTRAL] One moment, let me get back to that.
[AGENT][NEUTRAL] This claim was processed on [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] All right. OK. Well, thank you for providing me the detailed denial for this one. I guess this is all.
[AGENT][NEUTRAL] For you, yes, ma'am.
[AGENT][NEUTRAL] And if you need a copy, [PII], I don't know, you may already have our portal website but if should you need a copy of the explanation of benefits, you can actually print that or should be able to by going to our portal website located at [PII].
[CUSTOMER][POSITIVE] All right. OK, perfect. Well, have a beautiful day and thank you for assisting me on this 17.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Uh, well, absolutely. You're very welcome. So I hope you have a wonderful day as well, if that's all I can help you with, and thank you again for calling APL.
[CUSTOMER][POSITIVE] All right. Thank you. Have a good one.
[AGENT][POSITIVE] All right. You're welcome. You too. Bye-bye.
[CUSTOMER][POSITIVE] All right, thank you.
[CUSTOMER][NEUTRAL] OK. Bye-bye.