AccountId: 011433970860
ContactId: 55123041-79b9-43f9-be6d-884b0e57a736
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 894159 ms
Total Talk Time (AGENT): 207801 ms
Total Talk Time (CUSTOMER): 335231 ms
Interruptions: 0
Overall Sentiment: AGENT=2.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/31/55123041-79b9-43f9-be6d-884b0e57a736_20250131T17:41_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Yeah, [PII], my name is [PII], and I'm calling because I have a gap insurance, uh, through, through the city of [PII], my, my former employer, and they, uh, and I went to the gastroenterologist and I normally I give them the card for, for the co-payments and, and, well, basically they submitted the, the claim and it was denied. I'm not sure why it was denied, you know, and I wanted to check to make sure that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] That, uh, that, that there was a mistake.
[AGENT][POSITIVE] OK, yeah, I'd love to help you take a look at that. Do you have your policy number handy, sir?
[CUSTOMER][NEUTRAL] I have the group, let me see, in hospital.
[AGENT][NEUTRAL] Oh, that number.
[CUSTOMER][NEUTRAL] Initial certification
[AGENT][NEUTRAL] Yep, yep.
[CUSTOMER][NEUTRAL] 00198211.
[CUSTOMER][NEUTRAL] 3 M M as in Mike L 7.
[AGENT][POSITIVE] Thank you so much. Let me get that pulled up for you, [PII]. Hang tight.
[AGENT][POSITIVE] Perfect. Thank you so much for your patience. And [PII], could you verify your date of birth for me?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, and I'm just gonna verify some additional information with you real quick. Your mailing address, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Perfect and then the other thing to verify would just be the phone number on file if you can please.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you, thank you. And is that a good number to call you back at if we were to get disconnected?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][POSITIVE] OK perfect thanks and I am pulling up this recent claim for you, let me see.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] It was $60 from the years of me.
[AGENT][NEUTRAL] So, I do see this here, um.
[AGENT][NEUTRAL] Give me a second just to read up on it real quick for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said it was?
[AGENT][NEUTRAL] You of Miami Medicine. Was that the right one that I'm looking at?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, normally I like my dermatologist, I go and I present the car and everything is fine, but this one I'm not sure why.
[AGENT][NEUTRAL] All right, I am.
[AGENT][NEUTRAL] So I do see here that it came through and it was denied, um, and I have the reason stating that benefits payable under the certificate are limited to those outlined in the schedule of benefits. This is not a covered loss under the plan, therefore, no amount payable, therefore no amount is payable for this expense. Um, and so I'm just looking into that a little further for you, um.
[AGENT][NEUTRAL] And I am, if you don't mind, I'm actually going to
[AGENT][NEUTRAL] I'm gonna put you just on a brief hold and see if I have somebody available in my claims department that could explain why that was denied just because I'm not as familiar with this denial code and I'm not, I don't process claims so I'd just love to get you on the phone with somebody that might be able to give you more insight.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][POSITIVE] Perfect. One second, please.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I mean I don't.
[CUSTOMER][NEUTRAL] Sing.
[CUSTOMER][NEUTRAL] For calling APL, my name is [PII]. How may I assist you today?
[AGENT][NEUTRAL] Hey, [PII], this is [PII] with the care team. How are you doing?
[CUSTOMER][POSITIVE] I'm good. How are you?
[AGENT][POSITIVE] Hey, I'm so wonderful. I have a gentleman on the line, real sweet. His name is [PII]. His policy number is 1982113, and he's calling to get more information about why his claim was denied. um, and I'm looking at that claim, and I read the remark code to him, but I'm not.
[AGENT][NEUTRAL] I, I, it's not giving like the details that he's needing, like he's not sure why, and I'm not sure either. Um, so I have claim number 3541154.
[AGENT][NEUTRAL] And it just says that.
[AGENT][NEUTRAL] Benefits payable under the certificate are not limited to those outlined in the scheduled benefits. This is not a covered loss. Therefore, no benefit is payable. Um, and so I've seen that with like accident policies, but I'm not sure what not a covered loss means.
[AGENT][NEUTRAL] Um, and so he just would like more information.
[CUSTOMER][NEUTRAL] OK, I'd be happy to assist, but this is, um, basically the denial, how we deny for not covered in an office visit, but they, it's for when they have a clinic visit at an outpatient facility. So that's how they word it, but I'll break that down just for you for future reference, that's what that, that.
[AGENT][NEUTRAL] Thank you. So it's like that 001, like the office visits are not covered.
[CUSTOMER][NEUTRAL] Yeah, the DH 001 office, that's our DH 001 if they, they were in a, it's an office visit in an outpatient setting, so they must have sent in either a UV or they uh sent in a HIA with the place of service 22, but it was still an office visit.
[AGENT][POSITIVE] OK, that makes sense. Thank you. Now I feel like I could understand this a little better. Um, and do you mind if I listen to how you explain this to him so I could in the future use that to explain to further insureds?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][POSITIVE] OK perfect well then I'm gonna get him on the line and I'll introduce you Ms. [PII], OK?
[CUSTOMER][POSITIVE] All right, thanks.
[AGENT][POSITIVE] My pleasure.
[AGENT][NEUTRAL] Hi, [PII], are you still there with me?
[CUSTOMER][NEUTRAL] Yes, I'm here.
[AGENT][POSITIVE] Hey, thank you so much for your patience. I do have Ms. [PII] on the line and she's one of our claims examiners. She's gonna be able to help you understand why this claim was denied, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] how are you?
[CUSTOMER][NEUTRAL] Good [PII], how are you? I'm good. um, so the reason the claim denied is it was an um office or office basically it was an office visit, um, and office visits are not covered under the policy.
[CUSTOMER][NEUTRAL] An office visit?
[CUSTOMER][NEUTRAL] Yes, an office visit in an outpatient setting.
[CUSTOMER][NEGATIVE] They billed it as being the service facility was in an off um out excuse me.
[CUSTOMER][NEUTRAL] Outpatient setting.
[CUSTOMER][NEUTRAL] And, and
[CUSTOMER][NEUTRAL] And if I go, let's say, because this is just a gastroenterologist checking me, he wasn't, it was like a, a, a, a periodic visit, you know, that he checks me from time to time.
[CUSTOMER][NEUTRAL] And I have other guys in the office, but if, if that visit, visit would have been in another place, would it be covered.
[CUSTOMER][NEUTRAL] Uh, I apologize, um.
[CUSTOMER][NEUTRAL] I see that you actually have the physicians writer, one moment.
[CUSTOMER][NEUTRAL] I apologize, I didn't see your benefits.
[CUSTOMER][NEUTRAL] OK, so you have the office visit writer let me see how many visits you've used.
[CUSTOMER][NEUTRAL] This is for 2024.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] 5 I 5.
[CUSTOMER][NEUTRAL] I would think because I see 5 visits here in 2024.
[CUSTOMER][NEUTRAL] Or
[CUSTOMER][NEUTRAL] Yeah, I'm pulling up your policy to see, I'm pulling up your policy to see what your um dollar benefit amount for the office visits are. I apologize I didn't see that you had the physician's rider which does cover for.
[CUSTOMER][NEUTRAL] The um office visit.
[CUSTOMER][NEUTRAL] Let me, let me just pull up your policy one moment.
[CUSTOMER][NEUTRAL] OK. So your
[CUSTOMER][NEUTRAL] You have for the physician's office visit fee $25 per visit and for a specialist office fee $50 per visit.
[CUSTOMER][NEUTRAL] And it looks like you.
[CUSTOMER][NEUTRAL] Have a maximum of 4 visits per calendar year. I'm gonna have this claim sent back to be reprocessed so they can look at it.
[CUSTOMER][NEUTRAL] And see if they can get that covered under your.
[CUSTOMER][NEUTRAL] Specialist office visit fee.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK, OK. Oh, so I do apologize for that. Um, if you could please allow us 7 to 10 business days, I'm gonna get that sent back to, um, so they can take a second look at that to see if that would be eligible, uh, to be processed under the specialist office visit fee.
[CUSTOMER][NEUTRAL] Um, but, um, but just so that you know it is, um, the place of service was outpatient. It wasn't, um, the place of service wasn't a regular doctor's visit they billed it as being in an outpatient facility, um, but I'm gonna have, um, actually let me see if someone can just quickly answer that for me one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, um, actually if I can get your call back number I'm gonna have somebody take a look at this.
[CUSTOMER][NEUTRAL] OK. And then they can let me know whether or not um it is eligible to be processed under your physician writer um what's your callback number?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK, alright, Mr. [PII], um.
[CUSTOMER][POSITIVE] Give me about an hour to see if I can um get up with my team lead and then um once I get an answer I'll give you a call back.
[CUSTOMER][POSITIVE] OK, thank you very much. All right, well, was there anything else I could assist with today?
[CUSTOMER][NEUTRAL] No, no, your name is again you said? It's [PII].
[CUSTOMER][POSITIVE] [PII], OK, all right, thank you [PII]. Well thank you for calling APL you have a good day.
[CUSTOMER][NEUTRAL] OK bye bye.