AccountId: 011433970860
ContactId: 9b505407-8386-45e3-b651-32ea06888340
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 395070 ms
Total Talk Time (AGENT): 166696 ms
Total Talk Time (CUSTOMER): 127061 ms
Interruptions: 4
Overall Sentiment: AGENT=0.7, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/9b505407-8386-45e3-b651-32ea06888340_20250219T21:33_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] This is [PII]. How can I help you? Hi, uh, my name is [PII] calling from the doctor's office. I'm looking for a client status.
[AGENT][NEUTRAL] OK, you said your name is [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] And you have, you're wanting to check status on one member, is that correct?
[CUSTOMER][POSITIVE] Yes, you're right.
[AGENT][NEUTRAL] [PII]. OK, yes, I can help you with that. And what is your callback number, please?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII]. And may I have your first name one more time?
[AGENT][NEUTRAL] Again, your phone number is [PII]. Is that correct?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And again, my name is [PII]
[AGENT][NEUTRAL] And you would use my name along with today's date, [PII], if you're gonna need a call reference number for our call today.
[CUSTOMER][NEUTRAL] Sure. And may I have your last name initial?
[AGENT][NEUTRAL] Yes and yours?
[CUSTOMER][POSITIVE] Thank you. Mine is uh [PII].
[AGENT][NEUTRAL] What is yours?
[AGENT][NEUTRAL] Thank you. And the member's policy number, please?
[CUSTOMER][NEUTRAL] 018412777
[AGENT][POSITIVE] Thank you. One moment, please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And [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 their date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII] is the date of birth.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what is the date of service and total bill amount, please?
[CUSTOMER][NEUTRAL] [PII] and the bill on $91 even.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, so I do show the [PII] that this claim was received. One moment, I'll provide you that information.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] This claim was received on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Processed and denied on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 3512017.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And the reason for the denial state's policy provides no benefits.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For the treatment of conditions other than a sickness or injury as defined by the policy.
[AGENT][NEGATIVE] This is not covered under the member's plan.
[CUSTOMER][NEUTRAL] OK. Uh,
[CUSTOMER][NEUTRAL] So it's not related to the diagnosis?
[AGENT][NEUTRAL] No, sir. Again, policy provides no benefits for the treatment of conditions other than a sickness or injury as defined by the policy.
[CUSTOMER][NEUTRAL] OK. If, uh, defined by the policy means, may I know what are the services covered under this patient plan?
[AGENT][NEUTRAL] This plan covers.
[CUSTOMER][NEUTRAL] Is there any specific limitations?
[AGENT][NEUTRAL] That this is a supplemental policy to her primary insurance that helps with co-pays, deductibles, and co-insurance amounts of covered services.
[CUSTOMER][NEUTRAL] OK. And you guys a supplemental policy?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Uh, supplemental to Medicare or any other commercial insurance?
[AGENT][NEUTRAL] Private, no, her major medical. No, sir. This is a supplement to her major medical insurance.
[CUSTOMER][NEUTRAL] That's.
[CUSTOMER][NEUTRAL] OK, and you guys are all based on secondary, not as a primary.
[AGENT][NEUTRAL] No, sir, we are not a major medical insurance company.
[CUSTOMER][POSITIVE] OK. Thank you so much. And you guys have only covered the primary policy co-insurance and co-pay and deductible?
[AGENT][NEUTRAL] Of covered services, that is correct.
[AGENT][NEUTRAL] And if you need a copy of that explanation of benefits for that claim, [PII], you may print that by going to our portal at [PII].
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. So that's why the claim was denied because uh it was a supplemental policy to the medical insurance the patient have, uh, but any of the medical insurance. Is it correct?
[AGENT][NEUTRAL] This plan is a supplemental policy to her primary health care insurance, and under this policy, that is not covered, the service is not covered.
[CUSTOMER][POSITIVE] Got that. Thank you so much.
[CUSTOMER][NEUTRAL] Mhm. It only covers the primary, uh, paid and the remaining leftover co-pay and co-insurance.
[AGENT][NEUTRAL] I covered services.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. Are you guys uh cover the deductible or not?
[AGENT][NEUTRAL] Of covered services, and this is not covered under this patient's plan with our company.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Thank you so much. And
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] We need to file the claim first to the medical, the primary medical insurance, and then we need to submit the claim with their EOB to you guys uh secondary. Is it correct?
[AGENT][NEUTRAL] That was already received.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much and uh have a nice day.
[AGENT][POSITIVE] Yes, sir, if that's all I can help you with, and thank you again for calling APL and I hope you have a nice evening also.
[CUSTOMER][POSITIVE] Mhm thank you bye.
[AGENT][POSITIVE] You're welcome. Bye bye.