AccountId: 011433970860
ContactId: 7a80da22-6ecd-44c1-9b78-0f9381608f47
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1280819 ms
Total Talk Time (AGENT): 264148 ms
Total Talk Time (CUSTOMER): 320930 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/26/7a80da22-6ecd-44c1-9b78-0f9381608f47_20250226T14:26_UTC.wav
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[AGENT][POSITIVE] Morning, thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from provider's office to check on a claim status.
[AGENT][NEUTRAL] Sure, I can assist you with claim status. How do you spell your name?
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] OK, thank you. And may I have a callback number just in case we get disconnected, Mister [PII]?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, thank you, and you're calling from which facility for my notation, sorry?
[CUSTOMER][NEUTRAL] Um, I'm calling from the facility name uh.
[CUSTOMER][NEUTRAL] Cleveland Clinic, Florida. Also, it is known as Western.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][NEUTRAL] Just give me a 2nd. 018.
[AGENT][NEUTRAL] Which
[CUSTOMER][NEUTRAL] 16843, M as in Mike, L as in Lima, 8.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Yeah, sure. The name of the patient is
[CUSTOMER][NEUTRAL] [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Alright, perfect, thank you. And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Um, the data service is [PII] and the amount of the claim is 4 41,273 dollars.05 cents.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And let me see if I can find this claim, and that was [PII], correct?
[CUSTOMER][NEUTRAL] [PII], um.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me pull this ERP. One moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm gonna put you on a brief hold while I pull the EOB OK? One moment.
[CUSTOMER][POSITIVE] Yeah, OK. No problem. Take care on time. Thank you.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for me, Mr. [PII]. OK, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Yeah, it just took a long time to pull up and I'm still waiting for the denial. OK, here we go. Um, it looks like we processed the claim on [PII] and the claim was denied. The reason for this denial is there are no benefits payable for chemotherapy, radiation therapy, um, when it's administered in a physician's office or outpatient facility. So there's no benefits for chemotherapy or radiation therapy.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Oh OK. You're saying like uh there is no benefit, uh, for chemotherapy and radiology therapy for the patient. Am I right? Radiation.
[AGENT][POSITIVE] Radiation therapy. Correct.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] According to the patient plan, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, let me document that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, for, only for outpatient, um, sorry, out of network providers, am I right?
[AGENT][NEUTRAL] No, this has nothing to do with network. Um, this is more like it's not covered under the member's plan. So basically, chemotherapy or radiation therapy is not covered under the member's plan.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] OK, ready.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let me document that. Just give me a second.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, may I get the patient's plant type?
[CUSTOMER][NEUTRAL] Plan name and plan type.
[AGENT][NEUTRAL] This is a secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, for the same patient, I want more claim for the data services.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Of [PII].
[AGENT][NEUTRAL] [PII]. OK, one moment.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] How much is the claim for?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh, the claim is for.
[CUSTOMER][NEUTRAL] 41,273 dollars.05 cents.
[AGENT][NEUTRAL] All right, that's the same denial reason.
[AGENT][NEUTRAL] And um let me see when we process the claim.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Could you please repeat your name for my documentation purpose?
[AGENT][NEUTRAL] Sure. That is so. That's [PII].
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, so got it all.
[AGENT][NEUTRAL] OK. OK, so this one was processed on [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, it's the same reason, right?
[AGENT][NEUTRAL] Yes, the same reason.
[CUSTOMER][NEUTRAL] OK. Can we move to the next patient?
[AGENT][NEUTRAL] OK, bear with me. I need to make a note on this one about this other data for this one.
[CUSTOMER][NEUTRAL] Can I get a call reference number for this patient also?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in the state.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, so.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, what's the next policy number?
[CUSTOMER][NEUTRAL] Yeah, sure. Uh, the next policy number is gonna be 0.
[CUSTOMER][NEUTRAL] 245-535-6 ML 8.
[AGENT][NEUTRAL] Just one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Uh, the name of the patient is
[CUSTOMER][NEUTRAL] [PII], and the date of birth is [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Thank you. What's the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] The data services.
[CUSTOMER][NEUTRAL] [PII] for the bill amount of $232 even.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] We
[CUSTOMER][NEUTRAL] It was.
[CUSTOMER][NEUTRAL] No 7000.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] One moment, let me pull the image of the EOB.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, so it looks like this one was processed on [PII] and the claim was denied. The reason for this denial is that benefits payable under the certificate are limited to those um listed on the scheduled benefits.
[CUSTOMER][NEUTRAL] Um, could you please repeat that? I could not able to understand.
[AGENT][NEUTRAL] Benefits payable under the certificate are limited to those online in the schedule of benefits. So basically it's it's not a covered service.
[CUSTOMER][NEUTRAL] OK. As per patient plan, right?
[AGENT][NEUTRAL] And the member's plan. Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] This patient also has a um secondary supplement plan, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] The.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Got it. Uh, can we move to the next question.
[AGENT][NEUTRAL] OK, let me make a note on this one and you don't need any other information on this one, correct?
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] No, nothing else.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What's the next policy number?
[CUSTOMER][NEUTRAL] The next policy number is 01976099.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Uh, the name of the patient is gonna be
[CUSTOMER][NEUTRAL] [PII] and the date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah, I have
[AGENT][NEUTRAL] And may I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Uh, data services for [PII] for the bill amount of $232 even.
[AGENT][POSITIVE] OK thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Let me pull that here.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][POSITIVE] The best.
[AGENT][NEUTRAL] All right, let me.
[AGENT][NEUTRAL] It looks like we processed the claim on [PII].
[AGENT][NEUTRAL] And the claim was denied. Um, the reason for this denial is that
[AGENT][NEUTRAL] It's a non-cover service.
[AGENT][NEUTRAL] We do not cover preventative.
[CUSTOMER][NEGATIVE] This is also no.
[CUSTOMER][NEUTRAL] You do, you do not cover what service?
[AGENT][NEUTRAL] Preventative.
[AGENT][NEUTRAL] Preventative preventative service.
[CUSTOMER][NEUTRAL] Could you please repeat that?
[CUSTOMER][NEGATIVE] Prevented service.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, got it. Uh, OK. Can you move the last claim?
[AGENT][NEUTRAL] You don't need any other information on this one?
[CUSTOMER][NEUTRAL] No. Plan, uh, secondary supplement plan, right?
[AGENT][NEUTRAL] OK, let me make a note.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] What's the next pharmacy.
[CUSTOMER][NEUTRAL] The next policy number is
[CUSTOMER][NEUTRAL] 0245.
[CUSTOMER][NEUTRAL] 558 4.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yes, [PII]. And the date of birth of this patient is [PII].
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] May I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah, sure. The date of service is gonna be [PII] for the bill amount of $1,511 even.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Alright, um, we processed the claim on [PII], and we need the primary ELB to continue the processing of the claim.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. Uh, you need a primary UB, right? So can we submit it as a corrected claim with the primary UP?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] You can.
[CUSTOMER][NEUTRAL] OK, what is the TFL?
[AGENT][NEUTRAL] We don't have term limits.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, got it. Um, that's all the information I need. So.
[AGENT][POSITIVE] OK. Well, thank you for calling APL. You're welcome. You as well. Thank you for calling APL. Bye-bye, Mr. [PII].
[CUSTOMER][POSITIVE] Thank you. Have a nice day.
[CUSTOMER][NEUTRAL] Bye-bye.