AccountId: 011433970860
ContactId: 6e8152af-72d6-4151-8c6b-60884df812fe
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 442220 ms
Total Talk Time (AGENT): 135768 ms
Total Talk Time (CUSTOMER): 139493 ms
Interruptions: 0
Overall Sentiment: AGENT=2.1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/28/6e8152af-72d6-4151-8c6b-60884df812fe_20250128T18:58_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hello Way, uh, this is [PII]. My last name is [PII].
[AGENT][POSITIVE] Hi, um, how can I help you today, [PII]?
[CUSTOMER][NEUTRAL] Uh, I'm taking on a claim.
[AGENT][POSITIVE] OK, yeah, I'd love to help you with the claim status today. Do you mind if I snag a quick callback number?
[CUSTOMER][NEUTRAL] Uh, sure, sure. One moment.
[CUSTOMER][NEUTRAL] So, uh, it's [PII]. Is that right?
[AGENT][POSITIVE] [PII]. Thank you. And
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The policy number we want to look at today, [PII]?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] 02477690.
[AGENT][POSITIVE] Wonderful, thank you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] And let's see, give me just a moment to get everything pulled up for you.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Wonderful and would you be able to verify for me, [PII], your patient's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Uh, sure. Uh, the name is [PII] and uh date of birth is [PII].
[AGENT][NEUTRAL] All right, I do see [PII] here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, do you have the claim number or do we wanna search through date of service?
[CUSTOMER][NEUTRAL] No, I have a claim number. One moment. Let me just give that. Just, just one moment.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Take your time.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, uh, it's 354-96004.
[AGENT][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And the name of the facility on file with that claim?
[CUSTOMER][NEUTRAL] Uh, Mountain Eye Hospital Medical Center.
[AGENT][NEUTRAL] Thank you. Alright, so I'm showing that this claim came through as denied. It looks like it's saying that based on the information included on the claim form, this service was not rendered in a covered place of service as outlined in the policy contract. For this reason we're unable to provide benefits for this charge.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So, uh, it was denying because, uh, the place of service rendered was not in the contract for the patient, correct.
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] So what, what, what do we have to do further on this claim since you said it was denied for uh non-covered charges, right?
[AGENT][NEUTRAL] Yes, it was denied. And then what was your question about that? I'm sorry.
[CUSTOMER][NEUTRAL] So, do you need to do further anything on this claim to get the payment or it's gonna get uh write off on this claim?
[AGENT][NEUTRAL] Oh, so that will actually be up to the provider because APL is a supplementary insurance. We don't determine patient responsibility, so that will be up to the provider's office.
[CUSTOMER][NEUTRAL] OK, so, uh, can you just give me the detail, then I log in so I can document all those information. Can I have that please again? mhm.
[AGENT][POSITIVE] Yeah, absolutely.
[AGENT][NEUTRAL] Let me go back to that for you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, it says based on information included.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Information included, OK.
[AGENT][NEUTRAL] On the claim form.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] This service was not rendered in a covered place of service.
[CUSTOMER][NEUTRAL] That's.
[CUSTOMER][NEUTRAL] Uh, covered place of service, correct?
[AGENT][POSITIVE] Correct, as outlined.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] In the policy contract.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] For this reason.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] We are unable to provide.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Benefits for this charge.
[CUSTOMER][NEUTRAL] Uh, unable to provide what is it doctor?
[AGENT][NEGATIVE] Um, unable to provide benefits for this charge.
[CUSTOMER][NEUTRAL] OK. One moment. One moment, please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] One moment, I'm so sorry. Just give me a second.
[AGENT][POSITIVE] You're fine, no worries.
[CUSTOMER][NEUTRAL] So, um, and one more thing, just, just for confirmation, so, so the denial is based on the patient plan, right? Not because of the contract, correct?
[AGENT][POSITIVE] Correct, yes, absolutely, due to the patient's policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, uh, is it possible that we can, uh, build a member on this claim since it was because of the patient's policy, right? So is it OK that we can build a member?
[AGENT][NEUTRAL] So APL can't tell you what to do. That's gonna be up to the provider's office how they wanna handle it.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][POSITIVE] No worries.
[CUSTOMER][POSITIVE] Uh, thank you so much. So can I have a reference number for the call?
[AGENT][NEUTRAL] Yeah, you betcha. The reference number is my name, [PII], first initial last name, B [PII], in today's date.
[CUSTOMER][POSITIVE] Oh thank you so much [PII]. Have a great day and take care. Bye bye. Thanks so much.
[AGENT][POSITIVE] Hey my pleasure you too bye bye.
[CUSTOMER][NEUTRAL] Bye.