AccountId: 011433970860
ContactId: a11f1077-849c-4c0e-a3db-62fe41143648
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 324859 ms
Total Talk Time (AGENT): 133803 ms
Total Talk Time (CUSTOMER): 104817 ms
Interruptions: 0
Overall Sentiment: AGENT=1.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/19/a11f1077-849c-4c0e-a3db-62fe41143648_20250319T21:24_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] calling from broad office. I need to check on a patient claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status, [PII], and may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Mm, yes, it's [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Just a moment, please. I missed the blow where I can find the, just a moment, please.
[CUSTOMER][NEUTRAL] I'm calling via phone.
[CUSTOMER][NEUTRAL] This is the insurance company name, uh, just a one.
[CUSTOMER][NEUTRAL] OK, hold on.
[CUSTOMER][NEUTRAL] There's an armory public life, right?
[AGENT][NEUTRAL] American Public Life, yes.
[CUSTOMER][NEUTRAL] American public life.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The member's ID number is going to be 02324303.
[AGENT][NEUTRAL] 232-43003, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][POSITIVE] Take your time.
[AGENT][NEUTRAL] Can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] The patient name is in a Kim Bs, Kim Bisbo.
[CUSTOMER][NEUTRAL] And the date of patient date of birth of [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim you like me to check on?
[CUSTOMER][NEUTRAL] It's on [PII].
[AGENT][NEUTRAL] And the total bill amount?
[CUSTOMER][NEUTRAL] Could I charge the amount of $493 even?
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Sure. It's uh Reading Hospital.
[AGENT][NEUTRAL] All right, I have it here and I'm showing that we received the claim on
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The claim number is 342.
[CUSTOMER][NEUTRAL] 34
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] 2
[CUSTOMER][NEUTRAL] 342
[AGENT][NEUTRAL] 7039.
[CUSTOMER][NEUTRAL] 7039
[AGENT][NEUTRAL] And on [PII] I'm sorry, this is flipped. On [PII], the claim was received. On [PII], the claim was processed.
[AGENT][NEGATIVE] And it was denied.
[AGENT][NEUTRAL] Because the diagnostic.
[CUSTOMER][NEUTRAL] May I know the denial reason.
[AGENT][POSITIVE] Yes, the diagnostic benefit.
[AGENT][NEUTRAL] It's only, it only covers MRIs and CT scans and colonoscopies. So the diagnostic testing that was completed was not one of the three, so it's not a covered test.
[CUSTOMER][NEUTRAL] DX is not covered the MRI and
[AGENT][NEUTRAL] The diagnostic um benefit only covers MRIs, CT scans, and colonoscopies.
[AGENT][NEUTRAL] So all other diagnostic testing is not covered under this policy.
[CUSTOMER][NEUTRAL] Uh, what we have with the X-ray. We are able to do with the X-ray, right?
[CUSTOMER][NEUTRAL] Procedure code was 710466 was an X-ray.
[AGENT][NEUTRAL] The policy only covers MRIs, CT scans, and colonoscopy. So if it's not one of those three, it's not covered by the policy.
[CUSTOMER][NEUTRAL] Just 2.
[CUSTOMER][NEUTRAL] Uh, then it is a fully patient responsibility.
[AGENT][NEUTRAL] So we don't determine patient responsibility because we're not a major medical insurance company?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What's uh, what is the next action will be taken on this? It is a coding error or uh
[AGENT][NEUTRAL] Um, that
[AGENT][NEGATIVE] It's not covered under the member's policy.
[CUSTOMER][NEUTRAL] It is not covered under the patient, uh oh, not covered under the patient policy. That means we can bill it to patients as well.
[AGENT][NEUTRAL] We don't determine patient responsibility here.
[CUSTOMER][NEUTRAL] For the service?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, that would be, I'm sorry?
[CUSTOMER][NEUTRAL] Yes, go ahead, please.
[AGENT][NEUTRAL] So that would be whatever your um policies are for outstanding or remaining balances as the provider.
[CUSTOMER][NEUTRAL] OK. May I know the call reference number for this?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. And again, that's [PII] initial to my last name is [PII], and today's date.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're very welcome. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No, thank you.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. I hope you have a great day, [PII].
[CUSTOMER][NEUTRAL] Sure. Same to you.
[AGENT][POSITIVE] Thank you. Bye bye.