AccountId: 011433970860
ContactId: c1aecfa2-3819-4c6c-b8e3-04692e6c2353
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 832919 ms
Total Talk Time (AGENT): 189535 ms
Total Talk Time (CUSTOMER): 265392 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/27/c1aecfa2-3819-4c6c-b8e3-04692e6c2353_20250327T18:24_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. Good afternoon. My name is [PII], and I'm calling for uh the Cleveland Clinic Hospital to check on the claim status.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] OK. I'm happy to help with the claim. Do you have a policy number?
[CUSTOMER][NEUTRAL] Yes, the policy number is 01791.
[CUSTOMER][NEUTRAL] 985
[CUSTOMER][NEUTRAL] L as in Lima.
[CUSTOMER][NEUTRAL] L as in sorry, M as in Mike, L as in Lima, number 7.
[AGENT][POSITIVE] Thank you. And can I get your first name again please and a callback number?
[CUSTOMER][NEUTRAL] Yeah, [PII], spelled out [PII] And the callback number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And can I get patient's name and date of birth?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Patient name is uh [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and then what's the date of service?
[CUSTOMER][NEUTRAL] The date of services.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] With the total bill amount is
[CUSTOMER][NEUTRAL] $136 even.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Looks like we did receive a claim for this state of service. The claim was received on [PII].
[AGENT][NEUTRAL] Claim was denied. Uh, policy provides no benefits for treatment conditions other than sickness or injury as defined by the policy.
[CUSTOMER][NEUTRAL] I'm sorry, uh, benefits has been?
[AGENT][NEGATIVE] There were no benefits payable. Uh, this policy does not provide coverage for any sort of treatment other than sickness or injury.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] So basically it is non-covered. That's what I'm trying to explain.
[AGENT][POSITIVE] Yes, correct.
[CUSTOMER][NEUTRAL] Non-covered as per patient plan or the provider?
[AGENT][NEUTRAL] Per patient plan.
[CUSTOMER][NEUTRAL] As for the patient plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Non-covered as per patient plan. May I know the plan name for the patient policy name?
[AGENT][NEUTRAL] We're the members secondary insurance. This is a Medlink plan.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh medle, that is M E D K I N E.
[AGENT][NEUTRAL] M E D, L as in Lima, I as in India, N as in November, K as in kilo, Link.
[CUSTOMER][NEUTRAL] OK. Min plan, OK.
[CUSTOMER][NEUTRAL] So, for regarding this, this is the patient responsibility, right?
[AGENT][NEUTRAL] We're not able to advise on patient responsibility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much. And uh do you have a call reference number for this member?
[AGENT][NEUTRAL] Absolutely. Call references my name with my last initial than today's date. My name again is [PII], that's [PII], last initial [PII].
[CUSTOMER][NEUTRAL] OK, sir. So for the second claim for the different member?
[AGENT][NEUTRAL] Uh, let me just notate this and we can move on to the next 11 moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] 412501.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] I'm gonna do that
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] OK, go ahead with the next member ID when you're ready.
[CUSTOMER][NEUTRAL] Yes. So, the next member ID is
[CUSTOMER][NEUTRAL] 017
[CUSTOMER][NEUTRAL] 26,350
[CUSTOMER][NEUTRAL] And the member name is uh [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][POSITIVE] Thank you, data service.
[CUSTOMER][NEUTRAL] [PII], with the total bill amount is $232 even $232.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We did receive a claim for the state of service. The claim is received on [PII]. Uh, the claim was denied. Services are not covered under the member's plan.
[CUSTOMER][NEUTRAL] OK, for the same reason, right?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and the plan name, policy name?
[AGENT][NEUTRAL] Uh, this is a secondary meddling plan.
[CUSTOMER][NEUTRAL] OK, same, right, as for the previous one.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much. So I'll be going for the 3rd 1.
[AGENT][NEUTRAL] One moment.
[AGENT][POSITIVE] OK, I'm ready for the next member ID.
[CUSTOMER][NEUTRAL] Yeah, 024.
[CUSTOMER][NEUTRAL] 78759 M as in Mike. L as in Lima, number 8.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Member name is uh NF and uh date of birth is [PII].
[AGENT][NEUTRAL] Data service.
[CUSTOMER][NEUTRAL] [PII], with the total bill amount is $232 even $232.
[AGENT][NEGATIVE] We did receive this claim for the state of service, claim was denied. It looks like it was not a covered.
[AGENT][NEUTRAL] Uh, expense under the member plan.
[CUSTOMER][NEUTRAL] OK, for the same reason, right? Uh, non-covered and policy name is uh Medli plan, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK. Thank you so much. And so for the last one for the different member.
[AGENT][NEUTRAL] What's the data service?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] A different member actually.
[CUSTOMER][NEUTRAL] Uh, shall I give the member ID?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Is it a different number or same member?
[CUSTOMER][NEUTRAL] Mm no, different number.
[AGENT][NEUTRAL] 01 moment, please.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] OK, go with the next member ID when you're ready.
[CUSTOMER][NEUTRAL] Yeah, sure. Uh, the next member ID is 107.
[CUSTOMER][NEUTRAL] 1066.
[CUSTOMER][NEUTRAL] Member name member name is uh [PII]
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[CUSTOMER][NEUTRAL] I
[AGENT][POSITIVE] Thank you. Data service.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Data services.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] With the total bill amount is
[CUSTOMER][NEUTRAL] $232 even.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so it looks like we did receive this uh claim for the state of service. The calendar year maximum for this member had already been met. Patient was allowed 4 office visits per year. They had already used all 4 visits.
[CUSTOMER][NEUTRAL] OK. It is allowed only 4 visits, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. May I know when the latest uh most recent visit on that?
[AGENT][NEUTRAL] When the most recent.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] You have that date, the most recent visit date?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] I'm looking, you're wanting the last date of service that was paid for an office visit, correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] It looks like the uh last date of service was actually on [PII] for a physician's visit. That was the last date of service where benefits were paid.
[CUSTOMER][NEUTRAL] OK, thank you so much. And what is the uh timely filing limit to submit the corrected claim?
[AGENT][NEGATIVE] No timely filing.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] No TFO. OK. And the mailing address?
[AGENT][NEUTRAL] Plain's mailing address would be [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that's in [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] OK. Thank you so much, [PII].
[CUSTOMER][NEUTRAL] And the call reference number is your your name on today's date, right?
[AGENT][POSITIVE] That is correct, yeah.
[CUSTOMER][POSITIVE] Thank you. Thank you. Thank you so much for assisting me. Have a nice day. Thank you.
[AGENT][NEUTRAL] You as well bye bye.