AccountId: 011433970860
ContactId: 4f5b4952-5225-4d25-af9c-6f38818ab052
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 934849 ms
Total Talk Time (AGENT): 302102 ms
Total Talk Time (CUSTOMER): 333129 ms
Interruptions: 3
Overall Sentiment: AGENT=0.1, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/4f5b4952-5225-4d25-af9c-6f38818ab052_20250219T19:31_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], good afternoon. Uh, this is [PII], and I'm calling from provider office. How are you?
[AGENT][POSITIVE] I'm doing well, [PII]. How are you?
[CUSTOMER][POSITIVE] I'm good, thank you for asking.
[CUSTOMER][NEUTRAL] And I actually, I want to check with you some claim status for this patient.
[AGENT][NEUTRAL] OK, well, I'll be more than happy to help you with the claim status, and you said um there's multiple for one patient or you have multiple patients?
[CUSTOMER][NEUTRAL] No, only I have one patient, uh, but this patient have a multiple.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] Claims?
[CUSTOMER][NEUTRAL] You do services yeah.
[AGENT][NEUTRAL] OK, and may I have a good contact number in case we're disconnected and then the member's policy number?
[CUSTOMER][NEUTRAL] And contact number [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And my extension is [PII].
[AGENT][NEUTRAL] Thank you for that. And the member's policy number?
[CUSTOMER][NEUTRAL] The member policy number is 0233.
[CUSTOMER][NEUTRAL] 71
[CUSTOMER][NEUTRAL] 59
[CUSTOMER][NEUTRAL] M as in Mary. L as in Lima. 8.
[AGENT][POSITIVE] Thank you for that. Hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][POSITIVE] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And you can provide me with all the dates of service and the total bills and I'll check the claims for you.
[CUSTOMER][NEUTRAL] Uh, the first day of service is, uh, November [PII], 2024. The bill amount is $441.02.
[AGENT][NEUTRAL] OK, and the next, you can give them all to me.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] Do you have more than one data of service?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, you can give them all to me.
[CUSTOMER][NEUTRAL] Uh, the first is uh November 824.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Secondary services on November 1524.
[CUSTOMER][NEUTRAL] December 2nd, 24, December 5, 24, and December 1324.
[AGENT][NEUTRAL] OK, hold on, hold on. Do the, what are the total bill? You have to give me the date and the total bill for the claim.
[CUSTOMER][NEUTRAL] OK, November 824, the total bill is $441.
[CUSTOMER][NEUTRAL] And 2 cents
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] November 1524.
[CUSTOMER][NEUTRAL] The bill amount is $400.
[CUSTOMER][NEUTRAL] December 2nd 24 build on $255.
[CUSTOMER][NEUTRAL] December 5, 24 bill amount $295.
[CUSTOMER][NEUTRAL] Build on December sorry service [PII]. The bill amount $394.
[AGENT][NEUTRAL] OK, and again just for the call, all the information provided is a verification of benefits, not a guarantee of payment. And is it alright if I place you on just a brief hold while I go through the claims?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 35539.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes, I'm here.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So for the [PII] claim,
[CUSTOMER][NEUTRAL] And so that.
[AGENT][NEUTRAL] We received the claim on [PII].
[CUSTOMER][NEUTRAL] Wait, wait, wait, let me, let me, uh, write down some.
[CUSTOMER][NEUTRAL] [PII]. When did you receive?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And process.
[AGENT][NEUTRAL] It was processed on [PII].
[CUSTOMER][NEUTRAL] What is the claim number?
[AGENT][NEUTRAL] And the claim number
[AGENT][NEUTRAL] The claim number is 3553955.
[AGENT][NEGATIVE] And it was denied
[CUSTOMER][NEUTRAL] 3553955
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Code 99.
[CUSTOMER][NEUTRAL] Yeah, what is the reason?
[AGENT][NEUTRAL] Code 99205 was denied because office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] I
[AGENT][NEGATIVE] The other codes were all denied because the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Service is not covered under the patient plan.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh, that is the office visit code is 99205 and according to the patient, uh.
[CUSTOMER][NEUTRAL] Subscriber ID, so outpatient benefit uh will be covered under this member ID.
[AGENT][NEUTRAL] I'm sorry, are you saying this should have been covered?
[CUSTOMER][NEUTRAL] Yeah, if you, if you check the patient card so.
[AGENT][NEUTRAL] So primary
[AGENT][NEUTRAL] Primary has its own benefits and secondary has its own benefits. So for this secondary policy, office visits are not covered, which is why 99205 was denied and the other codes were denied because it was performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] To the secondary.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] OK, so the other code why not paid?
[AGENT][NEUTRAL] Because it's not covered when performed by a doctor's office or in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK, OK, uh, but, uh, this provider is, um, um.
[CUSTOMER][NEUTRAL] This provider is um um specialist so he can perform the service in our office.
[AGENT][NEUTRAL] The specialist can perform the service wherever, but the insurance policy does not cover office visits.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] So where it was performed is not covered by the patient's policy, secondary policy.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I don't understand uh uh because uh the 93,000 is an electrocardiogram will perform in the office in the uh because this provider is, uh, um.
[CUSTOMER][NEUTRAL] Specialist.
[AGENT][NEUTRAL] OK, so the member's policy is broken down into inpatient, meaning admission to the hospital or outpatient?
[AGENT][NEUTRAL] Um, under outpatient, there's on our policy, the secondary policy, there is no coverage for the in-office setting. Now, usually there is, there could be an additional rider, the office treatment rider, which would then cover the treatment in the office or the specialist office, but the insured does not have the office treatment rider, so the treatment nor the facility is covered by this policy.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] OK, you mean to say the facility service in the facility that service is not covered.
[AGENT][NEUTRAL] Correct. There is no in-office setting coverage for this patient.
[CUSTOMER][NEUTRAL] Um, it's not.
[CUSTOMER][NEGATIVE] Coward.
[CUSTOMER][NEUTRAL] Under the
[CUSTOMER][NEUTRAL] Facility.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEGATIVE] That was denied.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] OK, what about the other data services?
[AGENT][NEUTRAL] OK, so for [PII].
[AGENT][NEUTRAL] It's, um, they were all received on the same day, [PII].
[AGENT][NEUTRAL] Processed on [PII].
[AGENT][NEUTRAL] The claim number is 3553964.
[CUSTOMER][NEUTRAL] T
[CUSTOMER][NEUTRAL] Wait, wait, wait, 355.
[AGENT][NEUTRAL] Mhm. 3553964.
[CUSTOMER][NEUTRAL] So what is the reason?
[AGENT][NEGATIVE] And it was denied because the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEGATIVE] I don't understand that that denial in the secondary the service is not covered under the patient plan.
[CUSTOMER][NEUTRAL] Just
[AGENT][NEUTRAL] Yes, the secondary policy just does not have coverage for the office.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] Hang on
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, so what is it? OK.
[CUSTOMER][NEUTRAL] The service.
[CUSTOMER][NEUTRAL] Not
[CUSTOMER][NEUTRAL] Covered
[CUSTOMER][NEUTRAL] Under the.
[CUSTOMER][NEUTRAL] Patient plan.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] At office.
[CUSTOMER][NEUTRAL] OK, these services only covered in the hospital?
[AGENT][NEGATIVE] No, there's no, no, it's not only services in the hospital. The easiest way to explain it is there's no in-office coverage on this policy. They don't have the benefit.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, you mean to see the place for service 111 is not covered under the patient plan.
[AGENT][NEGATIVE] Yes, the the, it's not.
[AGENT][NEUTRAL] Office visits are not covered by the policy, and it's not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] OK, so the all services, OK, what about the next type of service, uh.
[CUSTOMER][NEUTRAL] For the [PII].
[AGENT][NEUTRAL] So I'll just give you the claim numbers for [PII], and [PII]. The dates received and processed are the same and the denial reason.
[AGENT][NEUTRAL] So for [PII],
[AGENT][NEUTRAL] That claim number is 355.
[AGENT][NEUTRAL] 3959.
[AGENT][NEUTRAL] For the
[CUSTOMER][NEUTRAL] And the the other all the region are same.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] For [PII], let me know when you're ready for that claim number.
[CUSTOMER][NEUTRAL] Just give me one moment here.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] on that.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah, what is the
[CUSTOMER][NEUTRAL] And did you receive the claim?
[AGENT][NEUTRAL] It's the same for all of them. They were received on [PII].
[CUSTOMER][NEUTRAL] The claim number
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, so I've already given you [PII], [PII] claim number is 355.
[AGENT][NEUTRAL] 3953.
[CUSTOMER][NEGATIVE] And that is also denied with the same reason.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, so what about the [PII]?
[AGENT][NEUTRAL] [PII] is 356-4813.
[CUSTOMER][NEUTRAL] [PII] and the same date uh the claim was received and the process.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For [PII], it was received on [PII].
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] And it was processed on [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEGATIVE] So that is also denied with the same reason.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] She
[CUSTOMER][NEUTRAL] 204778.
[CUSTOMER][NEUTRAL] OK, could you please give me a call reference number?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] Could you
[CUSTOMER][NEUTRAL] Could you please spell your name?
[AGENT][NEUTRAL] And my name
[AGENT][NEUTRAL] Yes, my name is [PII]
[CUSTOMER][POSITIVE] OK and uh thank you so much for cooperating with me.
[AGENT][NEUTRAL] You're welcome, [PII]. Was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] No, it's OK thank you have a wonderful day.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye bye.