AccountId: 011433970860
ContactId: 69d316d2-5d84-4181-a5db-e9b01ab7902e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 394239 ms
Total Talk Time (AGENT): 178536 ms
Total Talk Time (CUSTOMER): 105171 ms
Interruptions: 1
Overall Sentiment: AGENT=1.5, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/05/69d316d2-5d84-4181-a5db-e9b01ab7902e_20250605T18:14_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello, uh, my name is [PII] calling from provider office and looking for the reason of the denial.
[AGENT][NEUTRAL] OK [PII], you're needing the reason for denial on a claim, is that correct?
[CUSTOMER][NEUTRAL] Uh, yes.
[AGENT][POSITIVE] Yes, I can help you with that. And what is your callback number, please?
[CUSTOMER][NEUTRAL] [PII]. It's a direct line.
[AGENT][NEUTRAL] You said that was [PII]. Is that correct?
[CUSTOMER][NEUTRAL] to
[CUSTOMER][POSITIVE] Yes, yes, you're right.
[AGENT][NEUTRAL] Thank you. And the member's policy number please, [PII]?
[CUSTOMER][NEUTRAL] Member policy is 02549555.
[AGENT][NEUTRAL] Thank you. One moment while I get the member's information pulled up please.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And [PII], any information that I do provide for you today would be a verification of benefits and not a guarantee of payment. What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] The patient name is uh.
[CUSTOMER][NEUTRAL] The first name is Hotel Uniform, G as in Golf, H as in Hotel.
[CUSTOMER][NEUTRAL] And the last name is [PII].
[AGENT][NEUTRAL] And the date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And what is the date of service and total bill amount, please?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] [PII] and [PII], the billed amount is
[CUSTOMER][NEUTRAL] And the bill amount is $259 even.
[AGENT][NEUTRAL] And you said the date of service is [PII], is that correct?
[CUSTOMER][NEUTRAL] Yeah, uh, yes.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so I do see that this claim was received on [PII].
[AGENT][NEGATIVE] It was denied on [PII].
[AGENT][NEUTRAL] The claim number is 360.
[AGENT][NEUTRAL] 0615.
[AGENT][NEUTRAL] And the reason for the denial is office visits are not covered by the above number policy.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] The member's plan, the members supplemental policy, [PII] does not cover office visits.
[CUSTOMER][NEUTRAL] Ah,
[CUSTOMER][NEUTRAL] Why not covered office because primary is processed.
[AGENT][NEUTRAL] I, I just, yes, sir, I just, that is correct. I just explained that to you. Under the supplemental policy, the member's plan does not cover office visits. The supplemental policy does not cover offices.
[CUSTOMER][NEGATIVE] Correctly and secondly denied.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Under the
[CUSTOMER][NEGATIVE] Supplement policy does not
[CUSTOMER][NEUTRAL] Covered
[AGENT][NEUTRAL] Office visits. And if you need a copy of the explanation of benefits, [PII], with that remark on it, you can print that with.
[CUSTOMER][NEUTRAL] to
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Uh yes, sir. Give me one second, uh, one second. Actually, uh,
[CUSTOMER][NEUTRAL] Could you please tell me, uh,
[CUSTOMER][NEUTRAL] How many uh office is it allowed?
[AGENT][NEUTRAL] 90.
[CUSTOMER][NEUTRAL] Um, patient plan.
[CUSTOMER][NEUTRAL] 0
[AGENT][NEUTRAL] Office visits are not covered by the above numbered policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. So, please send that you'll be on our fax number.
[AGENT][NEUTRAL] Yes sir you can print that from our portal with the claim number that I gave you by going to secured.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, uh, do you have any information, uh, which services covered under the patient plan?
[AGENT][NEUTRAL] What type of service would you like benefit information on?
[CUSTOMER][NEUTRAL] Mhm. Actually, uh, you said office visit is not covered under the patient plan, so, uh, yes, yes, which service is covered under the supplement policy?
[AGENT][POSITIVE] That is, that is correct.
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] The maximum outpatient benefit for covered outpatient services under this plan?
[CUSTOMER][NEUTRAL] 52.
[AGENT][NEUTRAL] It's $750.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And the types of services that could be reviewed for benefits under this plan would be diagnostic testing procedures performed in an outpatient facility or hospital.
[AGENT][NEUTRAL] Treatment in the office, but an office visit is not covered.
[AGENT][NEUTRAL] And with any claim on this policy would always have to receive a copy of the primary insurance company's explanation of benefits along with the claim for review.
[CUSTOMER][NEUTRAL] Mm, OK.
[CUSTOMER][NEUTRAL] So, may I have your name?
[AGENT][NEUTRAL] Yes, sir. I gave you my name and again it's [PII] and my name in today's date will be your call reference numbers.
[AGENT][NEUTRAL] Or reference number rather, if you need one.
[CUSTOMER][NEUTRAL] Your name is [PII], right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] And uh today's name and date, your reference number, right?
[AGENT][POSITIVE] That is correct. Yes, sir.
[CUSTOMER][POSITIVE] OK. Thank you and have a nice day.
[AGENT][POSITIVE] Well, you're welcome. I hope you have a nice day too, [PII]. Is there anything else I can help you with today?
[CUSTOMER][NEGATIVE] Uh, no, no.
[AGENT][POSITIVE] OK, well then thank you again for calling APL and I hope you do have a nice day.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Uh-huh. Bye-bye.