AccountId: 011433970860
ContactId: 358ccb28-97e8-4466-b50e-ddf35c600c8a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 448260 ms
Total Talk Time (AGENT): 204031 ms
Total Talk Time (CUSTOMER): 127634 ms
Interruptions: 2
Overall Sentiment: AGENT=0.7, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/358ccb28-97e8-4466-b50e-ddf35c600c8a_20250207T17:26_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], yes, I have a question on a process claim.
[AGENT][NEUTRAL] OK, I can look at that claim for you. uh, what was your name? I'm sorry.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] [PII], OK, and are you with a provider, [PII]?
[CUSTOMER][NEUTRAL] Yes, California emergency physician.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Got it and then can I get a good call back number from you please in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, my direct line is [PII].
[AGENT][NEUTRAL] Thank you. Do you have the policy number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, it's 02450890.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and uh what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEGATIVE] Sorry, bear with me just a moment. My system is going so slow.
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] Here we are, OK, so sorry about that wait. I appreciate you verifying that information. OK, um, do you have a claim number or the date of service?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yes, your claim number.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] It's 354-2367.
[AGENT][NEUTRAL] OK, thank you. One moment, take a look.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so it looks like we paid a benefit of $25. We we just needing some clarification?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, because the other two procedures were unpaid, and I'm not sure if there was a network access to process this claim.
[AGENT][NEUTRAL] Let's see one moment.
[AGENT][NEUTRAL] OK, so yes, it looks like there were a couple of items. Um, one states, uh, only one surgical benefit is allowed when more than one surgical procedure is performed in the same operative field. So the benefit provided allowed for the last surgery performed in the operative field.
[AGENT][NEUTRAL] And the other states, if during this hospital consignment you required service, services as excuse me, services of a physician other than a surgeon, then we would need that itemized bill for review. So looks like that one might just be missing some information.
[AGENT][NEUTRAL] Um, as for the one that did pay the 25, that meant their excuse me, met their maximum, uh, benefit payable for the date of service.
[CUSTOMER][NEUTRAL] OK, so what information is missing on the um the 99284?
[AGENT][NEUTRAL] 19284.
[AGENT][NEUTRAL] OK, so that one was stating um if the patient required services of a physician other than the surgeon then we would need that itemized bill.
[CUSTOMER][NEUTRAL] OK, and who are you requesting the itemized bill from because we did submit a medical bill.
[AGENT][NEUTRAL] Was it
[CUSTOMER][NEUTRAL] And the patient went to the emergency room.
[AGENT][NEUTRAL] Sorry, um, I didn't mean to interrupt. So was it, did they receive services from a physician other than the surgeon?
[CUSTOMER][NEUTRAL] Yes, the patient went to the emergency room.
[AGENT][NEUTRAL] Mhm. OK, so it would be from.
[CUSTOMER][NEUTRAL] It's an emergency room physician.
[AGENT][NEUTRAL] Sure, OK, so then it would be from them so you did say that you uh submitted that information?
[CUSTOMER][NEUTRAL] Well, our bill is for the physician, so I'm not sure what's missing.
[AGENT][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] OK, um, let me, if you don't mind, [PII], I'm gonna put you on a brief hold, um, I'm gonna reach out to our claims specialist so we could kind of get some clarification if that information was correct but just might need a second look at it, um, I'll be right back with you, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[AGENT][NEUTRAL] Hi [PII], this is [PII]. How are you?
[CUSTOMER][POSITIVE] I'm good. How about you?
[AGENT][NEUTRAL] I was expecting to get you in the queue.
[AGENT][NEUTRAL] I don't, I think I might need to call back. I don't know because I, it's, I was trying to get to claims.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Uh oh, yeah, it depends on what type, uh, are you trying to call somebody in claims in the HI or is it?
[AGENT][NEUTRAL] Yeah, yeah, uh, somebody who had submitted a claim for HI and they needed some clarification.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK. Did you try to call the, um, what's it called, what's it called, what's it called, the do do do do do do do claim support? Yeah, it's, it's OK.
[AGENT][POSITIVE] Oh claim support you're right you're right. I'm sorry. I appreciate it this is how we learn.
[CUSTOMER][POSITIVE] It's fine. Have a good day. You're welcome. Bye-bye.
[AGENT][POSITIVE] Thanks, bye.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[AGENT][NEUTRAL] Hi [PII], this is [PII] over on the care team. How are you today?
[CUSTOMER][POSITIVE] I'm doing well thanks [PII] how are you?
[AGENT][NEUTRAL] Doing all right, thank you. I have a provider on the line uh calling regarding an HI claim um for one of the items it's stating that we needed the itemized bill from a physician if it was not the surgeon. Um, she said that she did send that information, so she wants to review what was submitted.
[CUSTOMER][NEUTRAL] Certainly, um, do you have a policy number here?
[AGENT][NEUTRAL] Yes, it is 02450890.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it is for the claim uh ending in 367.
[CUSTOMER][NEUTRAL] And do you um have the information of who I'm speaking to?
[AGENT][NEUTRAL] Yes, her name is [PII].
[AGENT][POSITIVE] And I've got that call back if you need that.
[CUSTOMER][NEUTRAL] OK, go ahead when you're ready please.
[AGENT][NEUTRAL] Mhm it is [PII].
[CUSTOMER][POSITIVE] Thank
[AGENT][NEUTRAL] 3952729
[AGENT][NEUTRAL] And she's specifically asking about the procedure code 9984.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] 99 OK 9284 OK and it's [PII], correct? Did I hear that right? OK, alright, you can transfer her and the patients have been verified, [PII].
[AGENT][NEUTRAL] Right, yes.
[AGENT][POSITIVE] All right, thanks, [PII].
[AGENT][NEUTRAL] Oh yes it's all been verified.
[CUSTOMER][POSITIVE] OK thanks great thank you so much bye.
[AGENT][POSITIVE] Thank you bye bye.