AccountId: 011433970860
ContactId: 5497c1d8-77dc-411e-8db2-c956f832ff81
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 505609 ms
Total Talk Time (AGENT): 222867 ms
Total Talk Time (CUSTOMER): 126799 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=1.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/02/5497c1d8-77dc-411e-8db2-c956f832ff81_20250402T14:56_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] Uh, hi, [PII]. This is [PII] calling from provider's office to check claim status.
[AGENT][NEUTRAL] OK [PII], you're needing claim status, is that correct?
[CUSTOMER][POSITIVE] Very good.
[CUSTOMER][POSITIVE] Yes, that is correct.
[AGENT][NEUTRAL] Yes, I can help you with that. And how many claims, [PII], do you have to check status on?
[CUSTOMER][NEUTRAL] Uh, same member. I have to date of service.
[AGENT][POSITIVE] OK, yes, I can help you. How many?
[CUSTOMER][NEGATIVE] Only 2 claims.
[CUSTOMER][NEUTRAL] Only 2.
[AGENT][NEUTRAL] 2. OK. Yes, I can help you with that. And what is your callback number, [PII]?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah, that is [PII].
[AGENT][POSITIVE] Thank you. Uh-huh.
[AGENT][NEUTRAL] Thank you. OK, and the member's policy number please, [PII]?
[CUSTOMER][NEUTRAL] Uh yeah. Uh, this is for the policy 02493728.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you said there's 2 dates of service for this member, is that correct?
[CUSTOMER][NEUTRAL] Yeah, 2 days the same number, yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And any information provided will be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh, sure. This is for the number [PII]. The date of birth [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and what is your first date of service and total bill amount, please?
[CUSTOMER][NEUTRAL] Yeah, that is for [PII].
[CUSTOMER][NEUTRAL] With the total charge, $624 even.
[AGENT][NEUTRAL] I'm sorry, 624. Is that correct?
[CUSTOMER][POSITIVE] Yes, that is correct, ma'am.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Welcome.
[AGENT][NEUTRAL] OK, so this claim has been received multiple times. Are you needing the original claim information?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, the original claim was received on [PII].
[AGENT][NEUTRAL] Processed on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 3,484,280.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And this claim was denied.
[AGENT][NEUTRAL] The reason for the denial, [PII] states the outpatient treatment benefit provides an indemnity amount when a covered person receives treatment in an emergency room, urgent care facility, physician's office, or a physical speech or occupational therapy facility.
[AGENT][NEUTRAL] Treatment in an outpatient hospital less than 18 hours is not covered by this policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh, just give me a sec. Uh, we build place of services under
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] 19
[AGENT][NEUTRAL] I'm sorry, what was your question?
[CUSTOMER][NEUTRAL] Uh, I'm just looking at, yeah, I do see the claim form. I found that we built this a service for uh outpatient hospital. It is not an inpatient.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] That is correct. And that is not covered, as I just stated, treatment in an outpatient.
[AGENT][NEUTRAL] Hospital less than 18 hours is not covered by this policy.
[CUSTOMER][NEUTRAL] Uh, so we can submit a claim or we can go ahead and bill the patient for this one.
[AGENT][NEUTRAL] Uh, we do not determine patient responsibility.
[AGENT][NEUTRAL] That would be up to the provider.
[CUSTOMER][NEUTRAL] Oh OK.
[CUSTOMER][NEUTRAL] OK, that's fine. In case you want to submit a claim, what will be the timely filing limit for this one?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] An appeal must be filed within 180 days from the date of the decision.
[CUSTOMER][NEUTRAL] Uh, if you want to submit claim, what is the timely filing?
[AGENT][NEGATIVE] There is no timely filing on that, and the claim has been submitted twice after this one and denied as a duplicate both times.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] OK, and did you need any other?
[CUSTOMER][POSITIVE] Uh, thank you very much for that information. I really appreciate it.
[AGENT][NEUTRAL] Oh, you're welcome and you said you had another data service?
[CUSTOMER][NEUTRAL] Uh no, uh, for this patient.
[CUSTOMER][NEUTRAL] Exactly, right. I do have one more data of service for the member that we, can I go with that?
[AGENT][NEUTRAL] OK, and what is that you can.
[CUSTOMER][NEUTRAL] Yeah, I'm just pulling it up and yeah it was uh.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] With the total charge $1,076 even.
[AGENT][NEUTRAL] And again you said [PII]?
[CUSTOMER][POSITIVE] Yup, you are right.
[AGENT][NEUTRAL] OK, so this claim has also been received multiple times. Do you need the original claims information?
[CUSTOMER][NEUTRAL] Uh yes. Uh, I need an original claim status.
[AGENT][NEUTRAL] OK, the original claim, right, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so the original claim was received on [PII].
[AGENT][NEUTRAL] Processed and denied on [PII].
[AGENT][NEGATIVE] And it was denied for the exact same reason as the excuse me, reason as the previous data service, [PII].
[CUSTOMER][NEUTRAL] Oh, same thing, like outpatient hospital, uh, less than 18 hours is not covered by partial policy.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Not covered.
[AGENT][NEUTRAL] Correct. And if you need a copy of either of these explanation of events, you can print them by going to our portal at [PII].
[CUSTOMER][NEUTRAL] I'm gonna
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][POSITIVE] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] So again, that's [PII]
[CUSTOMER][NEUTRAL] Got it. Thank you. And also, can I have a claim number for this?
[AGENT][NEUTRAL] 348.
[CUSTOMER][POSITIVE] I got it, uh, and thanks for that.
[AGENT][NEUTRAL] Mhm. 348-4274.
[CUSTOMER][POSITIVE] Got it. Thank you very much for that.
[AGENT][POSITIVE] You're welcome. And again, is there anything else that I can help you with?
[CUSTOMER][POSITIVE] Uh, no, I don't have any further questions. Thank you very much.
[AGENT][POSITIVE] OK, well, you're certainly very welcome and thank you again, [PII] for calling APL. I hope you have a very nice rest of your day.
[CUSTOMER][POSITIVE] Yeah, you too. Take care. Bye-bye.
[AGENT][POSITIVE] Uh-huh, thank you so much. Bye-bye.
[CUSTOMER][NEUTRAL] And before that, can I have a call reference? I'm sorry for that.
[AGENT][NEUTRAL] My name and today's date.
[CUSTOMER][POSITIVE] I got it. Thank you, ma'am. Have a good day.
[AGENT][POSITIVE] All right, you're welcome. You too.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] Bye-bye.