AccountId: 011433970860
ContactId: b68b6ec5-ad54-4e5f-8433-b33d680e3da8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 755799 ms
Total Talk Time (AGENT): 212848 ms
Total Talk Time (CUSTOMER): 180072 ms
Interruptions: 3
Overall Sentiment: AGENT=0.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/26/b68b6ec5-ad54-4e5f-8433-b33d680e3da8_20250326T13:31_UTC.wav
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[AGENT][POSITIVE] Good Morning, thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling you from provider's office to check a claim status.
[AGENT][NEUTRAL] OK, sure. I can assist you with claim status, Ms. [PII]. May I have a callback number just in case we get disconnected and the name of the facility?
[CUSTOMER][NEUTRAL] Oh yeah, it's [PII]. Extension is [PII] and the facility name is Endo Adation LLC. And can you please spell out your name for me?
[AGENT][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] My name is [PII]. That's [PII], last initial [PII]. And may I have the patient's policy number, Miss [PII]?
[CUSTOMER][NEUTRAL] D delta 43,302,090.
[AGENT][NEUTRAL] Do you see a policy certificate number? It's gonna start with the 0 followed by 7 digits. That's gonna be our number.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Um, no, I have only that number.
[AGENT][NEUTRAL] OK, we cannot pull that number. Um.
[AGENT][NEUTRAL] Let me have
[AGENT][NEUTRAL] Yes, spelling of the last name.
[CUSTOMER][NEUTRAL] Yeah, it's uh [PII], uh spelled like [PII].
[AGENT][NEUTRAL] OK. And what's the spelling of the first name?
[CUSTOMER][NEUTRAL] It's [PII]
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Do you have an address for Miss Miss [PII]?
[CUSTOMER][NEUTRAL] Yeah. It's [PII].
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And what's her date of birth?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Mhm. It's [PII], build on $900 even.
[AGENT][NEUTRAL] Yeah, that's [PII] for 900.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me pull the EOB, um, it's gonna be a minute, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You're waiting on the system, bear with me.
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, so we process the claim on [PII].
[AGENT][NEUTRAL] And the claim was denied, um, the reason for this denial is that anesthesia benefits are based on the benefits allowable under the surgery benefits. So we need the surgery charges so we can determine the benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hey uh.
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] Uh, means what exactly means, uh, anesthesia or this is not covered on that main plan.
[AGENT][NEUTRAL] No, it doesn't mean that. Let me read this again, OK?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] Anesthesia, and you can write it down as I say it, so you have a better understanding. Anesthesia, benefits.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Are based
[AGENT][NEUTRAL] On the benefits.
[CUSTOMER][NEUTRAL] No
[AGENT][POSITIVE] Allowable.
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] Under the surgery benefits.
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] Please send the surgery charges.
[AGENT][NEUTRAL] For this date.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So both benefits can be considered.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEGATIVE] Actually, your voice is cutting out.
[CUSTOMER][NEUTRAL] Who the 75.
[AGENT][NEUTRAL] Which one do you need me to say again?
[CUSTOMER][NEGATIVE] Your voice is breaking, that I'm not hear you properly.
[AGENT][NEUTRAL] I, I understand, Ms. [PII], which part you need me to repeat?
[CUSTOMER][NEUTRAL] Do you
[CUSTOMER][NEUTRAL] Uh, the surgery benefit.
[CUSTOMER][NEUTRAL] I see
[CUSTOMER][NEUTRAL] 25.
[AGENT][NEUTRAL] OK, can you uh repeat what you have there so I can just continue?
[AGENT][NEUTRAL] Can you read out what you have?
[CUSTOMER][NEUTRAL] Mm and you said that the, um, uh, you said that the anesthesia benefits are based on the benefits allowable on the surgery benefits.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] So we need the surgery charges to determine benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So do you have the hospital claim is on file?
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Do we have what I'm sorry?
[AGENT][NEUTRAL] Can you repeat?
[CUSTOMER][NEUTRAL] Of hospital claim, hospital claim is on file.
[AGENT][NEUTRAL] No, we don't have just the anesthesia charges. That's the only one I see. So we need the surgery charges. That's why we're asking for it because we don't have it.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] Uh, uh, let me just check.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Can I place your call on hold for 1 to 2 minutes while checking the information?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure, go ahead.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK. So, inpatient plan, the surgery uh is covered.
[AGENT][NEUTRAL] Under these policies, um, surgery and anesthesia are covered. Yes, we just need both of them to determine anesthesia benefits.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] We just need both of the claims to determine anesthesia benefits.
[CUSTOMER][NEUTRAL] Mm, OK. And what's the patient's plan type?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] This is a limited hospital indemnity plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] May I know the claim number for this claim?
[AGENT][NEUTRAL] Sure, the claim number is um.
[AGENT][NEUTRAL] 3561913
[CUSTOMER][NEUTRAL] And may I have the fax number?
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] The fax number is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And what's the filing limit?
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] You said uh what time the filing limit?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Appeal filing limit.
[AGENT][NEUTRAL] 180 days from the decision date.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And this is uh [PII], right?
[AGENT][NEUTRAL] Decision, let me see what the original because this was the 2nd submission. Bear with me just a second, OK? Let me get the original claim pulled up.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 22.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] The original claim was processed the same day, yes, the [PII]. Mhm.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mm, can you help me with the call reference number for this call?
[AGENT][NEUTRAL] We don't have reference numbers you can use my name in today's date.
[CUSTOMER][POSITIVE] OK, thank you so much, uh, so for your help and this information. wonderful day.
[AGENT][POSITIVE] You're welcome. You as well. Thank you for calling APL. Have a good day. Bye-bye, Miss. [PII].
[CUSTOMER][NEUTRAL] You too. Bye.
[AGENT][NEUTRAL] Yeah