AccountId: 011433970860
ContactId: 953ec50f-4275-4264-a8bf-997fb6dbc4ab
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 374399 ms
Total Talk Time (AGENT): 161770 ms
Total Talk Time (CUSTOMER): 153462 ms
Interruptions: 5
Overall Sentiment: AGENT=0.8, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/22/953ec50f-4275-4264-a8bf-997fb6dbc4ab_20250522T17:24_UTC.wav
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[AGENT][NEUTRAL] Afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEGATIVE] Uh, yes, I'm calling with a question on a denial we received.
[AGENT][NEUTRAL] OK, you're calling on behalf of the provider regarding a denied claim. Yes ma'am, I can help you with that and who am I speaking with please?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes, mhm.
[CUSTOMER][NEUTRAL] This is [PII].
[AGENT][NEUTRAL] Thank you and [PII], what is your callback number?
[CUSTOMER][NEUTRAL] [PII] that's correct.
[AGENT][NEUTRAL] Mhm. Mhm.
[AGENT][POSITIVE] Thank you and the member's policy number please [PII].
[CUSTOMER][NEUTRAL] Is D as in Delta 43733145.
[AGENT][NEUTRAL] OK thank you now [PII], that is not an APO policy number.
[AGENT][NEUTRAL] That is an IMA or a 90 degree benefit number. Were you trying to reach them or was the claim?
[CUSTOMER][NEUTRAL] Well, I don't have.
[AGENT][NEUTRAL] Filed with APL because there would be a different policy number.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Alright, let me go see this is an urgent care claim, so we don't, uh, let's see what the card looks like.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And that's the number um.
[CUSTOMER][NEUTRAL] And it it really doesn't give too much so um it says MAU go ahead.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm. No, go ahead.
[CUSTOMER][NEUTRAL] Oh, OK, 90 degree benefits, that's what it is. OK. So we got something back from American Public Life stating that it wasn't covered.
[AGENT][NEUTRAL] OK, so
[AGENT][NEUTRAL] OK, so on the explanation of benefits that you received from APL, there is a policy number and a claim number. I need the policy number first to look up the member's information.
[CUSTOMER][NEUTRAL] OK, the policy number because I did call you at the number that's on the EOB so it has the policy number 02609142.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, thank you, that's the one I need.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Like I said, they come through urgent care and it's always a, uh, an adventure.
[AGENT][NEUTRAL] It can be.
[CUSTOMER][NEUTRAL] It is for me, yes.
[AGENT][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK [PII], any information that I do provide for you today will be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] and date of birth [PII].
[AGENT][NEUTRAL] OK, thank you and the date of service and total bill amount.
[CUSTOMER][NEUTRAL] 328 25 total charge $320.
[AGENT][NEUTRAL] OK, and that claim number that you have?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] I've got 359-059-7.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so let me get that pulled up.
[AGENT][NEUTRAL] And the provider group.
[CUSTOMER][NEUTRAL] Is Northeast Georgia physicians group urgent care.
[AGENT][NEUTRAL] OK, thank you. So yes, ma'am, I can see that that claim was denied.
[AGENT][NEUTRAL] The reason for the denial on this claim states the outpatient rider allow only allows payment for outpatient surgery in an outpatient hospital or physician's office. Therefore, no benefits are payable.
[AGENT][NEUTRAL] Urgent care is not covered under this limited benefit plan.
[CUSTOMER][NEUTRAL] OK, alright, so that sounds like it's, it's denying because of the place of service 20.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Which indicates that it's an urgent care. It was done at an urgent care facility. So there's no coverage for urgent care under this policy. Is that correct?
[AGENT][NEUTRAL] Correct. That is correct because it's a hospital indemnity limited benefit plan.
[CUSTOMER][NEUTRAL] Let me write that down. Hospital limited benefit plan.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And, uh-huh.
[AGENT][NEUTRAL] Yes, ma'am. Hospital indemnity Limited. Yeah.
[CUSTOMER][NEUTRAL] OK, I knew it was limited.
[CUSTOMER][NEUTRAL] I knew it was limited but I didn't know as to what so OK is there a call reference number for this?
[AGENT][NEUTRAL] Yes ma'am, you would use my name along with today's date and then just one additional, yes [PII], uh huh and then just an additional piece of information for future reference we do have a portal as well [PII], that you should also be able to check claim status in for our members and the website for that portal is located at [PII].
[CUSTOMER][NEUTRAL] And you're [PII], is that right?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, that's [PII].
[AGENT][NEUTRAL] With a D on it.
[CUSTOMER][NEUTRAL] Oh [PII] OK let me.
[AGENT][POSITIVE] Mhm, [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]. Yes ma'am, that's it.
[CUSTOMER][POSITIVE] OK, very good, um, I appreciate it so much.
[AGENT][NEUTRAL] All right. Well, is there anything else? You're certainly welcome, [PII].
[CUSTOMER][NEUTRAL] Nope, that'll do it.
[AGENT][POSITIVE] OK, well then thank you for calling.
[CUSTOMER][POSITIVE] Have a great
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][POSITIVE] Yeah, thank you. I was gonna say have a great Memorial Day weekend. We're looking forward to it.
[AGENT][POSITIVE] Well, I was gonna say the same thing to you, so I hope you have one as well.
[CUSTOMER][POSITIVE] Thank you bye.
[AGENT][NEUTRAL] Yes, ma'am. Bye-bye.