AccountId: 011433970860
ContactId: 3dbe9276-30b5-4002-9ac4-77c0919db7e1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 380420 ms
Total Talk Time (AGENT): 136042 ms
Total Talk Time (CUSTOMER): 105768 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/30/3dbe9276-30b5-4002-9ac4-77c0919db7e1_20250130T17:41_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hello, uh my name is [PII] calling from provide office and looking for the uh sta status of the claim.
[AGENT][NEUTRAL] Sure, I can assist you with claim status, Mr. [PII], and may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Callback number is [PII].
[CUSTOMER][NEUTRAL] It's a direct line.
[AGENT][NEUTRAL] OK, and you say you're calling from which facility or provider?
[CUSTOMER][NEUTRAL] Medical specialist of Palm Beach.
[AGENT][NEUTRAL] OK, may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Patient policy number is 02496873.
[AGENT][POSITIVE] Thank you, one moment.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] It's [PII]. The date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. And what's the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Date of service is [PII].
[AGENT][NEUTRAL] How much is the total charge?
[CUSTOMER][NEUTRAL] The build amount
[CUSTOMER][NEUTRAL] Bill amount was showing that was the uh
[CUSTOMER][NEUTRAL] $341 even.
[AGENT][NEUTRAL] Let me see if I can find this claim and for future you can check claim status online through our website at [PII].
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] OK, so we processed this twice. um, let me give you the information of the most recent 11 moment.
[AGENT][NEGATIVE] OK, so we received the claim a second time on [PII] and processed on [PII]. The claim was denied stating office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] Office visit not covered by the patient policy.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Covered by patients.
[CUSTOMER][NEUTRAL] Patient policy. Um, give me one second.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Office visit 99204. So which units allowed in patient plan?
[AGENT][NEUTRAL] When you say units, what do you mean?
[CUSTOMER][NEUTRAL] Uh, pardon?
[AGENT][NEUTRAL] When you say units, what do you mean?
[CUSTOMER][NEUTRAL] Uh, uh, sorry, uh, it's not, uh, how many units allowed in the patient plan?
[AGENT][NEUTRAL] OK, what do you mean by unit?
[CUSTOMER][NEUTRAL] Uh, you need that means the services that was uh office visit allowed patient plan like uh.
[AGENT][NEGATIVE] There's no office visit benefit, 0 office visit benefit. There's no office visit benefit.
[CUSTOMER][NEUTRAL] OK. You mean to say this claim patient is not uh eligible for the office visit, right?
[AGENT][NEUTRAL] What I mean to say is that office visits are not covered by this policy.
[AGENT][NEUTRAL] So it's a non-covered service under the policy, under the member's plan.
[CUSTOMER][NEUTRAL] Of business.
[CUSTOMER][NEUTRAL] So do you have the information, uh,
[CUSTOMER][NEUTRAL] Which services covered under the patient plan?
[AGENT][NEUTRAL] OK, this, this is a secondary supplemental plan to the major medical so we cover hospitals, we cover outpatient facilities, um, we cover, let's see.
[AGENT][NEUTRAL] ER urgent care.
[AGENT][NEUTRAL] surgeries?
[AGENT][NEUTRAL] And those are the ones that are covered under the member's plan. So it doesn't cover office visits.
[CUSTOMER][NEUTRAL] Could you uh repeat the which services covered?
[AGENT][NEUTRAL] Do you need me to repeat again what services covered under the plan?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, so it covers hospital.
[CUSTOMER][NEUTRAL] Covered only hospital?
[AGENT][NEUTRAL] Outpatient facilities.
[AGENT][NEUTRAL] Urgent care facilities.
[AGENT][NEUTRAL] Surgery centers.
[AGENT][NEUTRAL] And diagnostic centers.
[CUSTOMER][NEUTRAL] Uh, and the last one, what did you say?
[AGENT][NEUTRAL] Diagnostic centers.
[CUSTOMER][NEUTRAL] Diagnostic.
[AGENT][NEUTRAL] Cents.
[CUSTOMER][NEGATIVE] Mm, it wouldn't it good.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] And uh you have the information about which DX code is not covered?
[AGENT][NEGATIVE] Because office visits are not covered, it's not gonna be covered.
[CUSTOMER][NEUTRAL] OK, OK, so, uh, could you spell out your name?
[AGENT][NEUTRAL] Sure. My name is [PII]. That's [PII]. Last initial [PII].
[CUSTOMER][NEUTRAL] And the reference number?
[AGENT][NEUTRAL] We don't have reference numbers, you can use my name in today's date if you will.
[CUSTOMER][POSITIVE] Thanks for informing. Have a nice day.
[AGENT][POSITIVE] You're welcome. Is there anything else I can help you with today?
[CUSTOMER][NEGATIVE] Uh, no, no.
[AGENT][POSITIVE] OK. Thank you for calling APL. Have a good day. OK. Mm, bye-bye.
[CUSTOMER][POSITIVE] OK. Thank you.