AccountId: 011433970860
ContactId: d4624041-2c10-49fa-a7ae-9d03830a12d1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 965320 ms
Total Talk Time (AGENT): 235213 ms
Total Talk Time (CUSTOMER): 209478 ms
Interruptions: 3
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/25/d4624041-2c10-49fa-a7ae-9d03830a12d1_20250225T16:42_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah, hi [PII], this is [PII] calling from Bono to Jaana Cli center.
[AGENT][POSITIVE] OK, well, I'll be more than happy to assist you with the claim status, and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, the callback number is [PII] and the extension is [PII].
[AGENT][NEUTRAL] Thank you for that. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] This one.
[AGENT][NEUTRAL] Thank you. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yeah, the policy number is D as in Delta 46400982.
[AGENT][NEUTRAL] And do you have a copy of the member's ID card there?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, on the ID card, do you see anywhere that says inpatient or outpatient policy certification number?
[CUSTOMER][NEUTRAL] No, I don't see one.
[AGENT][NEUTRAL] It should start with a 01 or 02.
[CUSTOMER][NEUTRAL] Just a minute. I guess I do have a number starting with 02.
[AGENT][NEUTRAL] OK, may I have that number, please?
[CUSTOMER][NEUTRAL] It's 02427782.
[AGENT][NEUTRAL] 02427782
[CUSTOMER][NEUTRAL] Yeah, that's fine.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, it's [PII], and the date of birth is [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 for the claim you want me to check on?
[CUSTOMER][NEUTRAL] Yeah, the date of service is [PII].
[AGENT][NEUTRAL] And the total bill amount?
[CUSTOMER][NEUTRAL] Total amount is $2960 even.
[AGENT][NEUTRAL] That was $2,961?
[CUSTOMER][NEUTRAL] It's 2960.
[AGENT][NEUTRAL] 20, OK.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And do you mind if I place you on a brief hold while I look for the claim for you?
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] What?
[AGENT][NEUTRAL] Oh right.
[AGENT][NEUTRAL] 242-520.
[AGENT][NEUTRAL] 342-4211.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. There were quite a few claims that came in on that date. Um, can you verify the name of the provider's office on your claim?
[CUSTOMER][NEUTRAL] Yeah, it's partner physician group.
[AGENT][NEUTRAL] Alright, so I'm showing you received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 342-521-1.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] A total of $500.
[CUSTOMER][NEUTRAL] And may I know to which CBD it has been paid?
[AGENT][NEUTRAL] 315
[CUSTOMER][NEUTRAL] That's a total of 3 line items on our plan, OK.
[AGENT][NEUTRAL] 31,500.
[CUSTOMER][NEUTRAL] And may I know the mode of the payment?
[AGENT][NEUTRAL] Yes, it was a single check. Let me get that information for you. Hold on one second.
[AGENT][NEUTRAL] OK, so it's a single check in the amount of $500?
[AGENT][NEUTRAL] The check number is 183.
[CUSTOMER][NEUTRAL] He.
[AGENT][NEUTRAL] 857 9.
[AGENT][NEUTRAL] It was issued on [PII].
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] It cleared on [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] It's cleared on [PII], right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. Uh, it's a single check amount of $500.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] And may I also know the pay to address?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] And may I know the status of the other two CPD lines?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] The other two lines, the CPT code 93,010. Yeah.
[AGENT][NEGATIVE] They were denied
[AGENT][NEUTRAL] They would go ahead.
[CUSTOMER][NEUTRAL] Yeah, please go ahead.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] They were denied because the outpatient rider allows payment for outpatient surgery in an outpatient hospital or physician office.
[AGENT][NEGATIVE] Therefore, no benefits were payable.
[AGENT][NEUTRAL] It's the outpatient hospital or physician office only?
[CUSTOMER][NEUTRAL] OK. So, uh, on a claim, it's an emergency, so it is not covered?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's due to the CBD, right? For these two CBDs, the outpatient service, could you please repeat that line?
[AGENT][NEUTRAL] Right, the policy only pays for outpatient hospital and the physician office only.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So these two calls were neither the outpatient hospital or the physician office.
[CUSTOMER][NEUTRAL] And may I know why the CPT 31,500 paid? Is it because that's allowed per plan?
[CUSTOMER][NEUTRAL] Is it covered under the plan, the CPT 31,500 which is
[AGENT][NEUTRAL] Hold on, give me just a second. I understand. Hold on one moment, let me look. Thank you.
[CUSTOMER][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] Because that's a facility charge, 31,500.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It's listed as a um
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Outpatient facility.
[AGENT][NEUTRAL] That's a facility charge.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Uh, but actually this is a physician claim, so we won't be paying billing the for facility over here.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Um, so you're stating that the CPD 3150 is uh uh facility charge, that's the reason for the payment, right?
[AGENT][NEUTRAL] Yes, the facility benefit was used for that, for that, um.
[AGENT][NEUTRAL] Code
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Could you please hold on a moment? I need to check on something here.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you so much for being online.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] I know you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, did you have any more questions?
[CUSTOMER][NEUTRAL] Yeah, just you need to clarify with you, the other C2 CPTs are not covered as per patient plan because of the um outpatient hospital or patients of the office plan. That's the reason, right?
[AGENT][NEUTRAL] Right, 93,010 is an is an electrocardiogram, um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hey, you have to.
[AGENT][NEUTRAL] And that's for the reporting, that's not even for the service. Um, and then 99291.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEGATIVE] was also denied um because of the place of service. So on this um claim, the only facility
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Which was outpatient was the 31,500 and that was paid the full $500.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got it. Thanks so much for that. And could you please uh fax that you will be of the payment, pay your bill to me?
[AGENT][NEUTRAL] Sure, what's a good fax number for you?
[CUSTOMER][NEUTRAL] Yeah, the fax number is.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Attention, [PII].
[CUSTOMER][NEUTRAL] And that shows my name. It's spelled as [PII].
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, and that was [PII]?
[CUSTOMER][POSITIVE] Yeah, that's right.
[AGENT][NEUTRAL] Alright, so I'll go ahead and fax this over to you now. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] That's good. And may I know the turnaround time for the pack?
[AGENT][POSITIVE] Um, we usually say to give faxes at least an hour to be received. If it has not been received by the end of day today, you can give us a call and we'll be more than happy to resend it for you.
[CUSTOMER][NEUTRAL] OK, got it. And may I get the call reference number for this one?
[AGENT][NEUTRAL] Sure, so there's no um reference number, but you can use my name in today's date. And again, that's [PII], first [PII] to my last name is [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][POSITIVE] OK, got it. Thanks so much for your concern and have a wonderful day.
[AGENT][POSITIVE] You also and thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Um.