AccountId: 011433970860
ContactId: bed4a5de-eaf3-45f6-9026-2543c5919f25
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 517347 ms
Total Talk Time (AGENT): 210346 ms
Total Talk Time (CUSTOMER): 146570 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/31/bed4a5de-eaf3-45f6-9026-2543c5919f25_20250131T17:48_UTC.wav
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[AGENT][NEUTRAL] For calling APL, my name is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII] with the care team. How are you doing?
[AGENT][POSITIVE] I'm good, how are you?
[CUSTOMER][POSITIVE] Hey, I'm so wonderful. I have a gentleman on the line, real sweet. His name is [PII]. His policy number is 1982113, and he's calling to get more information about why his claim was denied, um, and I'm looking at that claim and I read the remark code to him, but I'm not.
[CUSTOMER][NEUTRAL] I, I, it's not even like the details that he's needing like he's not sure why, and I'm not sure either. Um, so I have claim number 3541154.
[CUSTOMER][NEUTRAL] And it just says that.
[CUSTOMER][NEUTRAL] Benefits payable under the certificate are not limited to those outlined in the schedule of benefits. This is not a covered loss. Therefore, no benefit is payable. Um, and so I've seen that with like accident policies, but I'm not sure what not a covered loss means, um, and so he just would like more information.
[AGENT][NEUTRAL] OK, I'd be happy to assist, but this is, um, basically the denial how we deny for not covered in an office visit, but they, it's for when they have a clinic visit at an outpatient facility. So that's how they word it, but I'll break that down just for you for future reference that's what that that.
[CUSTOMER][NEUTRAL] Thank you. So it's like that 001, like the office visits are not covered.
[AGENT][NEUTRAL] Yeah, the DH 001 office, that's our DH 001 if they, they were in a, it's an office visit in an outpatient setting, so they must have sent in either a UB or they uh send in a hiA with the place of service 22, but it was still an office visit.
[CUSTOMER][POSITIVE] OK, that makes sense. Thank you. Now I feel like I could understand this a little better. Um, and do you mind if I listen to how you explain this to us so I could in the future use that to explain to you further insureds?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] OK perfect well then I'm gonna get him on the line and I'll introduce you Ms. [PII], OK?
[AGENT][POSITIVE] All right thanks.
[CUSTOMER][POSITIVE] My pleasure.
[CUSTOMER][NEUTRAL] Hi, [PII], are you still there with me?
[CUSTOMER][POSITIVE] Yes, I'm here. Hey, thank you so much for your patience. I do have Ms. [PII] on the line and she's one of our claims examiner. She's gonna be able to help you understand why this claim was denied, OK?
[CUSTOMER][POSITIVE] OK. Thank you.
[AGENT][NEUTRAL] Hi [PII], this is [PII] how are you?
[CUSTOMER][POSITIVE] Good [PII], how are you?
[AGENT][NEUTRAL] I'm good. Um, so the reason the claim denied is it was an um office or office basically it was an office visit, um, and office visits are not covered under the policy.
[CUSTOMER][NEUTRAL] An office visit?
[AGENT][NEUTRAL] Yes, an office visit in an outpatient setting.
[AGENT][NEGATIVE] They billed it as being the service facility was in an off um out excuse me.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Outpatient setting.
[CUSTOMER][NEUTRAL] And, and
[CUSTOMER][NEUTRAL] And if I go, let's say, because this is just a gastroenterologist checking me, he wasn't, it was like a, a, a, a periodic visit, you know, that he checks me from time to time.
[CUSTOMER][NEUTRAL] And I have other gastroenterologists, but, but if, if that visit, this would have been in another place, would it be covered.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Uh, I apologize. Um.
[AGENT][NEUTRAL] I see that you actually have the physician's writer. One moment.
[AGENT][NEUTRAL] I apologize, I didn't see your benefits.
[AGENT][NEUTRAL] OK, so you have the office visit writer let me see how many visits you've used.
[AGENT][NEUTRAL] This is for [PII].
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] 5, I'm 5.
[CUSTOMER][NEUTRAL] I would think because I see 5 visits here in [PII].
[CUSTOMER][NEUTRAL] Or
[AGENT][NEUTRAL] Yeah, I'm pulling up your policy to see, I'm pulling up your policy to see what your um dollar benefit amount for the office visits are. I apologize, I didn't see that you had the physician's rider which does cover for.
[CUSTOMER][NEUTRAL] I know I went to another dermato.
[AGENT][NEUTRAL] The um office visit.
[AGENT][NEUTRAL] So let me, let me just pull up your policy one moment.
[AGENT][NEUTRAL] OK, so your.
[AGENT][NEUTRAL] You have for the physician's office visit fee $25 per visit and for a specialist office fee, $50 per visit.
[AGENT][NEUTRAL] And it looks like you.
[AGENT][NEUTRAL] Have a maximum of 4 visits per calendar year. I'm gonna have this claim sent back to be reprocessed so they can look at it.
[AGENT][NEUTRAL] And see if they can get that covered under your specialist office visit fee.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] Oh, so I do apologize for that. Um, if you could please allow us 7 to 10 business days, I'm gonna get that sent back to, um, so they can take a second look at that to see if that would be eligible, uh, to be processed under the specialist office visit fee.
[AGENT][NEUTRAL] Um, but, um, uh, but just so that you know, it is, um, the place of service was outpatient. It wasn't, um, the place of service wasn't a regular doctor's visit. They billed it as being in an outpatient facility. Um, but I'm gonna have, um, actually, let me see if someone can just quickly answer that for me, one moment.
[CUSTOMER][NEUTRAL] OK, so I
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, um, actually, if I can get your callback number, I'm gonna have somebody take a look at this.
[CUSTOMER][NEUTRAL] OK. It's uh
[AGENT][NEUTRAL] And then they can let me know whether or not um it is eligible to be processed under your physician writer. Um, what's your callback number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, all right, Mr. [PII], um.
[AGENT][POSITIVE] Give me about an hour to see if I can um get up with my team lead and then um once I get an answer I'll give you a call back.
[CUSTOMER][POSITIVE] OK, thank you very much.
[AGENT][NEUTRAL] All right, well, was there anything else I could assist with today?
[CUSTOMER][NEUTRAL] No, no, your name is again you said?
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][POSITIVE] [PII]. OK. All right. Thank you, [PII].
[AGENT][POSITIVE] Well, thank you for calling APL. You have a good day.
[CUSTOMER][NEUTRAL] OK, bye bye.
[AGENT][NEUTRAL] Mhm. Bye bye.