AccountId: 011433970860
ContactId: c155a97c-a38a-474b-a20c-9802d7df3d1a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 328640 ms
Total Talk Time (AGENT): 124394 ms
Total Talk Time (CUSTOMER): 103934 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/17/c155a97c-a38a-474b-a20c-9802d7df3d1a_20250417T16:14_UTC.wav
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[AGENT][NEUTRAL] 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 National Kidney Partners. I am checking on a denied claim on a member.
[AGENT][NEUTRAL] OK, well I can definitely help you with the claim denial and um just for my notes, can you spell your first name for me please and provide a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure, name is [PII] last initial [PII], call back number is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][POSITIVE] Yes, it is, let me grab that.
[CUSTOMER][NEUTRAL] Um, 01548508 M as in Mary, L as in Lima 8.
[AGENT][POSITIVE] Thank you for that. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes, [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 date of service and the total bill for the claim?
[CUSTOMER][NEUTRAL] Yes, service date is [PII] build amount $604.84.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 604, here we go.
[AGENT][NEUTRAL] And it's coming up now. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see what was the reason.
[AGENT][NEUTRAL] OK, so I'm showing the claim was denied because the services are not covered when performed in a doctor's office or clinic.
[AGENT][NEUTRAL] And what questions did you have?
[CUSTOMER][NEUTRAL] Yeah, I'm trying to figure out why it said that because this was actually done at a dialysis center.
[AGENT][NEUTRAL] As in like an outpatient hospital facility or like a dialysis clinic?
[CUSTOMER][NEUTRAL] Dialysis clinic, outpatient dialysis clinic.
[AGENT][NEUTRAL] Right, so it's doctor's office or clinic. So if this was a doctor's office, the policy wouldn't cover it or clinics, it wouldn't cover. Um, let me see, hold on one second. Let me pull up their full benefits.
[CUSTOMER][NEUTRAL] OK, let me see if any.
[CUSTOMER][NEUTRAL] Previous claims have been paid.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] I'm waiting for it to come up. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So for outpatient on this policy, it will cover like the hospital emergency room, urgent care, surgery in an outpatient facility, um, diagnostic testing in a hospital outpatient facility or MRI facility, um, outpatient treatment for mental and emotional disorder in an outpatient facility or um physical therapy in a physical therapy facility, but it's it.
[AGENT][NEUTRAL] For the secondary policy is inpatient and outpatient, but outpatient doesn't have any coverage for in-office or clinic setting.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Clinic setting.
[CUSTOMER][NEUTRAL] For office.
[CUSTOMER][NEUTRAL] So the dialysis, OK, can I, is it possible to look up this um location to see if it's in network on the members plan? If I give you the name?
[AGENT][NEUTRAL] Well
[AGENT][NEUTRAL] So we're the secondary policy, so we don't have network. We follow primary. We apply to the co-pay, deductible and co-insurance after primary.
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] I see, OK, so I guess then the the remaining balance will be the patient's responsibility.
[CUSTOMER][NEUTRAL] Because of the contract.
[AGENT][NEUTRAL] Well, we don't determine patient responsibility because we're not the major medical.
[CUSTOMER][NEUTRAL] Mm, let's see.
[CUSTOMER][NEUTRAL] Got you. OK, alrighty, let me see here.
[CUSTOMER][NEUTRAL] OK, that's all I need then. Can I get a reference number please?
[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][POSITIVE] OK, alrighty thank you so much appreciate your time.
[AGENT][POSITIVE] You're very welcome, [PII]. Thanks for calling APL. I hope you have a great day.
[CUSTOMER][POSITIVE] You too, thank you.
[AGENT][POSITIVE] You're welcome. Bye bye.
[CUSTOMER][NEUTRAL] Mhm bye bye.