AccountId: 011433970860
ContactId: 868eabf7-1866-4566-bc60-d878859d56b2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 391619 ms
Total Talk Time (AGENT): 118933 ms
Total Talk Time (CUSTOMER): 193346 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/10/868eabf7-1866-4566-bc60-d878859d56b2_20250210T20:41_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Uh yes, I have a couple of questions about some claims that aren't being paid.
[AGENT][NEUTRAL] OK. And your name is?
[CUSTOMER][NEUTRAL] My name is [PII]. Last name is [PII]. Do you need me to spell that?
[AGENT][NEUTRAL] Uh, yes.
[CUSTOMER][NEUTRAL] It is [PII]
[AGENT][NEUTRAL] OK. And Ms. [PII], do you have a policy information in regards to?
[CUSTOMER][NEUTRAL] Do I have a what?
[AGENT][NEUTRAL] The policy number is in regards to?
[CUSTOMER][NEUTRAL] 02440284
[AGENT][NEUTRAL] OK, thank you. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. And verify your date of birth, mail address, and email address.
[CUSTOMER][NEUTRAL] Date of birth [PII] mailing address [PII] and what was the last one?
[AGENT][NEUTRAL] Email.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And you say you have a question about a claim that was processed or checking status of the claim?
[CUSTOMER][NEUTRAL] Yes, yes, no, I, I claim that was processed.
[AGENT][NEUTRAL] Uh, do you have that claim number or the date of service?
[CUSTOMER][NEUTRAL] Date of service is.
[CUSTOMER][NEUTRAL] I'm sorry, date of service is going to be [PII].
[AGENT][NEUTRAL] OK, give me one moment.
[AGENT][NEUTRAL] 13 C.
[AGENT][NEUTRAL] SSM Health Medical Group.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] See.
[AGENT][NEUTRAL] OK, looks like it process is not a covered place of service.
[CUSTOMER][NEUTRAL] Why is it not a covered place of service? It was a doctor's office. Why is it not why is it a not covered place of service?
[AGENT][NEUTRAL] See what your benefits are.
[CUSTOMER][NEUTRAL] And I'm sorry, uh, go ahead.
[CUSTOMER][NEUTRAL] It went towards the deduct it went towards the deductible. I've been told that this policy pays my deductible.
[AGENT][NEUTRAL] No, you're fine.
[AGENT][NEUTRAL] OK one moment.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, well, under the policy, um, it only covers for inpatient, outpatient. It does have a rider covers treatment in the physician's office or clinic, but based on the place of service on here, it's not listed as a covered place. It does.
[CUSTOMER][NEGATIVE] That's it. I'm, I'm, uh, you know, this is every time I go to the doctor's office, and nothing is being covered. Um, you have a reason every time not to cover anything. The policy reads that it pays my deductible on when I go to the doctor. This is not coded as an office visit. This is coded as him reading a report. This needs to be covered.
[AGENT][NEUTRAL] Well, per the policy, it has to be in one of those places of service. Uh, you can submit an appeal if you disagree with how the claim was processed and they can review it, but
[AGENT][NEUTRAL] Per the places.
[CUSTOMER][NEGATIVE] OK, what you're telling me place of where am I this what you said that there is a writer that I'm, I'm confused. There's a writer that I can go to the doctor's office, and if it goes towards my deductible, it's covered. That's exactly what I did. I went to my doctor's office. It went towards the deductible, and now you're telling me it was a place of service that wasn't covered. Where do you want me to go to the doctor's office down at the coffee shop?
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That wouldn't be covered, but per the claim that we received, the places service is not listed as a doctor's office or clinic.
[CUSTOMER][NEUTRAL] And what is it listed as?
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Uh, home.
[CUSTOMER][NEUTRAL] It's listed at home. He did not, it was a study that I did at home, but he read at the doctor's office.
[AGENT][NEUTRAL] I understand.
[CUSTOMER][NEUTRAL] This is him reading this study. I am not going, I mean.
[CUSTOMER][NEGATIVE] this is like the 3rd time that you guys will not cover a claim this year. I had no problems in the years past. I don't know if you're changing your processing procedures or what, but nothing is being covered any longer. So why have the policy if it's if the policy is in place to cover my deductible, but it's not covering the deductible, what's the point of having the policy?
[AGENT][NEUTRAL] I understand your frustration, but per the policy, it only covers for procedures in a covered place of service and per the information we've received from the provider, it does not show a covered place of service. Um,
[CUSTOMER][NEGATIVE] So I need to have the doctor resubmit this because this was, this was something that he performed in his office. I mean, it's not like I peed in a, I, I shit in a bowl. I, I took it to his office and he looked at it. I, I mean, what do you want me to do? I'm not gonna shit in his office.
[CUSTOMER][NEUTRAL] [PII], please have a section one too.
[AGENT][NEUTRAL] OK, well, you can talk to the provider and they can call and we can verify how the claim was processed, but for the information that was received, it's not a covered place of service.
[CUSTOMER][POSITIVE] Great.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK doke and now I'm so frustrated I've lost all the other ones that you guys haven't paid, so now I'm gonna have to find them and call back. I thank you for your time.
[AGENT][POSITIVE] You're welcome. Thanks