AccountId: 011433970860
ContactId: a7b21496-e7fd-4b63-ae7a-c07ae1f5abc7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 401720 ms
Total Talk Time (AGENT): 131470 ms
Total Talk Time (CUSTOMER): 110673 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/25/a7b21496-e7fd-4b63-ae7a-c07ae1f5abc7_20250225T13:55_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] calling from the provider's office to checking on the claims.
[AGENT][POSITIVE] OK, I'll be more than happy to assist you with the claim. And may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure, ma'am. It's [PII].
[AGENT][NEUTRAL] Thank you for that. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] I have only one claim.
[AGENT][NEUTRAL] Alright, and may I have the member's policy number?
[CUSTOMER][NEUTRAL] 02582675.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] And my first name is [PII]. Last name is [PII], [PII]
[CUSTOMER][NEUTRAL] Date of birth is [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 want me to check on?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[CUSTOMER][NEGATIVE] The total charge $839 even.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] OK, and I just located the claim. And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Saint Peter's bone and joint.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So I'm showing received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 3559343.
[CUSTOMER][NEUTRAL] Mhm. Sorry, client number 3559343. OK.
[AGENT][NEUTRAL] 9.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] The claim submission received has been noted as an accident or injury.
[AGENT][NEUTRAL] The outpatient sickness rider allows payment for sickness only. Therefore, there are no benefits payable.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So need to patiently the actions, right?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Patient need to update the accident details information to the insurance, right?
[AGENT][NEUTRAL] No. So this is saying it's, it's, the documents are showing that it's an accident. The policy benefits cover sickness only. So an accident is not considered sickness, that's an injury. You can only use sickness like flu, you know, some sickness. So it's not a covered service because the policy only, or the rider only covers sickness, not accident or injury.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, uh,
[CUSTOMER][NEUTRAL] The two codes 99213 and 72,110 was not covered under the patient plan, right?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Oh definitely.
[CUSTOMER][NEUTRAL] 38
[CUSTOMER][NEUTRAL] Me patient plan type.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So this is a hospital indemnity policy?
[AGENT][NEUTRAL] So it's a limited medical policy?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, uh, it's
[AGENT][NEUTRAL] The policy covers sickness and this is for an accident. Accidents are not covered by the policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Cover one day.
[CUSTOMER][NEUTRAL] So this claim was accident, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] So, actually, while checking here, we received the payment for the same codes on the date of [PII].
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] So sorry.
[AGENT][NEUTRAL] So who was that claim filed with because this is the only claim that APL has processed for the member. Let me see if there's another policy.
[AGENT][NEUTRAL] No, this is their only medical policy with APL.
[CUSTOMER][NEUTRAL] OK, because one life, so accident claims.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Accident claims are not covered under this plan, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, ma'am. May I know the call reference number and your name?
[AGENT][NEUTRAL] My name is [PII] The first initial to my last name is [PII]. There's no call reference number, but you can use my name in today's date.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK. Uh
[CUSTOMER][POSITIVE] [PII], thank you so much for your assistance and have a nice day. Bye-bye.
[AGENT][POSITIVE] You also and thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah