AccountId: 011433970860
ContactId: 9f1cddc8-b9cf-409e-a376-2093ca7d8270
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 427579 ms
Total Talk Time (AGENT): 146846 ms
Total Talk Time (CUSTOMER): 205860 ms
Interruptions: 5
Overall Sentiment: AGENT=0.5, CUSTOMER=0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/23/9f1cddc8-b9cf-409e-a376-2093ca7d8270_20250523T14:40_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is. How can I help you?
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling from Su a Medical Foundation, and I just want to get the status of a claim. Could you please assist me with that?
[AGENT][NEUTRAL] Uh, we're just needing to check on a claim you said?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, yeah, I can check that for you. uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, the callback number is [PII] with an extension of [PII].
[AGENT][NEUTRAL] OK, thank you. And then do you have the policy number?
[CUSTOMER][NEUTRAL] Yeah, please wait a moment. I'm providing you the policy number of the patient.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Please allow me for a minute.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Actually, my system is lagging. I'm so sorry, ma'am. Please wait a moment, just one more moment.
[AGENT][POSITIVE] You are perfectly fine. It's all right, no worries.
[CUSTOMER][POSITIVE] Thank you so much for the understanding, yeah.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The member ID is, it's uh 02450890.
[AGENT][NEUTRAL] OK and then what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Member name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] Perfect, thank you for verifying that. uh, what was the date of service for this claim?
[CUSTOMER][NEUTRAL] But the services it's [PII] and the bill amount is $1,365 even.
[AGENT][NEUTRAL] OK, you said uh [PII]?
[CUSTOMER][NEUTRAL] Yeah, [PII]. Correct.
[AGENT][NEUTRAL] Got it. OK, so I will let you know, uh, [PII], that this policy terminated [PII]. Would you still like me to see if this claim has been received?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so please bear a moment. Actually I have a set of service. Please bear a moment. Uh, what is that [PII].
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][NEGATIVE] It's denied due to.
[CUSTOMER][NEUTRAL] Yeah, the date, the date of service is, it is [PII], which was well processed by insurance.
[CUSTOMER][NEUTRAL] And denied for non-covered services. So could you please check this information for me?
[AGENT][NEUTRAL] OK, I'm sorry, you said [PII]?
[CUSTOMER][NEUTRAL] [PII], correct, yes.
[AGENT][NEUTRAL] What was that bill amount? Was that the same?
[CUSTOMER][NEUTRAL] $387 even.
[AGENT][NEUTRAL] 387. OK, let's see.
[CUSTOMER][POSITIVE] Correct, yes, mhm.
[AGENT][NEUTRAL] Do you have that claim number by chance, ma'am?
[CUSTOMER][NEUTRAL] Yes, yes, yes. I have that claim number. The claim number is 3, sorry. It's 3,572,380.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Bear with me just a moment. OK, yes, um, so this one did deny, of course, this coverage was not um.
[AGENT][NEUTRAL] It's not covered under their policy, but again the policy did terminate uh [PII] regardless, um, this policy, uh, only provides uh treatment for outpatient services when it's in an emergency room, urgent care facility, physician's office, or uh physical speech or occupational therapy, or excuse me, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Emergency room, um.
[AGENT][NEUTRAL] So this was just not a covered facility under this policy regardless.
[CUSTOMER][NEGATIVE] No, that, that's totally fine. It's not, it's not covered under this facility. So that's why it was denied for Pier 96 like you not covered under the plan because if the policy was not uh active under the service, then how it was processed by insurance. This should also be simply denied as not eligible under the service, right?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] It would also see if that would be covered regardless as well so this was simply not a covered service even if it were to be active.
[CUSTOMER][NEUTRAL] Yeah, so is it.
[CUSTOMER][NEUTRAL] No, that's totally fine. So, see, not the covered service and not to cover the policy. Both are different, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, it's not covered under the policy.
[CUSTOMER][NEUTRAL] So if the policy itself was not covered, then it will not be processed.
[AGENT][NEUTRAL] Right. It's a treatment in an outpatient hospital is not covered under this policy.
[CUSTOMER][POSITIVE] Oh, that, that's totally fine.
[CUSTOMER][NEUTRAL] So this
[CUSTOMER][NEUTRAL] Uh, actually, see, actually, what I'm trying to say that uh if the policy was not active on the service, then how the claim was processed as a non-covered services uh under patient's plan. So there might be a chance that the policy was active on that service right.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure it still does process.
[AGENT][NEGATIVE] It was not right. It was not active during the state of service, however, it does still check to see it goes through our regular process as well, so it would not have been covered either way.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, no worries.
[CUSTOMER][NEUTRAL] So basically the policy of the member was turned on [PII].
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And could you please check the information that member have any other, any other active insurance under the service or not?
[AGENT][NEUTRAL] Um, I did look to see they don't have anything active with us.
[CUSTOMER][NEUTRAL] Mm, not with you. So any other active insurance a part of your insurance?
[AGENT][POSITIVE] Correct.
[AGENT][NEGATIVE] Oh, if they have active coverage elsewhere, I have no way of seeing that.
[CUSTOMER][POSITIVE] OK, no worries. No worries.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm locating it now.
[CUSTOMER][NEUTRAL] You see.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK, no worries. What is the call reference for this call?
[AGENT][NEUTRAL] It would be my first name, last initial [PII] Date. Uh so my name is spelled [PII] Last initial is [PII] Was there anything else I could help you with, [PII]?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] No, that's all for today. Thank you so much, [PII], for the information. Have a good day.
[AGENT][POSITIVE] Alright, yeah, thanks for calling ATO. Have a great rest of your day. Thank you, bye bye.
[CUSTOMER][POSITIVE] happy weekend. Bye-bye.
[AGENT][POSITIVE] You too thank you bye bye