AccountId: 011433970860
ContactId: 59add36f-8898-481e-9656-40dea863e8b2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 447140 ms
Total Talk Time (AGENT): 144237 ms
Total Talk Time (CUSTOMER): 187282 ms
Interruptions: 0
Overall Sentiment: AGENT=1.2, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/20/59add36f-8898-481e-9656-40dea863e8b2_20250220T17:22_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, sir, this is [PII] calling on behalf of provider's office, um, just checking for a claim status.
[AGENT][NEUTRAL] OK, sure, I can assist you with claim status, Miss [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yeah, um, our callback number is [PII].
[AGENT][NEUTRAL] I'm sorry, can you repeat that number one more time?
[CUSTOMER][NEUTRAL] Uh, it's OK. Um, it's [PII].
[AGENT][NEUTRAL] OK, thank you. And may I have the patient's policy number, Miss [PII]?
[CUSTOMER][NEUTRAL] Yeah, um, please bear with me. I wanna go ahead and check that one.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, what I have here is 251-029-9.
[CUSTOMER][NEUTRAL] And you mentioned your name is [PII] I correct?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So, that's [PII].
[CUSTOMER][POSITIVE] Alrighty thank you so much so.
[AGENT][NEUTRAL] You're welcome. And may I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah, um, the patient's date of birth was [PII], and the patient's name is [PII].
[AGENT][NEUTRAL] OK, thank you. And may I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah, um, the.
[CUSTOMER][NEUTRAL] Date of service was [PII], with the total charge amount of $582 even.
[AGENT][NEUTRAL] OK, [PII] for 582. Um, let me see if I have that claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And for future you can check my status. You're welcome online through our website at [PII] and that's just optional.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, um.
[CUSTOMER][POSITIVE] Alrighty thank you.
[AGENT][POSITIVE] OK. You're welcome.
[AGENT][NEUTRAL] Um, do you know the procedure, um, code for this charge?
[CUSTOMER][NEUTRAL] Um, procedure code. I actually have a limited to, um, limited visibility to check on that, but I can actually provide it. I can actually provide it to you the claim number if you would like.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Yeah, what, what, um, what do I have here is 3552225.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, I'm waiting on the system. OK, one moment.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][POSITIVE] Mhm. Take your time.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so that's 99255.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] OK. Um hm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, it looks like the claim was processed [PII] and the claim was denied stating that the policy provides no benefits for charges made by a doctor for inpatient visit.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Oh, I see. It is because, um, we've actually um received the denial as a lack information needed for adjudication. However, um, the reason why I'm calling is we just wanna know what is the required, um, information in order for us to resubmit a claim.
[AGENT][NEUTRAL] Um, well, it, it is not covered under the member's plan, um.
[AGENT][NEUTRAL] If you would like to submit an appeal, you have 180 days from the decision date to submit any appeals.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh, I see. So just to um confirm, um, Sal, that um based on the patient's benefits plan, the service is actually not covered. And we can actually file an appeal within 180 days from the decision date. Am I correct?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] That is correct, yes. Mhm.
[CUSTOMER][NEUTRAL] Mhm. I see. And by any chance, Sal, um, is, do you, um, where can we actually submit, uh, the, um, the appeal?
[AGENT][NEUTRAL] OK, that will be to um the address of [PII].
[AGENT][NEUTRAL] [PII] City, [PII].
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] I'm sorry, can you please spell that one?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] Oh, all right. Uh-huh.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, all right, I see. And the ZIP code, please?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's um [PII].
[CUSTOMER][NEUTRAL] All righty. Perfect. All right. So just to confirm if I got this correctly, what I have here is um [PII], correct?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] All right. Um, is there any chances, um, that
[CUSTOMER][NEUTRAL] So, uh, can you provide it to me the call reference number?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will.
[CUSTOMER][POSITIVE] Oh, are you there. Um, all right, I see. Thank you so much, [PII], for assisting me and you have a wonderful day. Bye for now.
[AGENT][POSITIVE] You as well, Mr. [PII]. Thank you for calling ATM. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] 9