AccountId: 011433970860
ContactId: 9973accb-21b8-414b-9b7b-e6137fcc8867
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 258678 ms
Total Talk Time (AGENT): 133133 ms
Total Talk Time (CUSTOMER): 76002 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/30/9973accb-21b8-414b-9b7b-e6137fcc8867_20250430T14:22_UTC.wav
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[AGENT][NEUTRAL] Contacting APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling from Saint Charles Health, and I am looking to discuss a denied claim for a member.
[AGENT][POSITIVE] Yes, I can certainly uh help with that. And can I know the policy number, please?
[CUSTOMER][NEUTRAL] It is um let me make sure this is right.
[CUSTOMER][NEUTRAL] 019279993.
[AGENT][NEUTRAL] Thank you and the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Thank you. Is there a callback number I could have, please, in the event that we're disconnected?
[CUSTOMER][NEUTRAL] Sure, that's [PII].
[AGENT][NEUTRAL] Thank you. And what is the, the uh data service that we're looking for?
[CUSTOMER][NEUTRAL] Uh, this is [PII], and total bill charge is $727 even.
[AGENT][NEUTRAL] [PII]. OK.
[AGENT][NEUTRAL] Did you get a claim number on this, um, any chance?
[CUSTOMER][NEUTRAL] Uh, yeah, let's take a look. It is.
[CUSTOMER][NEUTRAL] 019
[CUSTOMER][NEUTRAL] 27993.
[AGENT][NEUTRAL] OK, yeah, I think that's, that's gonna be our policy number. Um, so what I have is, uh,
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Yeah, that is.
[AGENT][NEUTRAL] I have a couple of things. I, it looks like an office visit and some other things. Uh, is that what we might be looking at or?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, that's correct. There should be 3 charged lines.
[AGENT][NEUTRAL] OK, so let me just pull that up.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm gonna do is I'm just gonna get to the, to the documentation that was submitted and then we can talk about it. OK, now what I have here is uh is that the office visit, of course, isn't covered, um.
[AGENT][NEUTRAL] And then I think there was a code, uh.
[AGENT][NEUTRAL] G 22.
[AGENT][NEUTRAL] 11, is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And is there, are you wanting to know about that code or 96127?
[CUSTOMER][NEUTRAL] No, so just the, the office visit, so it looks like that's not a is that just not a covered benefit on her plan?
[AGENT][NEUTRAL] No, no, it is not. Um, now, treatment within the physician's office is treatment or procedures, but the office visit co-pay, uh, is not, will not ever be covered on this, uh, for any reason, whether it's sickness or accident. Uh, it's just not part of the policy.
[CUSTOMER][NEUTRAL] OK, so it doesn't cover office visits.
[AGENT][NEGATIVE] No, no, it doesn't.
[CUSTOMER][NEUTRAL] Like you said does OK.
[AGENT][NEUTRAL] Right. This, this treatment or, or procedures within the physician's office, um.
[AGENT][NEUTRAL] But not the offices that co-pay.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, so in this case what is is the claim denying to patient responsibility or?
[AGENT][NEUTRAL] Well, we can't really tell you that, uh, [PII]. The only thing I can tell you is that it's not covered by her policy here, um, but most likely you will have to get back in touch with the, with the insured. Um, she may have another, she may have another, uh, policy, uh, for this sort of thing. Um.
[CUSTOMER][NEUTRAL] So this claim just denied straight out, is that correct?
[AGENT][NEUTRAL] Yes, ma'am, that is correct. Yeah, it's just, it is just not covered under this policy. Um, there are many, many things that are, but the office visit co-pay is one of those things that specifically excluded within the, the, um, terminology of the policy as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] All right sounds great. Is there a reference for today's call?
[AGENT][NEUTRAL] Yes, my name is [PII]. The first letter of my last name is [PII]. We'll use that in today's date as a reference. Now is this the only time that we need to look at for um this member?
[CUSTOMER][POSITIVE] Yes, for right now thank you.
[AGENT][POSITIVE] OK, thanks for contacting AP have a good day.