AccountId: 011433970860
ContactId: adf99d6b-9404-4829-b05c-1672a85170bc
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 406579 ms
Total Talk Time (AGENT): 167276 ms
Total Talk Time (CUSTOMER): 56513 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/19/adf99d6b-9404-4829-b05c-1672a85170bc_20250619T14:06_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, good morning, [PII]. My name is [PII] calling from the provider's office. I needed to review the denial of a claim.
[AGENT][NEUTRAL] OK, I can help you with the denial, and you said your name was [PII]?
[CUSTOMER][NEUTRAL] Uh, [PII] Mhm.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Alright, and [PII], may I have a good contact number in case we're disconnected and then the member's policy number?
[CUSTOMER][NEUTRAL] 314747-4822 and the ID number is 01663330.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] All right, I have the member here. I just need you to verify the member's first and last name and date of birth.
[CUSTOMER][NEUTRAL] Mhm, um, [PII], [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 claim number for the claim you'd like to go over together?
[CUSTOMER][NEUTRAL] I have 361-099-0.
[AGENT][NEUTRAL] OK, hold on one moment. 361.
[AGENT][NEUTRAL] And can you verify the name of
[CUSTOMER][NEUTRAL] Mm oh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sorry, sorry.
[AGENT][NEUTRAL] It's OK.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] Oh, I just need you to verify the name of the provider's office on the claim.
[CUSTOMER][NEUTRAL] Missouri Baptist Medical Center.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, so I'm showing the claim was denied because it wasn't a covered loss. Um, the benefit only provides or benefits are only payable under those that are outlined on the schedule of benefits.
[AGENT][NEUTRAL] Um, let me see what this is.
[AGENT][NEUTRAL] Do you mind if I place you on a brief hold while I look at the claim?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, now what's happening?
[AGENT][NEUTRAL] Um, always.
[AGENT][NEUTRAL] BM 6430. OK, that's the right code. Benefits paid on um certificate are limited to those online on the schedule of benefits. This is not a covered loss under the plan. Therefore, no amount is OK.
[AGENT][NEUTRAL] So do we.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 696 10 0 Lord, there's two of them.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] 99204. Wait a minute.
[AGENT][NEUTRAL] I say 99204 cause 99214 is an office visit.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] So it's 99204.
[AGENT][NEUTRAL] Officer of the outpatient visit for elevation or evaluation and management and a new patient outpatient.
[AGENT][NEUTRAL] New patient outpatient visit?
[AGENT][NEUTRAL] New patient, office visit in an outpatient setting. So what's the problem?
[AGENT][NEUTRAL] The IBFT.
[AGENT][NEGATIVE] Oh, that's the problem.
[AGENT][NEUTRAL] Because it's for the office visit. This is the same as the 99214, but because it's an outpatient facility, oh, I got it.
[AGENT][NEUTRAL] Just had to think it through, but I figured it out. Hello [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, thank you so much for holding. I apologize for that wait. I was just trying to figure out what the um what the denial was saying. OK, so the policy itself doesn't have any coverage for the office setting in in outpatient or
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Just like a doctor's office, but they do have the office treatment rider. This particular claim was billed 499204, which is the facility. So that's why it's not covered because we would, we could cover the treatment in the office because of the rider, but there's no coverage for the office visit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so this is just uh overall non covered on this one.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright thanks [PII]. Can I get a call reference number?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. The first initial of my last name is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK perfect thank you.
[AGENT][POSITIVE] You're welcome. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] Um, that is all I've got today. Thank you.
[AGENT][POSITIVE] Alright well thanks for calling APL bye bye.
[CUSTOMER][NEUTRAL] Bye bye.