AccountId: 011433970860
ContactId: 572e96ca-ba7a-4a70-99cf-951e6e4c0a08
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 385359 ms
Total Talk Time (AGENT): 181603 ms
Total Talk Time (CUSTOMER): 118654 ms
Interruptions: 2
Overall Sentiment: AGENT=1.3, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/572e96ca-ba7a-4a70-99cf-951e6e4c0a08_20250408T14:43_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] Hi, this is [PII] with Health Advocate. I'm calling on behalf of the member, um, [PII]. I had a question regarding a denied claim.
[AGENT][NEUTRAL] OK, then you said that you have a question regarding a denied claim, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, I can help you with that. What is your callback number, please?
[CUSTOMER][NEUTRAL] Yes, the number is [PII].
[AGENT][POSITIVE] Thank you and the member's policy number, please.
[CUSTOMER][NEUTRAL] I have 02250224.
[AGENT][NEUTRAL] OK, thank you. Give me a couple of moments of that to get the member's information pulled up please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the patient's name and date of birth first off?
[CUSTOMER][NEUTRAL] [PII]. Date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and any information provided today would be a verification of benefits of that, not a guarantee of payment. What is the date of service and total bill amount for her that you're calling about?
[CUSTOMER][NEUTRAL] Yes, it's for [PII].
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Total charge amount 2,862.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] So my screens are starting to move slowly here.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] It, it, that it always ends up that way.
[AGENT][NEUTRAL] It's usually by Friday, it starts acting like that, but, you know, it was moving along and then it started to slow down a little bit. OK. And do you already have the claim number?
[CUSTOMER][NEUTRAL] Right when
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I do not. The member did get a bill and we spoke to the billing team. They stated that primary was, you know, the only, um, coverage, but they applied towards deductible. uh, APL would be her secondary, and they said that APL did deny the claim, so we just wanted to, um, ask what you know, I guess just to get information on why it was denied.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so you, OK, let me locate the claim because not just, I'm not just right off seeing even a claim for 2862.
[CUSTOMER][NEUTRAL] But I don't have a claim number. I just have the bill.
[AGENT][NEUTRAL] So just one moment. I'll file for her for that data service, OK, so just a moment.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] OK, so the claim, yes, this claim was received on [PII]. It was processed on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim number is 349.
[AGENT][NEUTRAL] 7, let me start over because my voice about gave out 349-3714.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Um, and this, yes, this was denied.
[AGENT][NEUTRAL] And the reason for the denial on the claim.
[AGENT][NEUTRAL] OK, it states the maximum amount payable for this occurrence has been met. Per occurrence means treatment for the same or related condition unless separated by a period of 90 days. Treatment for the same or related condition or an unrelated condition will be considered a new per occurrence.
[AGENT][NEUTRAL] There was another claim that was received and processed prior to your claim.
[AGENT][NEUTRAL] That matched the benefits for this per occurrence.
[CUSTOMER][NEUTRAL] OK, and that
[CUSTOMER][NEUTRAL] I see.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] That's fine. I think that was the facility claim. I believe, um, APL did pay towards the facility claim. So, um, just to kind of summarize, APL will only pay.
[CUSTOMER][NEUTRAL] One time for the same data service?
[AGENT][NEUTRAL] It's per occurrence. So that's, you know, the same or related condition, uh-huh, unless it's separated by a 90 period of 90 days. The maximum benefit per occurrence on this policy, if that is $500.
[CUSTOMER][NEUTRAL] Per account.
[CUSTOMER][NEUTRAL] I see, yes, and the $500 was paid towards the facility claim. OK, perfect. OK, so I will let [PII] know that, um.
[CUSTOMER][NEUTRAL] Uh, because we did work with her with her on another bill for the facility, and we did already have that in our notes. The APL paid $500 for the facility claim, so it makes sense. So I'll let [PII] know how the plan works, um, OK, yeah, that's, that's all we needed we just wanted to understand.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then if you need a copy of that.
[AGENT][NEUTRAL] Sure, and if you need a copy of that explanation of benefits of that, we do have a portal that you should be able to check claim status in and be able to print that by going to [PII].
[AGENT][NEUTRAL] [PII] and that is a self-registering portal.
[CUSTOMER][POSITIVE] OK, OK, perfect, well thank you so much.
[AGENT][POSITIVE] All right. Well, you are certainly very welcome. And is there anything else that I can help you with?
[CUSTOMER][POSITIVE] No, that was it thank you.
[AGENT][POSITIVE] OK, well, you're very welcome and thank you again for calling APL. I hope you have a wonderful day.
[CUSTOMER][POSITIVE] You too thank you bye bye.
[AGENT][NEUTRAL] Yes, ma'am