AccountId: 011433970860
ContactId: cb8e219f-7f6d-4372-bb2a-572c41f03ede
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 335769 ms
Total Talk Time (AGENT): 135048 ms
Total Talk Time (CUSTOMER): 106670 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/07/cb8e219f-7f6d-4372-bb2a-572c41f03ede_20250307T16:43_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. I'm calling for claim status, medical claim.
[AGENT][NEUTRAL] Sure, it's still gonna a claim for you. Uh, what was your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and can I get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And then do you have the policy number?
[CUSTOMER][NEUTRAL] I have 2 policy IDs. I'm not sure which one is correct.
[AGENT][NEUTRAL] OK, we can try one of them.
[CUSTOMER][NEUTRAL] The first, the first one is 02557066.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, one moment please.
[AGENT][NEUTRAL] And what was the name and date of birth for the member?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK perfect thank you for verifying that [PII]. What was the date of service for this claim?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, do you have that bill amount?
[CUSTOMER][NEUTRAL] $14,631.
[AGENT][NEUTRAL] OK, thank you, one moment please.
[AGENT][NEUTRAL] OK, so I did find this claim and.
[AGENT][NEGATIVE] It looks like there were a couple of different procedures on here, so we were unable to pay a benefit.
[AGENT][NEUTRAL] As uh the outpatient benefit only allows payment for outpatient surgery in an outpatient hospital or a physician's office.
[AGENT][NEUTRAL] And then for a procedure code um well for the CT scan I'm sorry um for that benefit um that amount had been exhausted for this date of service so we weren't able to pay that benefit either.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So, basically, the claim was denied for non-covered charges.
[AGENT][NEUTRAL] Right, uh, so not covered and then, um, the CT, uh, that benefit amount had been exhausted for that date of service, so we weren't able to pay anything for that.
[AGENT][NEUTRAL] If you'd like I can send you a copy of this uh EOB, Dan.
[CUSTOMER][NEUTRAL] Um, yeah, please. Can you also provide the claim number?
[AGENT][NEUTRAL] Sure. That claim number is 3569619.
[CUSTOMER][NEUTRAL] And how about the received date and the process date?
[AGENT][NEUTRAL] Oh yes, one moment, let me get that.
[AGENT][NEUTRAL] So this claim was received [PII], and it was processed [PII].
[CUSTOMER][NEUTRAL] All right, um, what's this patient, um, network? What type of network?
[AGENT][NEUTRAL] So this policy doesn't, is not a part of a network. It is a limited indemnity medical plan.
[CUSTOMER][NEUTRAL] OK. So ER charges will not be covered under this plan, correct? You said?
[AGENT][NEUTRAL] But for surgery. So the surgery um would have to be in a, uh, covered outpatient hospital or a physician's office.
[CUSTOMER][NEUTRAL] OK. Um, right. Uh, yeah, can you please, uh, send a copy of EOB? I can provide you the fax number.
[AGENT][NEUTRAL] Of course.
[AGENT][POSITIVE] All right, yes, I'm ready when you are.
[CUSTOMER][NEUTRAL] [PII] [PII]. Uh please do attention to this account number, which is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Got it. OK. I will get that sent to you. You should get it here within 10 to 15 minutes. Was there anything else I could help you with, [PII]?
[CUSTOMER][NEUTRAL] Mm, nope, that's, oh, by the way, uh, we can bill these charges to the patient, right? To the whole charges.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] We don't, we do not say what is patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] But they will be shows it is uh patient liability.
[AGENT][NEGATIVE] We don't say again like we were just simply unable to pay a benefit uh patient responsibility is up to the provider if they chose to build them.
[CUSTOMER][NEUTRAL] Oh, OK. Um, all right then. Do you have a car reference number?
[AGENT][NEUTRAL] All right, yes, that would just be my first name, last initial, and today's date. Uh so my name is spelled [PII]
[CUSTOMER][POSITIVE] Alright great thank you.
[AGENT][POSITIVE] Of course, thanks for calling APL. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Too. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye bye.