AccountId: 011433970860
ContactId: ae4f2fe0-f9d4-4bc1-af79-059ef306af37
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 694510 ms
Total Talk Time (AGENT): 313790 ms
Total Talk Time (CUSTOMER): 155937 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/19/ae4f2fe0-f9d4-4bc1-af79-059ef306af37_20250319T13:28_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] Yeah
[CUSTOMER][POSITIVE] Good morning [PII] how are you?
[AGENT][POSITIVE] I'm doing well. How are you?
[CUSTOMER][POSITIVE] I'm doing pretty good. [PII], this is [PII] calling from Manity Memorial Hospital calling to check on the claim status for a patient.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status. And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh huh, [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Uh huh, this is on 01947240 M as in Mary, L as in Lima 7.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Uh huh. [PII] [PII].
[AGENT][NEUTRAL] Thank you, 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 and the total bills?
[CUSTOMER][NEUTRAL] 1112 2024 $3,638.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] So this particular policy number um was no longer effective. Um it was effective from [PII], but there was, let me see if, yeah, so there was a um policy that was active on the data service, that's 256-637-3.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 63.
[CUSTOMER][NEUTRAL] 73 OK.
[AGENT][NEUTRAL] And let me
[CUSTOMER][POSITIVE] And that was effective what date.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Actually, hold on. How did this work like this? I'm gonna look at both of these policy numbers. So let me give you both. 2116869.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] was effective.
[CUSTOMER][NEUTRAL] So this is a different one.
[AGENT][NEUTRAL] Mhm, I'm gonna go back to that one.
[CUSTOMER][NEUTRAL] OK, OK, let me have that one again 211.
[AGENT][NEUTRAL] 686 9.
[AGENT][NEUTRAL] It was effective from [PII].
[AGENT][NEUTRAL] To [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But then the other one I gave you 256-637-3.
[AGENT][NEUTRAL] Has an effective date of [PII]. So I don't know if that's an error or not, so I'm gonna check both for the claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then I'll let you know which one is the correct policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] So the one that I gave you that one term.
[AGENT][NEUTRAL] Yes, um, let me go back. Hold on one second. That one turns.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So let me check these. Hold on one second.
[AGENT][NEUTRAL] So it's going to be the 2116869.
[AGENT][NEUTRAL] The other one doesn't have any claims on it and I'm checking for the data service for you now. [PII] 2024.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 68
[AGENT][NEUTRAL] And what is the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Uh huh, Manatee Memorial Hospital.
[AGENT][NEUTRAL] Here we go.
[AGENT][NEUTRAL] Alright, so I'm showing um we received the claim, hold on, it's coming up now.
[AGENT][NEUTRAL] We received the claim on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That claim number is 35398.
[AGENT][NEUTRAL] 01
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] And the reason it's coming up now.
[AGENT][NEUTRAL] The outpatient treatment due to sickness is not covered under this policy. If you have additional information that indicates an accident, please submit for further review.
[CUSTOMER][NEUTRAL] OK, so should we bill I the the other policy number?
[AGENT][NEUTRAL] Which policy number of the two I gave?
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] Yeah, the one ending 869.
[AGENT][NEUTRAL] No, no, no, that policy, I don't, no, don't use that one. There's no, there's no claims there. The claims that you're filing it under the correct claim, the claim, the policy doesn't cover sickness, it covers accident. So it's just saying if it's due to an accident, um, we're just needing information in reference to the accident, so we can process, but from the documents we received it shows sickness, but the policy doesn't cover sickness.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] signals.
[CUSTOMER][NEUTRAL] OK, so let me ask you a question. The first policy number that I gave you, I thought you said that was effective from [PII] to [PII].
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, hold on, let me go back. Hold on one second, let me pull up another screen.
[AGENT][NEUTRAL] So yes, the first policy number that you gave 91,947,240 was effective from [PII].
[CUSTOMER][NEUTRAL] OK, so I, I charge wouldn't be covered underneath that if our data service is 11-1224.
[AGENT][NEUTRAL] Right, which is why I gave you the active policy which covers your data service.
[CUSTOMER][NEUTRAL] OK, so should this charge be covered under the active policy?
[AGENT][NEUTRAL] Yes, it was, you filed the claim, the claim was filed under the active policy, but it was denied. It was denied because the policy only covers accidents.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] No, because we, we filed this claim under that 019 number 47,240 ML 7.
[AGENT][NEUTRAL] OK, so if you filed it under the inactive number and it was still processed under the active policy,
[AGENT][NEUTRAL] I don't understand. We, you, you sent it in under a policy number that was no longer active, and we processed under the policy that was active at the time.
[CUSTOMER][NEUTRAL] So, so
[CUSTOMER][POSITIVE] Exactly.
[AGENT][NEUTRAL] So, we still processed it for you.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] Right, under, under the old policy number, the policy number that wasn't effective.
[AGENT][NEUTRAL] No, sir, no, so this is what I'm saying to you. You submitted the claim under 1,947,240.
[AGENT][NEUTRAL] That policy number wasn't active. So APL then processed it under the active policy number, which is what I gave you. So yes, you sent in a policy that wasn't active, but it was still processed under the policy number that was active at the time.
[CUSTOMER][NEUTRAL] Process.
[AGENT][NEGATIVE] We could have denied it and sent it back and then you resubmit it and we processed it, we just processed it under what was active.
[CUSTOMER][NEUTRAL] OK, let me, OK, under.
[CUSTOMER][NEUTRAL] Active policy number.
[CUSTOMER][NEUTRAL] 2116869
[CUSTOMER][NEUTRAL] 10 1 243.
[CUSTOMER][NEUTRAL] 1
[CUSTOMER][NEUTRAL] 25 and the night.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can I ask you another question? Was the letter sent out?
[AGENT][NEUTRAL] Of course.
[AGENT][NEUTRAL] Like an explanation of benefits?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, yes, let me double check. Hold on one moment.
[CUSTOMER][NEGATIVE] Sickness not covered.
[CUSTOMER][NEUTRAL] On the policy.
[CUSTOMER][NEUTRAL] So did you all send us the member responsibility?
[AGENT][NEUTRAL] Um, we don't determine patient responsibility because we're not a major medical insurance company. I'm pulling up the explanation of benefits now to see if it was sent to you all.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, yes, sir, it was sent on [PII], but I can fax you over a copy if you need it.
[CUSTOMER][NEUTRAL] Yeah, yeah, can you fax me one?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] What's a good fax number for you?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And should I put attention, [PII]?
[CUSTOMER][NEUTRAL] Yes, mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So I'm faxing that over to you now.
[CUSTOMER][NEUTRAL] Hm
[AGENT][NEUTRAL] And was there anything else I could assist you with today, [PII]?
[CUSTOMER][NEUTRAL] That's gonna be it. Can I just 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 and again that's [PII]
[AGENT][NEUTRAL] The first initial to, my last name is [PII].
[CUSTOMER][POSITIVE] OK, thank you, [PII].
[AGENT][POSITIVE] You're very welcome, [PII]. Was there anything else I can help you with today?
[AGENT][NEUTRAL] You sure?
[CUSTOMER][NEUTRAL] That's gonna be it.
[AGENT][POSITIVE] All right, well, thanks for calling APL. I hope you have a great day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And you do the same.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][NEUTRAL] Bye bye. Mhm.