AccountId: 011433970860
ContactId: 7a370425-c094-4ea2-8b69-e0934a0dc4e0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 312709 ms
Total Talk Time (AGENT): 147980 ms
Total Talk Time (CUSTOMER): 84937 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/13/7a370425-c094-4ea2-8b69-e0934a0dc4e0_20250513T18:29_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]. This is [PII] from provider's office. I need help regarding claim denial.
[AGENT][NEUTRAL] OK, well, I'll help you with your claim [PII] and [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] It's [PII] and the callback number is [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] 20,370.
[AGENT][NEUTRAL] Is that the group number or the policy number? Do you have their card there?
[CUSTOMER][NEUTRAL] Yes, sorry, yes, the, yes. Uh, let me check.
[AGENT][NEUTRAL] Or a copy of the card?
[CUSTOMER][NEUTRAL] Actually it's just the group number mentioned over that and no member ID.
[AGENT][NEUTRAL] Do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] On the card, do you see the inpatient or outpatient policy cert number?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, I just need those numbers. That's the policy number.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] It's 02064268 M as in Mary, L Lima 8.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes, it is.
[CUSTOMER][NEUTRAL] [PII], [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 claim number or the date of service?
[CUSTOMER][NEUTRAL] Data services [PII].
[CUSTOMER][NEUTRAL] And the bill amount on the claim is $259 259 dollars.
[AGENT][NEUTRAL] Oh, OK, I see what's going on.
[CUSTOMER][NEUTRAL] So why is the claim denied now?
[AGENT][NEUTRAL] Give me just a moment so I can get to the claim. Um, so this policy number is no longer active. This policy number, um, termed in [PII], but there was an active policy. Let me see if the claim is on there. Hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Alright, so the active policy number is 2230058.
[AGENT][NEUTRAL] And you said the date of service was [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] In the amount of $259?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And what is the name of the provider's office?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] What is the name of the provider? Go ahead. Thank you.
[CUSTOMER][NEUTRAL] Yes, medical specialists for [PII].
[CUSTOMER][NEUTRAL] Medical specialist for [PII], yes.
[AGENT][NEUTRAL] The claim was received on October, I'm sorry, on [PII].
[AGENT][NEUTRAL] The claim number is 358.
[AGENT][NEUTRAL] 8509.
[AGENT][NEUTRAL] On [PII], the claim was denied because office visits are not covered on this policy.
[CUSTOMER][NEUTRAL] OK. So what type of services are covered?
[AGENT][NEUTRAL] So this is a secondary insurance, so it's broken down into inpatient and outpatient. Outpatient um includes the hospital emergency room, urgent care, outpatient services like surgeries, um.
[CUSTOMER][NEUTRAL] So, yes, please go on.
[AGENT][NEUTRAL] Off
[AGENT][NEUTRAL] Would you like me to continue?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you. So the office setting itself is not covered by the policy?
[AGENT][NEUTRAL] Which is why you're receiving the denial. They do have the office treatment rider in which treatment in the office could be covered, but for this particular claim, it is um procedure code 99214, which is the place of service, which is not covered.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[CUSTOMER][NEUTRAL] OK, inpatient and outpatient services, but not the office visits.
[AGENT][NEUTRAL] Right, because office visits are not outpatient, but they do have the treatment that could be covered in the office.
[CUSTOMER][NEUTRAL] OK, what's the reference number?
[AGENT][NEUTRAL] There's no call reference number, but you can use my name and today's date. First initial to my last name is [PII].
[CUSTOMER][POSITIVE] OK. Thank you so much for the help. Have a great day. Bye-bye now.
[AGENT][POSITIVE] You also, and thanks for calling APL. Bye-bye.