AccountId: 011433970860
ContactId: 569057ec-e669-45c4-b5a0-85c5291e704f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1003229 ms
Total Talk Time (AGENT): 316829 ms
Total Talk Time (CUSTOMER): 304036 ms
Interruptions: 4
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/04/569057ec-e669-45c4-b5a0-85c5291e704f_20250204T18:43_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] Hey, hi, [PII]. Good afternoon. This is [PII] calling from provider's office. I was checking on claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to assist you with the claim status, [PII]. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] So you have 3 creams, which is uh with one patient. It's for the same patient.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, sure. My contact number is [PII], and it's a direct line.
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Sure. That's uh D as in Delta 47305915.
[AGENT][NEUTRAL] And do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] Yeah, I do have that.
[AGENT][NEUTRAL] On the card, do you see anywhere that says inpatient or outpatient policy certificate number?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Um, so, uh, just a moment. Uh, let me check with that.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So yes, uh thanks for your patience, but uh I couldn't uh see uh things like that, uh, whether it's inpatient or outpatient, uh, I'm sorry for that.
[AGENT][NEUTRAL] OK, do you have the member social?
[CUSTOMER][NEUTRAL] So you're asking for social, right?
[AGENT][NEUTRAL] Social security number?
[CUSTOMER][NEUTRAL] Yeah, it could, uh,
[CUSTOMER][NEUTRAL] Yeah, I could provide the last four digits of the social security number of the member.
[AGENT][NEUTRAL] I would need the full social security number to search for a policy. So basically the the number that you gave is for 90 Degree benefits, which is a different company, so we can't use their policy number in our system. So I'm just asking for additional information to try to locate a policy for you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Do you have a claim number for the claim status?
[CUSTOMER][NEUTRAL] So could you please uh check with the member's name and the data?
[CUSTOMER][NEUTRAL] Yeah, I do, I do have that. I do have the claim number.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, just a moment.
[CUSTOMER][NEUTRAL] Oh, I'm sorry, sorry for that. I don't have that, uh, claim number with me. So, uh, would you please, uh, search with the member's name and the date of birth?
[AGENT][NEUTRAL] OK, what's the member's first and last name?
[CUSTOMER][NEUTRAL] Yeah, sure. So, the member's name is uh [PII]. The date of birth is [PII].
[AGENT][NEUTRAL] Hold on, hold on one second, hold on 1 2nd. Hold on 1 2nd. The phone is breaking up, and can you spell the last name for me, please?
[CUSTOMER][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] Sure, sure, sure.
[CUSTOMER][NEUTRAL] Sure, sure. That is [PII].
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][POSITIVE] Sure, sure. So, kindly take your time.
[AGENT][NEUTRAL] So I'm just waiting for the policy to populate here hold on one moment.
[CUSTOMER][NEUTRAL] Uh, sure.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and this is for his medical policy or dental?
[CUSTOMER][NEUTRAL] This is for medical.
[AGENT][NEUTRAL] And what is the member's date of birth?
[CUSTOMER][NEUTRAL] So, the member's date of birth is uh [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So the policy number is 257.
[AGENT][NEUTRAL] 4226.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] And is the claim for Rolling or the dependent?
[CUSTOMER][NEUTRAL] So, um,
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I think it's for the um
[CUSTOMER][NEUTRAL] Uh, it's not for the dependent.
[AGENT][NEUTRAL] You said it's not for the dependent?
[CUSTOMER][NEUTRAL] Yeah, so it's for uh the subscriber.
[AGENT][NEUTRAL] OK, so it's for. OK, and may I have the date of service for the claim?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Sure. So the date of service is uh [PII].
[CUSTOMER][NEUTRAL] And uh the total charge is $670 even, 670.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] So that's uh Texas Health physician group.
[AGENT][NEUTRAL] Alright, so I'm sure you received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 355-0411.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Um, because the policy does not provide a benefit for charges made by a doctor for inpatient visit.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So the policy don't support uh the patients inpatient inpatient, right?
[AGENT][NEUTRAL] When it's, when the, when the charges are made by a doctor for inpatient visits, yes.
[CUSTOMER][NEUTRAL] So, just a moment.
[CUSTOMER][NEUTRAL] So yes, thanks, thanks for that information. So for this one, so what, uh, we need to do, so we have set a claim, um, so we have set in like uh lacks of info needed for adjudication. So what type of uh information do you need to, uh, process this claim?
[AGENT][NEUTRAL] It's not because of lack of information. It's because the the policy doesn't provide benefits. If the charges are made by a doctor, inpatient, the um
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] The the policy doesn't cover it.
[AGENT][NEGATIVE] So the place of service was not covered.
[CUSTOMER][POSITIVE] Sure, thanks for that information.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure. Thanks for that information. So for this, uh, so can we submit a claim with appropriate modifier or?
[AGENT][NEUTRAL] OK. So let me see, let me pull up the benefits and see if there's a, um, hold on one second.
[CUSTOMER][NEUTRAL] Or what else we can do for this?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] So this is a um
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] So this is a hospital indemnity policy. So there's no coverage for just inpatient visits. You have to be admitted to the hospital confined for over 2018 to 24 hours, and then the inpatient benefits will go into effect. So that's why this is saying that the benefits, there's no benefits for for doctor inpatient visits.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So thanks for that. The patient's policy is uh hospital internity, right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Yes, thanks for that. So for this one, so this is not covered as per patient's policy, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][POSITIVE] Yes, thanks for that. So for this, uh, can you really be patient?
[AGENT][NEUTRAL] So we don't determine patient responsibility because we're not a major medical insurance company. Um, so if there's an outstanding balance, it would just be whatever the policies are for outstanding balances.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] We do not determine patient responsibility because we're not a major medical insurance company.
[AGENT][NEUTRAL] So, the outstanding balance would be up to you as the provider.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] To determine if it's patient responsibility, do you write it off, whatever your procedures are, that's what would go. We can't determine that for you.
[CUSTOMER][NEUTRAL] So yes, thanks for this. So just a moment. Uh, so just a moment. So could you please, uh, bear with me for a moment so that I'll uh check from my end so I'll get back to you.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thanks for
[CUSTOMER][POSITIVE] So, yes, [PII], thanks for your patience and I, and I appreciate your um waiting. Yeah, thanks for that. So, um, can I have a copy of uh uh patient responsibility so that uh it will be easy for us to be the patient.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEGATIVE] There's no there's no explanation of benefits from APL for medical that will show a patient responsibility.
[AGENT][NEUTRAL] Because we don't determine patient responsibility. Would you, I can send you a copy of the explanation of benefits. It's just you ask for patient responsibility that won't be on there because we don't determine that.
[CUSTOMER][NEUTRAL] OK. So how
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Sure. Sure, thanks, thanks for that.
[AGENT][NEUTRAL] Did you
[AGENT][NEUTRAL] You still want a copy sent to you. I can fax a copy over to you. I just want you to know that wasn't on there.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Sure. Uh, so could you please, uh, fax that.
[AGENT][NEUTRAL] Sure, what's a good fax number for you?
[CUSTOMER][NEUTRAL] So, yeah, uh, so the fax number is [PII].
[AGENT][NEUTRAL] And should that be attention, [PII]?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and the next member's policy number? Oh, you said it's all for the same member, right?
[CUSTOMER][NEUTRAL] So it will be, yeah, it's for the same number. So the next date of service is from uh [PII].
[CUSTOMER][NEUTRAL] And uh the total charge is $476 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said the total bill was $476?
[CUSTOMER][POSITIVE] Yes, you're right.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Oh, is this, yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Sure, sure.
[AGENT][NEUTRAL] Oh, it's only one, so it's that one.
[AGENT][NEUTRAL] So I'm showing we received the claim on.
[AGENT][NEUTRAL] [PII], I'm sorry, [PII].
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] The claim number is 355.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 0408.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hold on one moment while I get the code for you.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEGATIVE] Um, same denial reason. The policy provides no benefits for charges made by a doctor for inpatient visits.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] So, yes, thanks. Thanks for the information. So, would you please fax me a copy of you before this one too?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] And the last date of service?
[CUSTOMER][NEUTRAL] So the last date of service is for um [PII]. The total charge is $353 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] 43. OK, so you received the claim on [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim number is 355-0413.
[CUSTOMER][NEUTRAL] you
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And on [PII], the claim was denied for the same reason.
[CUSTOMER][NEUTRAL] Thanks for the information. And uh so could you please uh not, yeah, so could you please fax me a copy of you before this one too.
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] Yes, I'll be sending all 3.
[CUSTOMER][POSITIVE] Sure. So, yes, thanks, thanks for that and also. So, can I have it for this conversation?
[AGENT][NEUTRAL] Um, so the call reference number for the entire call will be my name and today's date. The first initial to my last name is [PII].
[CUSTOMER][POSITIVE] So yes, thanks for that and uh so I'm done from my end. So thanks for your assistance and have a great day and uh take care.
[AGENT][POSITIVE] You're very welcome, [PII], and thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Yeah, bye-bye. Bye-bye.