AccountId: 011433970860
ContactId: 84576594-64a7-4ab8-bd46-de45f7ee3d3f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1001700 ms
Total Talk Time (AGENT): 267937 ms
Total Talk Time (CUSTOMER): 210896 ms
Interruptions: 5
Overall Sentiment: AGENT=0.4, CUSTOMER=-1.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/19/84576594-64a7-4ab8-bd46-de45f7ee3d3f_20250519T18:03_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII] I need to check on a claim for a patient. Can you help?
[AGENT][POSITIVE] Sure, [PII], I can assist you with that. I have a callback number for you.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Thank you [PII] What is the policy number of the member that you're calling to verify benefits for today?
[CUSTOMER][NEUTRAL] Sure. 971-111.
[AGENT][NEUTRAL] Can you verify that patient's name and date of birth?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Patient is [PII]. DOB is [PII].
[AGENT][NEUTRAL] And you're calling to verify benefits and eligibility?
[CUSTOMER][NEUTRAL] Mm, for a claim.
[AGENT][NEUTRAL] What is the date of service that you're calling to the status of a claim for?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], what is your procedure code?
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Uh, the code is 99213.
[AGENT][NEUTRAL] Thank you. This claim was received [PII]. It was processed [PII].
[AGENT][NEUTRAL] There was no payment made on this claim, and the reason why is because office visits are not covered, nor is the treatment received in the office covered under the policy.
[CUSTOMER][NEUTRAL] Just a second.
[CUSTOMER][NEUTRAL] Like we have previously received the payment for office visit for the same patient. It is for [PII]. You can check by yourself.
[AGENT][NEUTRAL] Give me one moment.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Do you have a data service?
[CUSTOMER][NEUTRAL] Yup. [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And what's the bill, what is the procedure called?
[CUSTOMER][NEUTRAL] It's the same, uh, no, it's an office is it but 99214.
[AGENT][NEUTRAL] And what was the bill amount?
[CUSTOMER][NEUTRAL] The total bill for the plane.
[CUSTOMER][NEUTRAL] Would be just a sec.
[AGENT][NEUTRAL] How many procedure codes are there?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] There are like 5 CPT codes.
[AGENT][NEUTRAL] 1568, there was no payment made on this claim.
[CUSTOMER][NEUTRAL] The total bill is
[AGENT][NEUTRAL] 1568.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] What do you mean no payment made?
[AGENT][NEGATIVE] There was no payment made here at American Public Life pertaining to that claim because it was noncovered.
[CUSTOMER][NEUTRAL] Uh, OK. So, lastly, I spoke to one of your representatives. She sent it back for review. She mentioned that there should be a payment. I have the reference number for it. Can you check? It was like we last we talked.
[AGENT][NEUTRAL] The member's policy, we don't have reference numbers. We don't have, we don't provide reference numbers here at American Public Life.
[CUSTOMER][NEUTRAL] Yes. Uh
[CUSTOMER][NEUTRAL] Right, right, right. Actually, she has given her name and uh that was the date. But like we spoke on [PII]. So do you have any records on it?
[CUSTOMER][NEUTRAL] She mentioned that that uh turnaround time was 20 days since [PII].
[AGENT][NEUTRAL] You said [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII], yes. [PII].
[AGENT][NEUTRAL] I'm not showing anything in the system.
[CUSTOMER][NEUTRAL] Just a sec. So you are saying this patient or this plan will not cover?
[AGENT][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] Office visits or the treatment received in the office.
[CUSTOMER][NEUTRAL] OK, just a sec.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Just a sec.
[CUSTOMER][NEUTRAL] UHC
[CUSTOMER][NEUTRAL] You have been paid $30.
[CUSTOMER][NEUTRAL] All right. Uh, do you have any UP for it?
[AGENT][NEUTRAL] We do.
[CUSTOMER][NEUTRAL] OK. I would need the UB for [PII] of [PII] for this particular date.
[CUSTOMER][NEUTRAL] And also for
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, what's the first date I can only pull one at a time. What's the first date?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] I need the claim number for this one as well, please.
[AGENT][NEUTRAL] It is 357-1568. That's 3571568.
[CUSTOMER][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] 568.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] And she mentioned offices it might not be covered, but what about G2211 cause she sent it back for that specific code as well cause it, it was denied incorrectly. She mentioned that it should be paid.
[AGENT][NEUTRAL] I don't see that in the notes anywhere.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] She specifically mentioned, I do remember she stated that the 99214 might be in question, but that should certainly not be any concern or question regarding the payment of SWIFT code G2211.
[CUSTOMER][NEUTRAL] That was the patient responsibility left by the primary, which should be covered by you guys.
[AGENT][NEUTRAL] May I place you on a brief hold?
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hey, [PII], how are you doing?
[AGENT][NEUTRAL] I'm OK. [PII], I have, could you look at a claim with me? I have a provider on the phone. He's calling about a claim that was denied.
[AGENT][NEGATIVE] And it looked like it was processed incorrectly cause the remarks code.
[AGENT][NEUTRAL] Yes it is.
[AGENT][NEGATIVE] No benefits are payable. Mhm.
[AGENT][NEGATIVE] This is the room was cold.
[AGENT][NEUTRAL] Let me go back to the client.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] You got the actual claim itself. Let me pull this up so you can see it.
[AGENT][NEUTRAL] But he, I don't deny it. You see the claim with all the procedure codes.
[AGENT][NEUTRAL] But he denied it like vision.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] The CLME screen or the actual client?
[AGENT][NEUTRAL] Uh, oh, what did it do to my stuff?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] But the member has a treatment rider, would this not be covered under the treatment rider?
[AGENT][NEUTRAL] Auto
[AGENT][NEUTRAL] So now I have a question.
[AGENT][NEGATIVE] Mhm. He denied it. No, he actually put it on the outpatient, but he denied his vision is not covered.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] When I do an error cause I'll be aggressive when you talk to him about his claim, so I wanna do it.
[AGENT][NEUTRAL] When you do the error, it's not funny thing cause he do, he really do be aggressive. Yes.
[AGENT][NEUTRAL] When, um, cause he'd be like, how is it wrong? I'm like, I'm telling you how is wrong, but OK. When it's time for me to do an error, I do it right here, right?
[AGENT][NEUTRAL] Like, you know, before I do the error, I would give them a heads up like, hey, could you look at claims such and such, such and such, and yeah.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And I put the
[AGENT][NEUTRAL] Product name.
[AGENT][NEUTRAL] Let
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] Oh, I'm gonna let, I'm sorry, I'm sharing my stuff with you.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] I'm just typing away.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Well I don't know.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] The AD? OK.
[AGENT][NEUTRAL] And they see
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Where to save it. I.
[AGENT][NEUTRAL] Oh, you hiding it.
[AGENT][NEUTRAL] Teams side is I see the um this was in a way.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK. Thank you, [PII].
[AGENT][NEUTRAL] Oh, so you guys have to review it before they get it.
[AGENT][NEUTRAL] Oh, they got y'all doing a lot of stuff.
[AGENT][NEUTRAL] Oh
[AGENT][POSITIVE] All right. Well, thank you.
[AGENT][POSITIVE] Have a good day.
[AGENT][POSITIVE] Thank you for holding I apologize for the inconvenience, so I've sent this over to the adjusters so they can review it and for the research and if there's a payment due, then the payment will be sent out.
[CUSTOMER][NEUTRAL] Is there any other way that we can have it processed cause like it was already sent back for review on [PII]. So I don't know if it is the same thing.
[AGENT][NEUTRAL] No, I can just do that. I can only thing I can do is send it back to the adjuster for them to review it and then reprocess it. Can I have your fax number to send you an ELB?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] 866
[CUSTOMER][NEUTRAL] 473.
[CUSTOMER][NEUTRAL] Just a 2nd. 866-473.
[CUSTOMER][NEUTRAL] 1161.
[AGENT][NEUTRAL] [PII]. OK, I can do that for you, [PII] Is there anything else that I can assist you with?
[CUSTOMER][NEUTRAL] And attention to Max if you may.
[CUSTOMER][NEUTRAL] Yes, 866.
[CUSTOMER][NEUTRAL] Yup, so you did send back for review for [PII], right?
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. Please provide me the year for [PII] as well.
[AGENT][POSITIVE] Yes, I'm sending you that one as well along with the July.
[AGENT][NEUTRAL] Is there anything else that I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] Just a sec.
[CUSTOMER][NEUTRAL] OK. Do you have, you want to have a reference number, right? I would need your name, please.
[AGENT][NEUTRAL] We don't provide reference numbers you can use my name and today's date as a reference.
[CUSTOMER][NEUTRAL] Mm. That's what I would need your name.
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][POSITIVE] OK, that would be, [PII]. Thank you.
[AGENT][POSITIVE] You're welcome, [PII] Thanks for calling APL and have a great day.
[CUSTOMER][NEUTRAL] Mm