AccountId: 011433970860
ContactId: 60ab3287-a0ff-4550-a7b5-eebf781411a5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 485320 ms
Total Talk Time (AGENT): 160083 ms
Total Talk Time (CUSTOMER): 164562 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/03/60ab3287-a0ff-4550-a7b5-eebf781411a5_20250603T17:35_UTC.wav
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[AGENT][POSITIVE] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] calling the provider's office looking for the claim status.
[AGENT][NEUTRAL] OK, I could check on a claim for you. Uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII] direct line.
[AGENT][NEUTRAL] OK, thank you. And then uh do you have that policy number?
[CUSTOMER][NEUTRAL] Uh yes. Uh, the policy number is 02358091.
[AGENT][NEUTRAL] OK and then what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] [PII]. Date of birth [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that. uh, what was the date of service for this claim?
[CUSTOMER][NEUTRAL] The service was [PII].
[AGENT][NEUTRAL] [PII] and uh what was that bill amount please?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Bill amount was $902.
[AGENT][NEUTRAL] That was $902?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, thank you one moment please.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] OK, so we did receive this claim, [PII], we were unable to pay a benefit as it was not a covered, uh, diagnostic test for this policy. This policy only covers uh MRI, a CT scan, or colonoscopy under their diagnostic testing benefit.
[CUSTOMER][NEUTRAL] MRI CT scan.
[AGENT][NEUTRAL] And colonoscopy. Those are the only colonoscopy. Those are the only covered diagnostic tests, uh, under this policy.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] So, diagnosis KA2.
[CUSTOMER][NEUTRAL] Oh, it's only cover MRI CT scan, right?
[AGENT][NEUTRAL] Could you repeat that? I'm sorry.
[CUSTOMER][NEUTRAL] The diagnosis we have billed KA 2.4 only covered MRI CT scan.
[AGENT][NEUTRAL] And colonoscopies, those are the only covered diagnostic test benefits under this policy, so this one was not covered.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And if you'd like I can send you a copy of this uh EOB.
[CUSTOMER][NEUTRAL] When it was received,
[CUSTOMER][NEUTRAL] Uh, yes, sure, but, uh, uh, first, can you give me some information, please like the claim number was I think 3531061, right?
[AGENT][NEUTRAL] Of course.
[AGENT][POSITIVE] That's correct, yes.
[CUSTOMER][NEUTRAL] Where it was received?
[AGENT][NEUTRAL] [PII] and it was processed on [PII].
[CUSTOMER][NEUTRAL] I don't?
[CUSTOMER][POSITIVE] Cool.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Due to the diagnosis.
[CUSTOMER][NEGATIVE] Oh sorry.
[CUSTOMER][NEUTRAL] Only cover, not one. OK. So can we like change the diagnosis and rebuild the claim as a doctor?
[AGENT][NEGATIVE] If it was not one of those covered diagnostic tests, then it would not be covered under this policy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] But the diagnosis is not covered under the policy. It's only covered in a CT scan.
[CUSTOMER][NEUTRAL] So can't we like uh send the correct claim to change the diagnosis?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Uh, did, if it was an MRI, CT scan, or a colonoscopy, then that is a covered benefit under this policy. If not, then we would not be able to pay a benefit.
[CUSTOMER][NEUTRAL] That's.
[CUSTOMER][NEUTRAL] Sorry?
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] Um, let me check. 76705.
[CUSTOMER][NEUTRAL] Let me check something.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] It's like the CPTV have 76,760 Y is used for limited abdominal ultrasound.
[AGENT][NEUTRAL] OK, yeah, that's not going to be a covered benefit under this policy.
[CUSTOMER][NEUTRAL] So, OK, so both diagnosis and CPD is not covered under the policy, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What is the patient planning?
[AGENT][NEUTRAL] Uh, this is a limited indemnity medical plan.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Indemnity.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] What an appeal timely filing limit?
[AGENT][NEUTRAL] Appeal timely filing limit is within 180 days of the process date, so that was [PII].
[CUSTOMER][NEUTRAL] A mailing address, please.
[AGENT][NEUTRAL] That is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that is in [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII] and the city?
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the U be through fax, please.
[AGENT][NEUTRAL] Yes, what was that fax number for you?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 8642364759
[AGENT][NEUTRAL] OK, I'm going to read that back, make sure I heard that correctly. That was 864236-4759.
[CUSTOMER][NEUTRAL] No, 8642364759.
[AGENT][POSITIVE] Yes, that's what I got. OK, alright, I will go ahead and send that now. I should get it within about 10 minutes or so. Was there anything else I can help you with?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Nothing, uh, only, uh,
[CUSTOMER][NEUTRAL] Just be online.
[CUSTOMER][NEUTRAL] OK. Can I get the reference number, please?
[AGENT][NEUTRAL] Reference number would just be my first name, last initial, and today's date and so my name is spelled [PII]
[CUSTOMER][POSITIVE] Thank you so much for the information. You have a nice rest of the day.
[AGENT][POSITIVE] Of course, thanks for calling APL you too thank you bye bye.
[CUSTOMER][NEUTRAL] Bye-bye.