AccountId: 011433970860
ContactId: df55c166-d963-4c82-95ea-dd76cf4205d1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 651969 ms
Total Talk Time (AGENT): 230900 ms
Total Talk Time (CUSTOMER): 150362 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/07/df55c166-d963-4c82-95ea-dd76cf4205d1_20250107T19:34_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello, [PII]. This is [PII]. I'm calling from the provider office for the claim.
[AGENT][NEUTRAL] OK, could you please repeat your first name?
[CUSTOMER][NEUTRAL] It's uh [PII].
[AGENT][NEUTRAL] [PII], OK, thank you, [PII], um, could you please provide your callback number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you, [PII]. Could you confirm the insurance policy number?
[CUSTOMER][NEUTRAL] 60801.
[AGENT][NEUTRAL] OK, that is gonna be our electronic payer ID. I'm gonna need the insured's policy number.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] This is the ID?
[AGENT][NEUTRAL] That's the payer ID. I'm gonna need the insured policy number in order to look up a claim for you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, wait a moment.
[CUSTOMER][NEUTRAL] In the customer ID where I can find the, it, it's uh showing in uh
[CUSTOMER][NEUTRAL] It's 023703.
[CUSTOMER][NEUTRAL] 40 M as in Mary, L as in Lima, number 7.
[AGENT][NEUTRAL] OK, thank you and can you confirm the insured's name and date of birth for me?
[CUSTOMER][NEUTRAL] name.
[CUSTOMER][NEUTRAL] It's uh American Public Life.
[AGENT][NEUTRAL] The insured's name, the patient's name and date of birth for me please.
[CUSTOMER][NEUTRAL] OK, sorry, sir, [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] OK thank you and you said you're calling to check claim status?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, I can definitely take a look. What's that data service and build amount please?
[CUSTOMER][NEUTRAL] Date of service is [PII] and the charge amount is 1054.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] 4. OK. Um.
[CUSTOMER][NEUTRAL] And I'll provide you, this is the correct ID number?
[AGENT][NEUTRAL] That's the correct policy number, yes, sir.
[AGENT][NEUTRAL] Give me just a second and let me see if we have this claim on file. Bear with me for just a minute.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, so I do have a claim number.
[AGENT][NEUTRAL] Let me know when you're ready for the claim number.
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK, so the claim number is 34869994.
[AGENT][NEUTRAL] It was received [PII], processed [PII].
[AGENT][NEUTRAL] The CPT code.
[AGENT][NEUTRAL] 99204. It denied as office visits are noncovered under the policy.
[CUSTOMER][NEUTRAL] Why
[AGENT][NEUTRAL] Office visits are non-covered under the policy.
[CUSTOMER][NEUTRAL] Then which service this uh policy was covered?
[AGENT][NEUTRAL] Sir,
[CUSTOMER][NEUTRAL] Then which service this policy covered?
[AGENT][NEUTRAL] OK, so office visits are not covered under this policy.
[CUSTOMER][NEUTRAL] OK. And the second code, 31231?
[AGENT][NEUTRAL] This
[AGENT][NEUTRAL] This service is not covered when performed in a doctor's office or clinic, so the place of service is non-covered.
[CUSTOMER][NEUTRAL] So we need to change the place of service?
[AGENT][NEUTRAL] You can't just change the place of service if it was done in a doctor's office.
[AGENT][NEUTRAL] Or a clinic you can't just automatically change the place of service.
[AGENT][NEUTRAL] If you don't agree with that decision, you can always appeal.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But uh this service is not covered under this policy, am I correct?
[AGENT][NEUTRAL] The place of service is not, no, sir.
[CUSTOMER][NEUTRAL] The place of service is not covered under the.
[CUSTOMER][NEUTRAL] And the the patient policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, shall we move ahead for the different data service, another data service?
[AGENT][NEUTRAL] You have another claim?
[CUSTOMER][NEUTRAL] Yes, I have.
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] For the same member
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, give me just a second.
[AGENT][NEUTRAL] What is that data service to bill amount?
[CUSTOMER][NEUTRAL] The rate of service is
[CUSTOMER][NEUTRAL] 919-2024 and the charge amount is 264.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so that claim number is gonna be 352.
[AGENT][NEUTRAL] 7793.
[AGENT][NEUTRAL] That claim was received on 11-5-24 processed 11-8-24 and denied as office visits are not covered under the policy.
[CUSTOMER][NEUTRAL] But why this is non-covered services and which services you are covered?
[CUSTOMER][NEUTRAL] Because this is the ENM service.
[AGENT][NEUTRAL] OK, that place of service is just non-covered under the policy.
[CUSTOMER][NEGATIVE] This is not the correct
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And could you please check which place of service they cover?
[AGENT][NEUTRAL] It's gonna cover emergency room or clinic. However, a, I mean, emergency room or urgent care, however, uh office visit or a clinic is non-covered under the policy.
[AGENT][NEUTRAL] However, I did say, um, as I stated, if you don't agree with the decision, you can always appeal the decision.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You have 6 months from the denial date to appeal the decision of the claim, and it has to come in the form of a letter signed and dated.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I have one more claim for the same patient. The the date of service is [PII].
[AGENT][NEUTRAL] OK, give me just a second.
[AGENT][NEUTRAL] What is that bill amount?
[CUSTOMER][NEUTRAL] The bill amount is 360.
[AGENT][NEUTRAL] You said 360?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And the patient only cover emergency and.
[AGENT][NEUTRAL] OK, let's see here so the claim number is gonna be 351.
[AGENT][NEUTRAL] 531 8.
[AGENT][NEUTRAL] That claim was received 10-7-2024 process 10-9-2024. It did deny.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Stating that these services is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] And which service they covered patients, only the emergency end?
[AGENT][NEUTRAL] Urgent care.
[CUSTOMER][NEUTRAL] Uh, sorry?
[AGENT][NEUTRAL] Urgent care
[CUSTOMER][NEUTRAL] Urgent care.
[CUSTOMER][NEUTRAL] OK. And what is the call reference number for today's call?
[AGENT][NEUTRAL] It's gonna be my name.
[AGENT][NEUTRAL] [PII], and today's date. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I have one more thing. Shall we move ahead for another patient?
[AGENT][NEUTRAL] Is it for a different patient?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, give me just a second.
[AGENT][NEUTRAL] What is that policy number?
[CUSTOMER][NEUTRAL] Policy number is 304941153.
[AGENT][NEUTRAL] 204941153
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, give me just a second. I don't.
[AGENT][NEUTRAL] OK, what's the patient's name and date of birth?
[CUSTOMER][NEUTRAL] The name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK, that's not gonna be our policy number. If you look on the front of the insurance card, it's gonna state policy certificate number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, no problem, [PII]. Thank you and have a good day. Bye for now.
[AGENT][POSITIVE] OK, well, thank you for calling APL. I hope you have a great day. Bye-bye.