AccountId: 011433970860
ContactId: dcae024b-a171-411b-a09e-d9ecd12e50bb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 341140 ms
Total Talk Time (AGENT): 86880 ms
Total Talk Time (CUSTOMER): 107732 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/11/dcae024b-a171-411b-a09e-d9ecd12e50bb_20250611T18:44_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], this is [PII] calling from Saint Luke's Cataract Laser Institute.
[AGENT][POSITIVE] Hi, um, how can I help you today, [PII]?
[CUSTOMER][NEUTRAL] I'm calling in regards for a cream that has been denied uh for a patient. So, do you want any
[CUSTOMER][NEUTRAL] Member ID?
[AGENT][NEUTRAL] OK, um, what's a good callback, yeah, what's a good callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] Or the claim number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure [PII].
[CUSTOMER][NEUTRAL] 2020.
[AGENT][NEUTRAL] And what is the policy number?
[CUSTOMER][NEUTRAL] The member ID it is.
[CUSTOMER][NEUTRAL] 0214
[CUSTOMER][NEUTRAL] 465 9.
[AGENT][NEUTRAL] Alright, give me just one moment to look that up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Can you verify the patient's name and date of birth for me, please?
[CUSTOMER][NEUTRAL] Patient name is [PII] and date of birth is [PII].
[AGENT][POSITIVE] OK, thank you so much.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said you do have the claim number?
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] What is the claim number?
[CUSTOMER][NEUTRAL] Sure, it is 3603.
[CUSTOMER][NEUTRAL] 286.
[AGENT][NEUTRAL] And what was the provider's name or the hospital name?
[CUSTOMER][NEUTRAL] Saint Luke's Cataract Laser Institute.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEGATIVE] It looks like it was denied due to the service not being covered when performed in a doctor's office or a clinic.
[CUSTOMER][NEUTRAL] Yeah, but that's actually medical service. That's why I was wondering why was it denied.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] It was.
[CUSTOMER][POSITIVE] And Medicare actually paid the uh amount I mean sorry, Blue Cross paid the amount which actually follows the CMS guidelines.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, let me pull up their policy.
[CUSTOMER][NEUTRAL] that's.
[AGENT][NEUTRAL] Alright, let me see, give me just one moment while I pull it up.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I will.
[AGENT][NEUTRAL] OK. It looks like for their outpatient benefits, um, depending on what the procedure was, it looks like it's surgery in an outpatient hospital or facility or freestanding surgery center, um, diagnostic testing in a hospital outpatient facility or MRI facility.
[AGENT][NEUTRAL] Or physical therapy at a physical therapy facility.
[CUSTOMER][NEUTRAL] But that, that, that was done in office.
[AGENT][NEUTRAL] So if it was done in um the provider's office.
[AGENT][NEGATIVE] It won't be covered. It needs, it has to be um as outlined in the policy.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] But it is at a patient responsibility or is it ours because.
[CUSTOMER][NEUTRAL] That's how uh our claims get paid through Medicare or any other services, I mean, any other payer.
[AGENT][NEUTRAL] OK, um,
[CUSTOMER][NEUTRAL] Because we do that in office and then take the.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] I was just gonna say we don't determine patient responsibility. That's up to the provider.
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] Let me check the chart now hold on.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEGATIVE] You can't get it.
[CUSTOMER][NEUTRAL] I think I'm gonna go ahead and um.
[CUSTOMER][NEUTRAL] To discuss with theo and then get an update on it. Thank you, [PII]. Can I get the call reference?
[AGENT][POSITIVE] Great.
[AGENT][NEUTRAL] So we don't have call reference numbers, but you can use my name and last initial in today's date and it's [PII].
[CUSTOMER][POSITIVE] Perfect thank you have a good one.
[AGENT][POSITIVE] Thank you for calling APL. Have a great day.
[CUSTOMER][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] You too. Bye.