AccountId: 011433970860
ContactId: 7406c5c2-66d0-4b5e-89a7-9763fd9386f6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 221160 ms
Total Talk Time (AGENT): 80627 ms
Total Talk Time (CUSTOMER): 51791 ms
Interruptions: 0
Overall Sentiment: AGENT=0, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/04/7406c5c2-66d0-4b5e-89a7-9763fd9386f6_20250604T19:41_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] Hey [PII], this is [PII] on the care team. How are you doing?
[AGENT][NEUTRAL] Fine, how are you?
[CUSTOMER][NEUTRAL] I'm good. Um, I have an insured on the other line. They wanna go over this claim and why it was denied.
[AGENT][NEUTRAL] What's the policy number?
[CUSTOMER][NEUTRAL] Um, 248-801-4.
[AGENT][NEUTRAL] And who was it on?
[CUSTOMER][NEUTRAL] Um, it's for part 3, but the policyholder is on the line.
[AGENT][NEUTRAL] Let me see, for [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let's see what we got here what we received, give me a moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it looks like this is.
[AGENT][NEUTRAL] For an ER visit.
[AGENT][NEUTRAL] You get the
[AGENT][NEUTRAL] Coverage here.
[AGENT][NEUTRAL] OK, so all they have is hot inpatient benefits.
[AGENT][NEGATIVE] They don't have outpatient services. That's why nothing was payable. They only have when they're confined in the hospital.
[CUSTOMER][NEUTRAL] Oh, and these are all outpatient? OK.
[AGENT][NEUTRAL] Mhm. It doesn't the policy doesn't cover outpatient services. It only covers inpatient.
[AGENT][NEUTRAL] So that's why they weren't covered.
[CUSTOMER][NEUTRAL] OK. I can
[CUSTOMER][NEUTRAL] OK, I can let him know because he was saying it was a hospital stay and I'm thinking inpatient and um OK.
[AGENT][NEUTRAL] Yeah, it says out out outpatient facility. It looks like it was in the ER um it looks like this is 421 to 422. So based on what we have, it looks like outpatient isn't there's no room charges, no observation information on, on this information that we have. Looks like this is just the explanation of benefits, not the actual itemized billing.
[CUSTOMER][NEUTRAL] We see, right.
[AGENT][NEUTRAL] So if he was confined at least 18 hours or more, then we definitely will need the itemized billing with diagnosis code and that information to further review it. But what we have now is just indicating ER outpatient visit, which is not covered.
[CUSTOMER][NEUTRAL] OK. Um, I will still transfer him to you because he's gonna have more questions. I can explain that, but when he goes further, um,
[CUSTOMER][NEUTRAL] I just don't wanna get stuck cause he's asking a lot of questions. Um.
[CUSTOMER][POSITIVE] I'll go ahead and help him if I need help, I'll call back.
[AGENT][NEUTRAL] OK, that's fine.
[CUSTOMER][POSITIVE] All right, thank you.
[AGENT][POSITIVE] OK. You're welcome.
[CUSTOMER][NEUTRAL] Alright bye bye.
[AGENT][NEUTRAL] Mm bye.