AccountId: 011433970860
ContactId: 8e9abfe1-dd0d-4df7-aa89-d55c342b69b4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 648049 ms
Total Talk Time (AGENT): 148909 ms
Total Talk Time (CUSTOMER): 255249 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/03/8e9abfe1-dd0d-4df7-aa89-d55c342b69b4_20250203T20:51_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII], and I'm calling for a provider to check on additional information about the claim that has been denied. Please note this call will be monitored and recorded for quality and training purposes. What's your day?
[AGENT][NEUTRAL] I can barely hear you.
[CUSTOMER][NEUTRAL] Hi, this is [PII], and I'm calling for provider to check on additional information about the claim that has been denied. Please note this call will be monitored and recorded for quality and training purposes. How was your day?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, can you spell, it's fine. Can you spell your first name and provide the policy number, please?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes. Uh, my first name is [PII]. [PII].
[AGENT][NEUTRAL] And the policy number?
[CUSTOMER][NEUTRAL] Uh, the policy number is, it's 02455926, the member ID number.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And your phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] Uh, it's [PII]. It's a direct line with no extension.
[AGENT][POSITIVE] Thank you. One moment.
[CUSTOMER][POSITIVE] Yes, please take your time.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Thanks for holding, [PII] and what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Patient's first name is [PII] and the last name is [PII].
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][NEUTRAL] You said that you're checking claim status Gladwin?
[CUSTOMER][POSITIVE] Yes, yes, yes.
[AGENT][NEUTRAL] OK, what's the date of service in charge?
[CUSTOMER][NEUTRAL] The date of services [PII].
[CUSTOMER][NEUTRAL] And the total charge amount is $790 even.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And what are the procedures on the claim?
[CUSTOMER][NEUTRAL] Uh yes. The, uh, the CPT uh procedure codes are 992-049938690715 and 963772.
[AGENT][NEUTRAL] So you've already received a copy of the explanation?
[CUSTOMER][NEUTRAL] Uh yes.
[AGENT][NEUTRAL] OK, and what was your questions regarding the claim?
[CUSTOMER][NEUTRAL] Uh, I have, I want to know additional information about the, about the CPT codes.
[CUSTOMER][NEUTRAL] And for your reference, we have submitted 2 claims for the data service. May I know the status of the recent claim?
[AGENT][NEUTRAL] Yeah, so the remark code is on the back of the explanation. It appears that you did receive it.
[AGENT][NEUTRAL] Um, so one of the remark codes says that the outpatient rider only allows payment for outpatient surgery in an outpatient hospital or a surgery in a physician's office.
[AGENT][NEUTRAL] So if, if that did not occur, then it's not payable per the patient's policy.
[AGENT][NEUTRAL] And the other denial code?
[AGENT][NEUTRAL] this policy does not provide benefits for vaccinations and immunizations.
[AGENT][NEUTRAL] That's the other code of denial.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Let me.
[CUSTOMER][NEUTRAL] OK. Uh.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] For what are these, uh, for this CPD codes, may I know the remark and the reason? It's for 99204?
[AGENT][NEUTRAL] It's the remarks that I just read.
[CUSTOMER][NEUTRAL] So, well, so it is not covered under the member's plan, right? All these codes. May I know the member's plan name, please?
[AGENT][POSITIVE] Correct, correct.
[AGENT][NEUTRAL] It's a limited hospital indemnity policy.
[CUSTOMER][NEUTRAL] Hospital.
[CUSTOMER][NEUTRAL] Identity policy. Thank you. And may I have the claim number, please?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 344-533-6.
[CUSTOMER][NEUTRAL] Can you repeat that?
[CUSTOMER][NEUTRAL] And may I know the uh whether this process on?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So just a moment.
[AGENT][NEUTRAL] Received [PII].
[CUSTOMER][NEUTRAL] Uh, may I know the is
[AGENT][NEUTRAL] Received [PII], processed [PII].
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] April
[CUSTOMER][NEUTRAL] [PII] and
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Just a moment, please.
[CUSTOMER][NEUTRAL] And can I have the spelling of your name, please?
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] First initial of my last name is [PII]
[AGENT][NEUTRAL] As in [PII] and [PII], any other questions I can help out with today?
[AGENT][NEUTRAL] Any other questions I can assist with today?
[AGENT][NEUTRAL] [PII], are you there?
[CUSTOMER][POSITIVE] Uh yes, I'm there. I'm sorry for that. I was speaking, um, I was speaking and without um unmuting the mic. Sorry for that.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Oh, OK. Anything else I can help you with today?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes. Uh, we have received an EOB from you, um, but it doesn't match the claim number and, and it does not have the outstanding CDs. I can provide you the claim number. Can you please verify that?
[AGENT][NEUTRAL] OK, I did not understand the question. So what am I checking?
[CUSTOMER][NEUTRAL] Mhm. Now, we have received an EOB.
[AGENT][NEUTRAL] So I, so you gave me, you gave me claim number 3445336?
[CUSTOMER][NEUTRAL] Uh no. The claim number is 345-0823.
[AGENT][NEUTRAL] OK, so that's a different claim number than what you gave me before.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] But it's for the same service.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEGATIVE] Same date of service it just denied as a duplicate.
[AGENT][NEUTRAL] Of the one that we just went over.
[CUSTOMER][NEUTRAL] Oh, it's they're not as.
[CUSTOMER][NEUTRAL] OK. uh, may I know the duplicate, uh, claim was, when it, when it was processed, the duplicate claim?
[AGENT][NEUTRAL] It was processed on the [PII], received [PII].
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] It's [PII]. So you provided uh the claim number 344-5336 was uh our original claim, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] That's original claim number. Thank you.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the original claim was processed on [PII].
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Thank you. So it was denied because uh the service is not got under the member's plan. Uh, the member's plan name is limited hospital indemnity Policy.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Thank you. Uh, just only one second. Give me a moment, please.
[CUSTOMER][NEUTRAL] Give me a moment. Give me a moment, please.
[CUSTOMER][NEUTRAL] OK, I do see that. OK, thank you. And thank you for, and can I have the call reference number, please?
[AGENT][NEUTRAL] My name and today's date.
[CUSTOMER][POSITIVE] Thank you. And thank you for assisting me today. Kindly. Have a great, great day.
[AGENT][POSITIVE] Oh, you're welcome, [PII], and you can also check your status on our online service center at [PII]. And if no other questions, thank you for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And are you still there?
[CUSTOMER][NEUTRAL] [PII], are you still alive?
[AGENT][NEUTRAL] Anything else?
[CUSTOMER][NEUTRAL] Uh, may I know who is responsible for this, whether it is providers write up for patient responsibility?
[AGENT][NEUTRAL] We do not determine
[CUSTOMER][POSITIVE] Thank you. Thank you for assisting me today. Have a great day.
[AGENT][POSITIVE] Thank you for calling APL. Have a good day.