AccountId: 011433970860
ContactId: da86fd35-fb9f-4898-a0d2-37e441da1a77
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 434989 ms
Total Talk Time (AGENT): 159551 ms
Total Talk Time (CUSTOMER): 136601 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/15/da86fd35-fb9f-4898-a0d2-37e441da1a77_20250515T13:13_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning and thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Morning, this is [PII] from provider's office. I'm looking for a claim startup.
[AGENT][NEUTRAL] Sure, I can assist you with claim status, Mr. [PII] May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure you can note it down it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. Thank you. And may I have the name of the facility you're calling from for my notes?
[CUSTOMER][NEUTRAL] Yeah, the facility name is South Florida Orthopedics and Sports Medicine.
[AGENT][NEUTRAL] OK. Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Yeah sure the patient's policy number is.
[CUSTOMER][NEUTRAL] It's 02273345.
[CUSTOMER][NEUTRAL] Mary Lima #8.
[CUSTOMER][NEUTRAL] Also, can you please spell your name for me?
[AGENT][NEUTRAL] My name is [PII]. That's [PII], last [PII] [PII].
[CUSTOMER][POSITIVE] Got it, thank you so much.
[AGENT][NEUTRAL] You're welcome, Mr. [PII], and may I have that policy number one more time?
[CUSTOMER][NEUTRAL] Sure. 02273345 Mary Lima number 8.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] The first name is [PII].
[CUSTOMER][NEUTRAL] The last name is [PII].
[CUSTOMER][NEUTRAL] And date of birth is [PII].
[AGENT][POSITIVE] Perfect, thank you. And may I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Sure, the date of service for the claim is.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And for the bill amount it's.
[AGENT][NEUTRAL] And how much
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Let me grab the spell them out quickly.
[AGENT][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] One, it's $1,995 and the primary insurance that is BCBS, it has paid an amount of $212.62 on the claim and the patient copay amount was left by them that was transferred to your insurance.
[AGENT][NEUTRAL] OK, let me see if I can find this claim. And Mr. [PII], for future, you can check claim status online through our website at [PII] and that's just optional.
[AGENT][NEUTRAL] And bear with me.
[CUSTOMER][NEUTRAL] Alright, do we need to uh sign in over there or it's free?
[AGENT][NEUTRAL] You can sign in. Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Give me one moment, let me.
[AGENT][NEUTRAL] Let me check and see if this is your claim.
[AGENT][NEUTRAL] It's gonna be one more minute.
[AGENT][NEUTRAL] Mr. [PII], do you know if it's facility charges or was it like uh procedure charges?
[CUSTOMER][NEUTRAL] These are the procedure charges. There are two procedure codes, 62321 and the other one is J1100.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. OK, so yes, it is this claim. Um, let me give you the information on this claim.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] OK, we received the claim on [PII] process [PII].
[AGENT][NEUTRAL] And the claim was denied. The reason for this denial is that the service is not covered when rendered in the office or clinic.
[CUSTOMER][NEUTRAL] So the services are not covered when they are performed in the office or in the clinic?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Alright, can you please verify what specific services do the insurance covers?
[AGENT][NEUTRAL] OK, so this is a secondary supplemental plan to the major medical. And let me go ahead and check and see.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. So this one only covers if it's an ER visit, um, diagnostic center, surgical centers, um, urgent care facilities.
[AGENT][NEUTRAL] Cancer treatment.
[AGENT][NEUTRAL] Independent lab.
[AGENT][NEUTRAL] And those are the only benefits.
[CUSTOMER][NEUTRAL] All right, but, uh, our office is actually it's an, uh, you can say it's like an orthopedics related office, so basically these CBD codes which are built.
[AGENT][NEUTRAL] We don't cover office.
[CUSTOMER][NEUTRAL] OK, so these CPD codes which are well.
[AGENT][NEUTRAL] We don't cover office. Office is not part.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So we need to change the place of service might be or they should be billed with like some other place of service in order to be covered.
[AGENT][NEUTRAL] No, Mr. [PII], we cannot uh tell you you need to change that place of service if that's the place of service that she went into. Um, so basically all you need to know is that we do not cover office, we do not cover specialists. We do not cover any service done in an office setting.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, I got it.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So can you please confirm me the claim number?
[AGENT][NEUTRAL] Sure, the claim number is 3,593,030.
[CUSTOMER][NEUTRAL] And what's our caller reference number?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will.
[CUSTOMER][POSITIVE] Sure, why not? Thank you so much all have a great rest of your day. Take care.
[AGENT][NEUTRAL] You as well, Mr. [PII] Is there anything else I may help you with today?
[CUSTOMER][NEGATIVE] No take care bye bye.
[AGENT][POSITIVE] Mhm. Have a good day. Bye-bye.