AccountId: 011433970860
ContactId: 83bba553-f7df-461b-94a0-0703ecaacc72
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 406589 ms
Total Talk Time (AGENT): 143910 ms
Total Talk Time (CUSTOMER): 118078 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/27/83bba553-f7df-461b-94a0-0703ecaacc72_20250127T17:17_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII]. My name is [PII]. I'm calling a provider of Doage Medical Group, and I want to know general claim status, [PII].
[AGENT][NEUTRAL] Sorry, can you repeat that slowly? You said you're calling for a claim status?
[CUSTOMER][POSITIVE] That's correct. Uh.
[AGENT][NEUTRAL] OK, can you repeat your name for me, please?
[CUSTOMER][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes. The contact number is [PII].
[AGENT][NEUTRAL] Thank you. May I have the member's policy number?
[CUSTOMER][NEUTRAL] 02007928.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][POSITIVE] Sure, take your time.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Uh, just a moment. The first name is [PII] and the last name is [PII], and the date of birth is [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 for the claim you like me to check on?
[CUSTOMER][NEUTRAL] 8 18 2024 and the total charge amount is $239 even.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] The provider office name is DuPage Medical Group.
[AGENT][NEUTRAL] So I'm showing we received the claim on [PII].
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that claim number is 350.
[AGENT][NEUTRAL] 1769.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And on [PII], the claim was denied?
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][NEUTRAL] Yes, [PII].
[AGENT][NEGATIVE] It was denied because the policy provides no benefits for treatment or conditions other than what's listed in the policy.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] here.
[CUSTOMER][NEUTRAL] I got a date.
[CUSTOMER][NEUTRAL] Uh, OK. Uh, and uh, I have an explanation of benefit, uh, and the posted date is [PII] and get denied for CO 96 non-covered charges. Can you check, please?
[AGENT][NEUTRAL] I'm not sure. I'm sorry, I don't understand. You're wanting me to check the reason for the denial?
[CUSTOMER][NEUTRAL] Yes, but I have a, uh, you'll be explanation of benefit and serving me C 96 denied and non-covered charges.
[AGENT][NEGATIVE] Right, it's not covered because it wasn't, it's not a listed service on the schedule of benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So what can I do with the claim, [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] What can you do with the claim? Um, I mean, so it's not covered by the insurance, so it would depend on what your policies are. Do you bill the patient? Do you write it off? I, I don't, I'm not sure how to advise on what to do with the claim, but it's not covered by their insurance policy.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] It's a nonco as the provider contact, right?
[AGENT][NEUTRAL] As per the patient's policy?
[CUSTOMER][NEUTRAL] So patient policy. The patient is out of network or in-network?
[AGENT][NEUTRAL] It's not, it's none of that. So there's a, there's a list of benefits that our policy will cover what the patient got was not on that list, so we can't cover it.
[CUSTOMER][NEUTRAL] So can I send to uh amount to patient?
[AGENT][NEUTRAL] We do not determine patient responsibility. That will be up to you as the provider.
[AGENT][NEUTRAL] And what your next steps would be when a when a claim is not covered.
[CUSTOMER][NEUTRAL] So, what can I take final exam?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] So what should I take in final action?
[AGENT][NEGATIVE] The questions that you're asking me, I'm unable to answer. You would need to speak with a supervisor on your team or someone who works there. Once a claim has been denied.
[AGENT][NEUTRAL] If you're not, you can't, I mean, you can appeal it if you like, but
[AGENT][NEUTRAL] What they had is not covered, so it wouldn't make sense to appeal. So you would have to see what your next steps are.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, provide me, can you provide me a call reference number, [PII]?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name and today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] OK. Your name is [PII], right?
[AGENT][NEUTRAL] My name is [PII]
[CUSTOMER][NEUTRAL] [PII], OK.
[CUSTOMER][NEUTRAL] The last name is [PII], right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][POSITIVE] OK, thank you so much and uh have a great day. Bye for now.
[AGENT][POSITIVE] Thank you also and thanks for calling APL.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.