AccountId: 011433970860
ContactId: 44aa3d7f-f6f8-402e-b119-054668b3c6d5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 539030 ms
Total Talk Time (AGENT): 140422 ms
Total Talk Time (CUSTOMER): 217288 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/30/44aa3d7f-f6f8-402e-b119-054668b3c6d5_20250530T19:18_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APL this is [PII] how can I help you?
[CUSTOMER][NEUTRAL] Hello, my name is [PII], and I'm calling from provider's office. Today I call you regarding claim denials. And before we proceed, we will let you know that the call has been recorded for quality and training purposes. So would you like to continue with us?
[AGENT][NEUTRAL] Yes, um, can I get your name one more time?
[CUSTOMER][NEUTRAL] Yes, sure. My name is [PII]. So it's spell it as A [PII] name [PII]. Can you spell it out your name for me?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, [PII]. Thank you so much.
[AGENT][NEUTRAL] Can I get a good callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure. Our callback number is going to be [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And what's the policy number?
[CUSTOMER][NEUTRAL] Policy number 02320074.
[AGENT][NEUTRAL] OK. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Can you verify the patient's name and date of birth for me, please?
[CUSTOMER][NEUTRAL] Sure. Patient's name is [PII] Date of birth [PII].
[AGENT][NEUTRAL] OK, I have a different last name.
[CUSTOMER][NEUTRAL] And the date of birth?
[CUSTOMER][NEUTRAL] With [PII]
[AGENT][NEUTRAL] Is there a different last name that she would have?
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Wait, wait. Let me just check again.
[CUSTOMER][NEUTRAL] Yes, that is correct. [PII] and patient's ID 02320074.
[AGENT][NEUTRAL] I have her under a different last name.
[AGENT][NEUTRAL] But you said you got a denial letter from us?
[CUSTOMER][NEGATIVE] I cannot understand.
[CUSTOMER][NEUTRAL] I do apologize. I cannot understand.
[AGENT][NEUTRAL] We don't have her last, can you spell her last name for me, please?
[CUSTOMER][NEUTRAL] Of the patient's name?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And what about her last name?
[CUSTOMER][NEUTRAL] Sorry, it's uh wait.
[CUSTOMER][NEUTRAL] Last name [PII]
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] What's the date of service?
[CUSTOMER][NEUTRAL] [PII] and total bill amount $340.
[AGENT][NEUTRAL] You said $340?
[CUSTOMER][NEUTRAL] Yes, $340.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Looks like we received this claim on [PII].
[AGENT][NEUTRAL] The claim was processed on [PII]. Claim number is 35.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 73
[AGENT][NEUTRAL] 281.
[CUSTOMER][NEUTRAL] 3573281. OK.
[AGENT][NEUTRAL] Yes, ma'am. And it looks like this claim was denied because the um because the benefits payable under the certificate are limited to what's in the schedule of benefits, and this is not a covered, um.
[AGENT][NEGATIVE] This isn't covered under the plan.
[CUSTOMER][NEUTRAL] This uh procedure code 99214?
[AGENT][NEUTRAL] Let me check.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Give me just a second.
[AGENT][NEUTRAL] Yeah it looks like this isn't under their this uh procedure isn't sched uh in their schedule of benefits so it's not in their plan as a covered service.
[CUSTOMER][NEUTRAL] OK. So the 99214.
[CUSTOMER][NEUTRAL] It's not covered under the member's policy?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. And uh the remaining $25.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You, you are not covering this uh remaining dollars. So it's a patient responsibility.
[AGENT][NEUTRAL] Uh, we don't determine patient responsibility, uh, but the claim was denied.
[AGENT][NEUTRAL] Cause it's not a covered service.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes. This cover, or this payer is denied. I know that. But uh the remaining amount, $25 you pay the copay and co-insurance, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEGATIVE] But, but just because this is an office visit, you know, you are not covered.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] This procedure code and it means this uh remaining dollars, $25 it's a co-pay. So we can bill the patient.
[AGENT][NEUTRAL] Um, that would be up to the provider, yes.
[CUSTOMER][NEUTRAL] So, can you, um, can you just provide me, uh, who is, uh, I can see here the United Health is the primary and secondary despair and
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Oh, can you just provide me if the, this uh member has tertiary plan?
[AGENT][NEUTRAL] Let me check.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] I don't see anything else on my end, no.
[CUSTOMER][NEUTRAL] OK. If the secondary is not covered this uh remaining amount, so it's some patients responsibility, right?
[AGENT][NEUTRAL] We don't determine patient responsibility, that will be up to the provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] So just because 99214 is an office visit, you, you are not covering this co-pay, right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And this patient is, uh, this patient has no tertiary plan, right?
[AGENT][NEUTRAL] Not that I can see.
[CUSTOMER][NEUTRAL] For the date of service?
[AGENT][NEUTRAL] Right, not that I can see. Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. Thank you. Thank you, [PII], for helping me today. And may I have the call reference number?
[AGENT][NEUTRAL] Uh, we don't have call reference numbers, but you can use my name and last initial in today's date. So [PII], in today's date.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK. Thank you for helping me today.
[AGENT][POSITIVE] Alright, thank you for calling APL.
[CUSTOMER][NEUTRAL] And yes, that's it for today, [PII].
[AGENT][POSITIVE] OK. If there's nothing else I can help you with, have a great day, bye.
[CUSTOMER][POSITIVE] Thank you. Have a great day.
[CUSTOMER][NEUTRAL] No, thank you for asking. Bye-bye.
[AGENT][NEUTRAL] Bye.