AccountId: 011433970860
ContactId: 56745d5d-7147-4ec9-b1bf-219429f0b794
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 434940 ms
Total Talk Time (AGENT): 164503 ms
Total Talk Time (CUSTOMER): 130763 ms
Interruptions: 2
Overall Sentiment: AGENT=0.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/10/56745d5d-7147-4ec9-b1bf-219429f0b794_20250110T13:31_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII]. This is [PII]. I'm looking for the claim status.
[AGENT][POSITIVE] Well, [PII], it would be my pleasure to assist you with claim status today. What is your callback number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII] were the last four digits?
[CUSTOMER][POSITIVE] Yes, you're right. Yes, you're right.
[AGENT][POSITIVE] Thank you, [PII].
[AGENT][NEUTRAL] And I can help you with claim status today. Do you have the patient's policy number or the claim number?
[CUSTOMER][NEUTRAL] Yeah, I'll give you that information. The policy ID number is 02353165.
[AGENT][NEUTRAL] Thank you, [PII]. And what is the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] The member name is uh [PII] [PII].
[AGENT][NEUTRAL] Alright thank you [PII], and what is the date of service please?
[CUSTOMER][NEUTRAL] Mhm mhm. uh [PII] and the bill amount is $2,855.78.
[AGENT][NEUTRAL] And what is the facility name, please?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Hello
[CUSTOMER][NEUTRAL] What do you need? Uh, minimal distribution.
[AGENT][NEUTRAL] What is
[AGENT][POSITIVE] All right, thank you.
[CUSTOMER][NEUTRAL] They
[AGENT][NEUTRAL] Now, [PII], I'm showing that we did re I'm sorry?
[CUSTOMER][NEUTRAL] Bro.
[CUSTOMER][NEUTRAL] Hey
[CUSTOMER][NEUTRAL] Yeah, go ahead, please.
[AGENT][NEUTRAL] [PII], I'm showing that we did receive that claim on [PII].
[CUSTOMER][POSITIVE] Thank you
[AGENT][NEUTRAL] The claim was processed and denied on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[AGENT][NEGATIVE] And this, it was denied as this item does not meet the definition of durable medical equipment under the policy contract.
[CUSTOMER][NEUTRAL] This.
[CUSTOMER][NEUTRAL] I will take.
[AGENT][NEGATIVE] Therefore, we're unable to provide benefits.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] One minute, please.
[AGENT][NEUTRAL] Would you like
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Well, yeah.
[CUSTOMER][NEUTRAL] OK, you need to
[CUSTOMER][NEUTRAL] Yeah, can you repeat that information or does uh.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] I'm here.
[CUSTOMER][NEUTRAL] Yeah, can you repeat that?
[AGENT][NEUTRAL] I'm sorry, can you repeat that?
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Uh, yeah, what is the denial reason?
[AGENT][NEGATIVE] These items does not meet the definition of durable medical equipment under the policy contract. Therefore, we're unable to provide benefits.
[CUSTOMER][NEUTRAL] What does it mean?
[AGENT][NEGATIVE] It does not meet the definition of covered durable medical equipment according to the patient's policy.
[CUSTOMER][NEUTRAL] I'm
[CUSTOMER][NEUTRAL] Yeah, but what we have to do that does not meet means uh I am not getting understand that one, so.
[AGENT][NEUTRAL] Sure. So these
[CUSTOMER][NEUTRAL] I thought it would take
[AGENT][POSITIVE] Durable medical equipment items.
[AGENT][NEUTRAL] They are not covered under the patient's plan. They do have DME coverage, but it has to be um fall within the guidelines of the policy contract.
[CUSTOMER][NEUTRAL] Alright
[AGENT][NEGATIVE] And that means that it can withstand repeated use. It is not disposable.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It is used to serve a medical purpose with respect to treatment of an inpatient cover charge or outpatient cover charge.
[AGENT][NEGATIVE] It is not useful to a person.
[CUSTOMER][NEUTRAL] Can we go ahead and build this to member?
[AGENT][NEUTRAL] And that would be determined by the provider. We are secondary, not major medical. Therefore, we can't determine if you bill the patient or not.
[AGENT][NEUTRAL] So that is between
[CUSTOMER][NEUTRAL] No, if it's not counted as a member plan, do we have an option to build this to member that's why I'm asking.
[AGENT][NEUTRAL] Uh, yes, I understand the question and thank you. So we cannot tell you whether to bill the patient or not. We're not major medical, we're secondary.
[CUSTOMER][NEUTRAL] Sleep.
[AGENT][NEUTRAL] So if the, if the provider bills the patient, that would be determined by the provider, not by APL.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Would you like the claim number?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK, I have a claim number. I just need a reference number.
[AGENT][POSITIVE] The reference number is my name and today's date, and I spell my name [PII] First initial of my last name is [PII] and [PII], it was a pleasure to assist you with that claim status. Anything else I can assist you with today?
[CUSTOMER][NEUTRAL] So one minute.
[CUSTOMER][NEUTRAL] With the
[CUSTOMER][NEUTRAL] Give me one moment, OK.
[AGENT][POSITIVE] All right thank you [PII].
[CUSTOMER][POSITIVE] Thank you, bye.