AccountId: 011433970860
ContactId: 715c1c4a-c162-4058-a9d2-2f5c30756398
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 508940 ms
Total Talk Time (AGENT): 156071 ms
Total Talk Time (CUSTOMER): 205229 ms
Interruptions: 9
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/10/715c1c4a-c162-4058-a9d2-2f5c30756398_20250310T20:08_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] and I'm calling from Norton Hospital and I'd like to check claim status.
[AGENT][POSITIVE] OK, I'll be more than happy to help you with the claim status and how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I have one thing.
[AGENT][NEUTRAL] All right, [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, the contact number was [PII], no extension. It was a direct line.
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] How
[CUSTOMER][NEUTRAL] Yes, the member policy number was.
[CUSTOMER][NEUTRAL] 02544684
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] The member name was [PII] and her date of birth was [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bill for the claim?
[CUSTOMER][NEUTRAL] Yes, this is for date of service [PII] for the total charges of $1,101 even.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you verify the members, hold on, the name of the provider on the claim, I'm sorry.
[CUSTOMER][NEUTRAL] The provider name was Norton Hospital.
[CUSTOMER][NEUTRAL] Monday.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I'm showing the claim was received on [PII].
[CUSTOMER][NEUTRAL] Not
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Claim number 3,547,780.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] As it was not a covered diagnostic test, this policy um has specific tests that are considered diagnostic.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] One moment, please.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Actually, we have received UB and it was denied as information requested from patient or
[CUSTOMER][NEUTRAL] May I know what information requested from patient?
[AGENT][NEUTRAL] That's not the denial reason for this claim.
[CUSTOMER][NEUTRAL] No this one.
[AGENT][NEUTRAL] The denial reason for this claim is the medical test for this date of service is not a covered diagnostic test.
[CUSTOMER][NEUTRAL] This place in the middle.
[CUSTOMER][NEUTRAL] Well let's put it that
[AGENT][NEGATIVE] Therefore, no benefit is payable for this claim.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Medical test for this service was not covered.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEGATIVE] So, it was denied due to medical test for this service was not covered.
[AGENT][NEUTRAL] Right, it was not a covered test.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It was not covered under patient's plan or provider plan?
[AGENT][NEUTRAL] Patients plan.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So you mean the bill diagnosis code was not covered?
[CUSTOMER][POSITIVE] We do love.
[AGENT][NEUTRAL] Right, so this policy has particular tests that are covered, an MRI, a CAT scan, CT scan, it lists the names that are covered on this policy. This code is not covered under this patient's policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You would be the lead.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] So the bill procedure codes was not covered under the patient's policy.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So how much will be a patient responsibility on this plan?
[AGENT][NEUTRAL] We don't determine patient responsibility because we're not a major medical insurance company, um, but there was nothing applied to the claim, so the total balance is still remaining that you billed us for.
[CUSTOMER][NEUTRAL] Applied to the
[CUSTOMER][NEUTRAL] So if the total balance is patients the claim balance of $1,101 was a patient responsibility or it was a provider discount?
[AGENT][NEUTRAL] Again, we don't determine patient responsibility, which is why there is no patient responsibility column on the explanation of benefits. It would be whatever your company does for with outstanding balances or remaining balances.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] May I know the claim last process date?
[CUSTOMER][NEUTRAL] Oh my.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The claim was processed on [PII].
[CUSTOMER][NEUTRAL] Got it. And
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] The claim number was 3,547,780, right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] One moment, please. Sorry for the delay.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][POSITIVE] Yeah, thanks for waiting on the line. And your name, please?
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] My name is
[CUSTOMER][NEUTRAL] May I know why it was not covered under the patient's plan?
[AGENT][NEUTRAL] Yes, um, as I explained, so the policy has a particular list of diagnostic tests that it covers. The testing that was done is not on the list, so it's not a cover test.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. What is the call reference number for this call?
[AGENT][NEUTRAL] There's no call reference number, but you can use my name, which is [PII], first initial is [PII] like [PII].
[CUSTOMER][NEUTRAL] The call reference number was your name on today's date?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK, so it was not related to coding-related issue, right?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Not, there is, so it was not related to coding-related, right? There is no issue in the diagnosis code, right? The bill diagnosis code.
[AGENT][NEUTRAL] No, it wasn't an issue with the code. It's just not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got it, and uh, that's it for today. Thank you very much for your explanation and have a good day. Bye.
[AGENT][POSITIVE] You're welcome and thanks for calling APL. I hope you have a great day. Bye-bye.