AccountId: 011433970860
ContactId: 85b6e0d7-2c54-4d49-8b19-8673800d17e4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 367489 ms
Total Talk Time (AGENT): 129645 ms
Total Talk Time (CUSTOMER): 99220 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/07/85b6e0d7-2c54-4d49-8b19-8673800d17e4_20250107T16:52_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling you from Ellis Hospital. I do have a claim for a member. I just want to check the status for that.
[AGENT][NEUTRAL] OK, sure, Mr. [PII], I can assist you with claims and may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yeah, it's [PII]. It's a direct line.
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's 133083.
[CUSTOMER][NEUTRAL] 6, M as in Mike, L as in Lima, and 8.
[AGENT][NEUTRAL] OK, can you repeat that number one more time? That's not what I pulled.
[CUSTOMER][NEUTRAL] OK. It's 1330836 M as in Mike, L as in Lima, 8.
[AGENT][POSITIVE] Thank you. One moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah. Patient's full name is [PII] and the date of birth, it's [PII].
[AGENT][NEUTRAL] OK. And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Date of service it's [PII]. The total bill amount is.
[CUSTOMER][NEUTRAL] $153.
[AGENT][NEUTRAL] OK. Thank you. Let me see if I can find this claim for you and that was for [PII] for 153.
[CUSTOMER][POSITIVE] That's right.
[AGENT][NEUTRAL] OK. And for future, you can check claim status online through our website at [PII].
[AGENT][NEUTRAL] Yeah let's see, yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK bear with me just a minute, let me pull this information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Could you please spell your name and the last name initial, please?
[AGENT][NEUTRAL] That's [PII]. Last initial is [PII].
[CUSTOMER][POSITIVE] Thank you so
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] All right, and it looks like we have received the claim [PII], processed the claim [PII].
[AGENT][NEUTRAL] And it was denied stating that office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] OK. May I know the denial reason one more time?
[AGENT][NEUTRAL] Office visits are not covered under the member's plan.
[CUSTOMER][NEUTRAL] OK. May I know when it was denied?
[AGENT][NEUTRAL] It was [PII].
[CUSTOMER][NEUTRAL] May I know the claim number?
[AGENT][NEUTRAL] Claim number is 353-055-2.
[CUSTOMER][NEUTRAL] Sorry, could you please repeat that?
[AGENT][NEUTRAL] 353-0552.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 0552, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. One moment, Sol.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, so could you please check any of the previous payment for this number has been made?
[AGENT][NEUTRAL] Any other payments for office visits? No, it's not covered under the policy.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK. May I know the member's plan type?
[AGENT][NEUTRAL] This is a secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] So, may I know the primary policy for this member?
[AGENT][NEUTRAL] Um let me see if I can have, if I have that information. OK, one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Of action
[AGENT][NEUTRAL] All right, that is Cigna.
[CUSTOMER][NEUTRAL] OK, Cigna is primary, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. May I know the plan type?
[AGENT][NEUTRAL] Secondary supplemental plan.
[CUSTOMER][NEUTRAL] Is there any letter, supplement plan, letter?
[AGENT][NEUTRAL] No, it's, it's not a, it's not a Medicare. It's not a Medicaid. It's, it's a supplemental plan to the major medical. So it's not um it's not a Medicare.
[AGENT][NEUTRAL] So it doesn't have any letters or anything like that.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so thank you for that. If it is denied as office visit visit is not covered on this member's plan, it's so it will be members responsibility.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Correct, it's up to the provider's discretion.
[CUSTOMER][NEUTRAL] OK, then that's it for today. So can I get the call reference number for this conversation?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will. Is there anything else I may help you with today?
[AGENT][NEUTRAL] Mr. [PII].
[CUSTOMER][POSITIVE] No, that's it for today. So thank you for your assistance and have a good day.
[AGENT][POSITIVE] You as well thank you for calling APO bye bye.
[CUSTOMER][NEUTRAL] Bye.