AccountId: 011433970860
ContactId: 573e75e1-7ccc-4d30-9b0d-53be75610f56
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1621349 ms
Total Talk Time (AGENT): 439495 ms
Total Talk Time (CUSTOMER): 333534 ms
Interruptions: 3
Overall Sentiment: AGENT=0.5, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/15/573e75e1-7ccc-4d30-9b0d-53be75610f56_20250515T14:00_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I am calling from Multi-care Health System, and I'm calling to check on the status of a medical claim. Um, the claim is for IMA.
[CUSTOMER][NEUTRAL] Is that what you, whoever, uh, I'm talking to?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] No ma'am, but I can transfer you to IMA and give you the phone number in case the calls dropped while I'm transferring I can get you over there.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, yeah, it just, it asks for different options and I'm not too sure what plan this is.
[AGENT][NEUTRAL] OK. Um, do you, do you have the um member's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, so when, um, can you give that to me and I can see if I can find them in my system so you know what kind of plan it is.
[CUSTOMER][POSITIVE] Sure, that'd be great.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] And I'm ready for the name.
[CUSTOMER][NEUTRAL] Uh, the name I'll spell it to you, it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Last name is [PII]
[AGENT][NEUTRAL] OK, let me see if I can find it by the name real quick.
[AGENT][NEUTRAL] OK, do you have their social? I can try to pull it in with the social.
[CUSTOMER][NEUTRAL] Um, I have an ID number, but you need their social?
[AGENT][NEUTRAL] Yes, it's not pulling in and, and let, yes ma'am, in the um let me make sure I spelled the first name right. [PII]
[CUSTOMER][POSITIVE] That works better.
[CUSTOMER][NEGATIVE] It's [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII], no [PII]
[AGENT][NEUTRAL] OK, let me try it that way and see if I can find them by the name first.
[AGENT][NEUTRAL] Oh, I think I found them.
[AGENT][NEUTRAL] OK, is it for a medical claim or accident or dental? Medical?
[CUSTOMER][POSITIVE] Oh good.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Medical.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, let me check on my side first on the data service and the charge amount to see if we have it on our side.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. What is the data service?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, this, well, I have several, um.
[CUSTOMER][NEUTRAL] But let the uh one the first ones I'm checking on [PII] for 566.
[AGENT][NEUTRAL] OK, let me look at that one first and see if we've got it on our side yet.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh, I'm showing it.
[AGENT][NEUTRAL] OK, let me see what it says.
[AGENT][NEUTRAL] OK, so on this claim.
[AGENT][NEUTRAL] I do see, let me give you the claim number, it's 355.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 8551.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] And real quick Miss [PII], can I get your call back number just in case the calls dropped I'll be able to call you back.
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, ma'am. OK, and on that claim number it states that treatment in an outpatient hospital less than 18 hours is not covered by this policy.
[AGENT][NEUTRAL] That the outpatient treatment benefit provides an indemnity amount.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh when a covered person receives treatment in an emergency room, urgent care facility, physician's office, or physical speech or occupational therapy.
[CUSTOMER][NEUTRAL] OK, so this particular one is a radiation charge.
[CUSTOMER][NEGATIVE] So, that would be denied.
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK, is there a way, because it looks like she does have a secondary insurance, can I get a copy of an EOB from you stating that this was denied?
[AGENT][NEUTRAL] Yes, what's your fax number and I'll send this COB to you.
[CUSTOMER][NEUTRAL] It is 253.
[CUSTOMER][NEUTRAL] 864.
[CUSTOMER][NEUTRAL] 2880.
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold, Miss [PII] while I get this EOB over to you and I'll be right back.
[CUSTOMER][POSITIVE] OK, thanks.
[AGENT][POSITIVE] You're very welcome.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Come on
[AGENT][NEUTRAL] Mm
[AGENT][POSITIVE] Thank you for holding for me, Ms. [PII]. I've got that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] He'll be on its way to you now.
[CUSTOMER][NEUTRAL] OK, and then I have several other dates of service. Can you help me with those as well?
[AGENT][NEUTRAL] Yes ma'am, um, is it all for the same member?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, what's the next day service and charge amount?
[CUSTOMER][NEUTRAL] [PII] for 490.
[AGENT][NEUTRAL] OK, let me see if that one's in here.
[AGENT][NEUTRAL] OK, this one
[AGENT][NEUTRAL] Let me give you the claim number for this one.
[AGENT][NEUTRAL] It's 359.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 1003 and it was denied for the same reason.
[AGENT][NEUTRAL] Would you like for me to send?
[CUSTOMER][NEUTRAL] OK, now this is an office visit.
[CUSTOMER][NEUTRAL] Oh I guess it was an outpatient but OK.
[CUSTOMER][NEUTRAL] Uh, yes.
[AGENT][NEUTRAL] OK, uh, let me put you on.
[CUSTOMER][NEUTRAL] Outpatient denial, yes, if you could fax that one.
[AGENT][POSITIVE] Yes ma'am, I'm gonna put you on a quick hold while I get that fax ready for you and I'll be right back.
[CUSTOMER][NEUTRAL] OK, thank you. You are on hold.
[AGENT][NEUTRAL] You
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK, thank you for holding for me. I've got that one on its way to you now.
[CUSTOMER][POSITIVE] OK, perfect.
[CUSTOMER][NEUTRAL] OK, the next one is 128.
[CUSTOMER][NEUTRAL] For $899.
[AGENT][NEUTRAL] OK, let me see if I can find that one.
[AGENT][POSITIVE] I'm glad we decided to check here first.
[CUSTOMER][POSITIVE] Yeah me too thank you so much.
[AGENT][POSITIVE] Cause I'm finding them. You're very welcome.
[AGENT][NEUTRAL] OK, and this one, let me give you the claim number for this one.
[CUSTOMER][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] It's 357-2015.
[AGENT][NEGATIVE] And it was also denied for the same reason.
[CUSTOMER][NEUTRAL] No outpatient.
[CUSTOMER][NEUTRAL] OK, the next one is [PII]. 0, yeah.
[AGENT][NEUTRAL] OK. And I'm
[CUSTOMER][NEUTRAL] I'll take the fax too.
[AGENT][POSITIVE] Let me send you the EOB for this one, yes ma'am.
[CUSTOMER][NEUTRAL] Sure. You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, Miss. and that one's on its way too, and the next one was for [PII], and what was the charge amount?
[CUSTOMER][NEUTRAL] 133.
[AGENT][NEUTRAL] OK, let me check that one.
[AGENT][NEUTRAL] OK, on this one, the claim number is 356.
[AGENT][NEUTRAL] 7235 and this one was denied because the um calendar year maximum on diagnostic services has been met.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let me get that one.
[CUSTOMER][NEUTRAL] But this one is um.
[CUSTOMER][NEUTRAL] Oh, is that a radiation? What is this?
[AGENT][NEUTRAL] Procedure code is 77014.
[CUSTOMER][NEUTRAL] Yeah, this is also.
[CUSTOMER][NEUTRAL] Yeah, and it's also a uh kind of radiation therapy.
[CUSTOMER][NEUTRAL] And the one for January denied is not covered period so it didn't say anything about it being maxed.
[AGENT][NEUTRAL] OK, I can send you the EOB for it um.
[CUSTOMER][NEUTRAL] OK, and then we'll go from there.
[AGENT][NEUTRAL] And and then if, yes ma'am, if you needed to go to the claims department after that to see how they processed it through a specialist we can do that.
[CUSTOMER][POSITIVE] Very good, OK.
[AGENT][POSITIVE] OK, all right, it's gonna be a quick hold while I get this one ready for you.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK Miss [PII] I've got that one sent over to you now.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, very good, um, the next one is, um, actually there's 223 and 24.
[CUSTOMER][NEUTRAL] I don't think let's see if they're together.
[CUSTOMER][NEUTRAL] No, they're separate. OK, so for [PII] for 133.
[AGENT][NEUTRAL] OK, let me check.
[AGENT][NEGATIVE] And this one was also denied for the same reason as the previous one, the calendar year maximum on diagnostic services has been met.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let me get this one over to you.
[AGENT][NEUTRAL] It's gonna be a brief hold again.
[CUSTOMER][NEUTRAL] And then I'll take that claim number.
[AGENT][NEUTRAL] Yes, oh, I'm sorry about that. The claim number is 356-7235. 0 wait, no, wait a minute, maybe I put hold on, that was the previous.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, it's the previous one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see what this one says.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's 357-207-6.
[CUSTOMER][POSITIVE] OK very good thank you.
[AGENT][NEUTRAL] You're welcome and then.
[AGENT][NEUTRAL] Brief hold again while I get this uh EOB sent to you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, that one's on its way now too. And then you said the next day the service was [PII], and was it also for $133?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes it is.
[AGENT][NEUTRAL] OK, let me check that one.
[AGENT][NEUTRAL] OK, this one, the claim number is 3572073.
[AGENT][NEGATIVE] And it was denied for the same reason as the previous.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, now on these um I did get them, so thank you for that um.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] It just says um.
[CUSTOMER][NEUTRAL] The outpatient treatment benefit provides an indemnity amount when a covered person receives treatment and a blah blah blah blah blah, um, treatment less than 18 hours not covered.
[CUSTOMER][NEUTRAL] It doesn't say anything.
[CUSTOMER][NEGATIVE] It says total benefits paid 0, but it doesn't show anything that says this is patient responsibility.
[AGENT][NEUTRAL] That's because we don't give patient responsibility. We let the provider determine patient responsibility.
[CUSTOMER][NEUTRAL] Is that
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, got it, because this is an indemnity plan, is that why?
[AGENT][NEUTRAL] Yes ma'am.
[CUSTOMER][NEUTRAL] OK, just wanted to clarify that. Cool, OK.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] OK, and now I'm trying to get this other one over to you also.
[AGENT][NEUTRAL] I put you on hold just because it takes a moment for the computer to think about what it's doing.
[CUSTOMER][NEUTRAL] Oh, sure.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] This is
[AGENT][NEUTRAL] OK, that one has been sent now too.
[CUSTOMER][NEUTRAL] 325
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So then the next one that I have is 213 of 2025 for 490.
[AGENT][NEUTRAL] OK, do you know how many more you have?
[CUSTOMER][NEUTRAL] Um, I just, I have, um,
[CUSTOMER][NEUTRAL] One for 36 and then I just I had a couple in [PII].
[CUSTOMER][NEUTRAL] In [PII].
[CUSTOMER][NEUTRAL] Uh, 1234 and 2024.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can we do those or do I need to call back or get back in the queue?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, you may need to get back in the queue and it's only because I have a meeting.
[AGENT][NEUTRAL] And I don't wanna be late for the meeting, but um I'll keep on the phone with you until we get them all sent that I can do before that meeting time.
[CUSTOMER][NEUTRAL] Oh got it OK.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, this next one's EOB number, I'm sorry claim number is 3600424.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And it was also denied for the same reason.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's the same procedure code.
[CUSTOMER][NEUTRAL] The calendar year max.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] 00.
[AGENT][NEUTRAL] This one, well, let me look and see what it says.
[AGENT][NEUTRAL] I think this was the same as.
[AGENT][NEUTRAL] OK, this is the same as the first ones that um.
[AGENT][NEUTRAL] Outpatient hospital less than 18 hours. And then it also has another
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEGATIVE] Another um remark this policy does not provide a benefit for services in which no charges were incurred.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So let me get this one over to you.
[CUSTOMER][NEUTRAL] OK, yeah, as long as I can get the payment this to the payment posters, then they can post it.
[CUSTOMER][NEUTRAL] And then we can work it from there.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] 32
[AGENT][NEUTRAL] OK, that one's been set now.
[AGENT][NEUTRAL] And I am gonna have to get off the phone so I could bump into that meeting real quick.
[CUSTOMER][NEUTRAL] OK, OK, and that was the one you sent 24 and OK, um, I can call back and I will check.
[AGENT][NEUTRAL] And I have time to do my notes.
[AGENT][NEUTRAL] Yeah, that was for [PII].
[CUSTOMER][NEUTRAL] OK, very good. So [PII], do I need to um call back and get the same extension that will work but um should I get what an hour for your meeting?
[AGENT][NEUTRAL] Right. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Yes, that would be wonderful thank you I appreciate that you working with us like that.
[CUSTOMER][NEUTRAL] OK, that would be.
[CUSTOMER][POSITIVE] OK, that sounds great thank you so much for your help, much appreciated.
[AGENT][POSITIVE] You're very welcome and I hope you have a blessed rest of your day if I don't get to talk to you the next time you call, and we appreciate you calling APL.
[CUSTOMER][POSITIVE] Thank you you as well bye bye.
[AGENT][NEUTRAL] Bye bye.