AccountId: 011433970860
ContactId: d51972f6-110f-4856-9d94-80ef32318d3f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 869030 ms
Total Talk Time (AGENT): 196912 ms
Total Talk Time (CUSTOMER): 287164 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/17/d51972f6-110f-4856-9d94-80ef32318d3f_20250217T21:45_UTC.wav
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[AGENT][NEUTRAL] Afternoon. Thank you for calling APL. This is speaking. May I help you?
[CUSTOMER][NEUTRAL] Very good afternoon. This is [PII]. initially my last name is [PII] like [PII], and I'm calling from the provider's office to discuss on a claim. And before we proceed, I would like to inform you this call has been recorded for quality and training purposes. Is that OK with you?
[AGENT][NEUTRAL] Oh, that's fine. And I can verify claim status for you. Your name is again?
[CUSTOMER][NEUTRAL] [PII] spelled as [PII]. And can you spell your name as well?
[AGENT][NEUTRAL] Sure, [PII] last initial [PII] And what is that policy number, please?
[CUSTOMER][NEUTRAL] Oh, sure. The policy number on this claim, it is going to be just a second.
[CUSTOMER][NEUTRAL] Let me open the claim form here. OK, policy number starts with 02544684.
[AGENT][NEUTRAL] OK, thank you. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Mhm it's [PII].
[AGENT][NEUTRAL] OK. And verify the patient's name, date of birth.
[CUSTOMER][NEUTRAL] Uh, just a moment. Got it here. It is going to be [PII], and the date of birth it is [PII].
[AGENT][NEUTRAL] OK. And what was the date of service and the amount of the charge?
[CUSTOMER][NEUTRAL] OK, give me a second here and I got the details. Uh, it's going to be um [PII] and the total bill amount is $267.
[AGENT][NEUTRAL] $267.
[CUSTOMER][NEUTRAL] Yeah, 267.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Mhm mhm mhm.
[AGENT][NEUTRAL] OK. And you're calling from?
[CUSTOMER][NEUTRAL] The provider's office?
[AGENT][NEUTRAL] Name of the provider's office?
[CUSTOMER][NEUTRAL] American Health Network.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] Was there several line items, like 5 line items on this claim?
[CUSTOMER][NEUTRAL] Actually, for, uh, I guess you were checking for.
[CUSTOMER][NEUTRAL] Give me a second here. You got it's 267. We have two light light items which is 99299386 and 36415.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, give me one moment.
[CUSTOMER][POSITIVE] Take your time.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, I'm showing the claim process as wellness screenings are not covered under the policy and be puncture is not covered.
[CUSTOMER][NEUTRAL] OK, again, uh, can I have the claim received it first?
[AGENT][NEUTRAL] Sure, this claim received on
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, and processed on.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Sorry, what's the claim number?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 3555535.
[CUSTOMER][NEUTRAL] OK, so yeah, now let's go ahead and let me know line item 1 I mean CBD code 99386.
[AGENT][NEUTRAL] Uh, that process is wellness is not covered.
[CUSTOMER][NEUTRAL] It's the night.
[CUSTOMER][NEUTRAL] So both of the CPT codes are not covered under the patients plan you want to say.
[AGENT][NEUTRAL] Correct, part of the patient's policy is not covered.
[CUSTOMER][NEUTRAL] Give me 1 2nd, OK?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Do you see any active policy in patients plan?
[AGENT][NEUTRAL] Uh, no other policy with our company.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So basically for this patient we have uh one more claim for the same date of service for $95. Can you check for that as well?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Uh, I do show we received that claim and it processed as services other than for sickness or an injury is not covered under the policy.
[CUSTOMER][NEUTRAL] So this claim is also not covered on the patient's plan you wanna say, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Give me a moment.
[CUSTOMER][NEUTRAL] OK, and what was the received it and process it for the claim?
[AGENT][NEUTRAL] Claim received on [PII], processed on January, I'm sorry, [PII], processed on [PII].
[CUSTOMER][NEUTRAL] Same thing happened here as well and the claim number ends with 598.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK, OK, no problem.
[CUSTOMER][NEUTRAL] OK, and for this patient, the last data services [PII] $136.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK, and I show on this claim, we paid $50 which is the max benefit payable for the data service and
[AGENT][NEUTRAL] See
[CUSTOMER][NEUTRAL] Received it.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] Uh, this claim was received on [PII].
[AGENT][NEUTRAL] Processed on [PII].
[CUSTOMER][POSITIVE] OK, that's great. OK, let's move forward for the next patient. I do have one more patient here.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Give me. Sure.
[CUSTOMER][POSITIVE] Take your time.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK. What is the next policy number?
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Just a second here I got it. So the next member ID number it is 025.
[CUSTOMER][NEUTRAL] 44684
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the patient's name, date of birth?
[CUSTOMER][NEUTRAL] Patient's name and date of birth would be um give me a second here.
[CUSTOMER][NEUTRAL] It is [PII] [PII].
[AGENT][NEUTRAL] Oh, it's the same patient policy number. Go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] The date of birth it is going to be [PII].
[AGENT][NEUTRAL] Uh, verify that again because I see a different date of birth for this patient.
[CUSTOMER][NEUTRAL] Oh, it's [PII].
[AGENT][NEUTRAL] [PII]. And what was the date of service and the amount of the charge?
[CUSTOMER][NEUTRAL] Uh, the date of service it is [PII] total charge amount $225.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][POSITIVE] Sure, take your time.
[AGENT][NEUTRAL] OK. Uh, show that claim and process uh services other than for sickness or injury is not covered under the policy.
[CUSTOMER][NEUTRAL] Mm, so basically this is not go under the patient's plan you wanna say?
[AGENT][NEUTRAL] Correct. Policy does not cover any wellness services.
[CUSTOMER][NEUTRAL] OK, no problem. Can I have your claim received date?
[AGENT][NEUTRAL] Sure. Claim received on [PII].
[CUSTOMER][NEUTRAL] [PII] of
[AGENT][NEUTRAL] [PII] at [PII].
[CUSTOMER][NEUTRAL] OK. And the process date?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, the claim number is 355 and 35568 and then after.
[AGENT][NEUTRAL] 681-3.
[CUSTOMER][POSITIVE] 681-3 that's great.
[CUSTOMER][NEUTRAL] Give me one moment here.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So do you see any other active insurance for the patient for that service?
[AGENT][NEGATIVE] Not with our company.
[CUSTOMER][NEUTRAL] Yeah, not the company.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][POSITIVE] OK, no problem.
[CUSTOMER][POSITIVE] No problem with that. OK, let's move forward for the last one, the last patient whenever you're ready.
[AGENT][NEUTRAL] Is it on the same policy number or a different policy number?
[CUSTOMER][NEUTRAL] I have to check that. Give me a second.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] It is [PII] and the policy number it is 02544684. So basically the same, right?
[AGENT][NEUTRAL] Yeah. What is the patient's name, date of birth?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Patient's name is [PII] and the date of birth it's January, not January, it's [PII].
[CUSTOMER][NEUTRAL] Mm hm.
[AGENT][NEUTRAL] OK, and data service amount on the charge?
[CUSTOMER][NEUTRAL] Same, it is going to be [PII]. I mean, uh, yeah, their service is [PII]. Total bill amount is $225. So basically they have taken same services for themselves around around on the same data service similar to same, yeah, and these services are not covered under the plan, I guess.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Probably not. Let me one moment.
[CUSTOMER][NEUTRAL] Am I right?
[CUSTOMER][NEUTRAL] Yeah, because all of them have been denied for the same reason uncovered.
[AGENT][NEUTRAL] Well, I had to pull up the policy, but yes, wellness screening is not covered under this policy.
[CUSTOMER][NEUTRAL] Yeah, that's what that's what I was saying that it is denying for the same reason.
[AGENT][NEGATIVE] I understand what you were saying, but I had to look up myself and look at the denial, but yes, you are correct, it was processed as wellness it's not covered.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right, so what is the claim received it? Is that [PII] and [PII]?
[AGENT][NEUTRAL] [PII] and process on the [PII].
[CUSTOMER][NEUTRAL] [PII] and [PII]. OK.
[CUSTOMER][NEUTRAL] Um, the claim number is 3,556,190.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, uh.
[CUSTOMER][NEUTRAL] OK, there is nothing left to discuss on this game now. What would be the call reference number?
[AGENT][NEUTRAL] We don't give reference numbers, you may use my name in today's date.
[CUSTOMER][POSITIVE] Great, thank you, thank you very much for providing all the information that's all for now. Have a nice day.
[AGENT][POSITIVE] You too. Thanks for calling APL. Bye.