AccountId: 011433970860
ContactId: e0d4969e-6290-470b-a6c8-6fb4f8ba518d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 419179 ms
Total Talk Time (AGENT): 164897 ms
Total Talk Time (CUSTOMER): 131051 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/05/e0d4969e-6290-470b-a6c8-6fb4f8ba518d_20250305T22:27_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is. How may I assist you?
[CUSTOMER][NEUTRAL] I'm sorry, your phone was cutting out. What was your first name?
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] Hi, so, my name is [PII] with Cook Children's Physician Network.
[AGENT][NEUTRAL] OK, um, and how may I assist you today, Miss [PII]?
[CUSTOMER][NEUTRAL] I'm calling to verify a denied claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, I can assist you with claims. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Uh, yes, it's [PII].
[AGENT][NEUTRAL] OK, thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Um, sure. We have 02298397.
[AGENT][NEUTRAL] Thank you one moment let me pull this policy.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's gonna be a system as well.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK. What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Uh, this is for patient [PII], [PII].
[AGENT][NEUTRAL] All right. Thank you, Ms. [PII]. Let me see if I have a new policy. This one is terminated. One moment.
[CUSTOMER][NEUTRAL] Yeah, it's for [PII].
[AGENT][NEUTRAL] Oh, OK. So yes, the policy was effective [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it terminated [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah, I have a claim for uh [PII] that I need to check on.
[AGENT][NEUTRAL] Oh, [PII].
[AGENT][NEUTRAL] How much is the total charge?
[CUSTOMER][NEUTRAL] $151.
[AGENT][NEUTRAL] Oh, OK. Yeah, I see it here.
[CUSTOMER][NEUTRAL] So this policy termed 11 of 25?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Uh-huh, yes. Now, the, the claim was received on [PII], processed [PII], and it was denied because office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, hold on, OK, OK, I'm sorry, you said the claim was processed when?
[AGENT][NEUTRAL] On [PII].
[CUSTOMER][NEGATIVE] And denied as office visits are not covered.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] Under
[CUSTOMER][NEUTRAL] What kind of policy does the patient have? Or did they have coverage?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Yeah, this was a secondary supplemental plan to the major medical. Now this one, will cover outpatient service, um, in outpatient facility or hospital, ER urgent care diagnostic centers.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So the supplemental, you said supplemental, what?
[AGENT][NEUTRAL] Mhm, supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] OK, let me check.
[CUSTOMER][NEUTRAL] Medical.
[CUSTOMER][NEUTRAL] Well. OK. So, basically, um,
[CUSTOMER][NEUTRAL] Would you say hospital outpatient hospital?
[CUSTOMER][NEUTRAL] Services were covered.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] What did you say? What, what kind of services were covered?
[AGENT][NEUTRAL] Yeah, this, OK, this policy has benefit have benefits for outpatient facilities including the ER, um, diagnostic centers, surgical centers, urgent care facilities.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] No office.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK do you need the claim number?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] All right, um, the claim number is 345.
[AGENT][NEUTRAL] 7766.
[CUSTOMER][NEUTRAL] And let's see, and your name was [PII], correct?
[AGENT][NEUTRAL] My, my name is [PII] so.
[AGENT][NEUTRAL] That initial M.
[CUSTOMER][NEUTRAL] Is there a call reference number?
[AGENT][NEUTRAL] We don't have reference numbers so you can use my name in today's name.
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Today, OK.
[CUSTOMER][POSITIVE] Alright, so thank you so much for confirming that.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] You're welcome and thank you for calling APL. Is there anything else I may help you with today?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK, so, yeah, sorry, I forgot to ask you. Uh, the patient's Blue Cross Blue Shield major medical policy, um, applied this claim to the patient's deductible. Um, so what's the remaining balance patient responsibility, or did you?
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Providing any discount?
[AGENT][NEUTRAL] Well
[AGENT][NEUTRAL] Mm. We're not the primary, we're the secondary, so there's no discounts with us. We, we, what we do is we help with the co-payments, co-insurance and deductibles from the major medical. Now this particular policy doesn't have any office coverage, so it was only for outpatient facilities. So, um, I guess you go back to the primary EOB.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right. OK.
[CUSTOMER][NEGATIVE] Gotcha.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah, OK. So I guess whatever the primary didn't cover, that's what the patient's gonna owe because it wasn't covered, right? OK. OK, thank you.
[AGENT][NEUTRAL] Mm.
[AGENT][POSITIVE] Mm, right. Mhm. Yes. More than likely, yes. Mhm. You're welcome. Is there anything else I can help you with today?
[CUSTOMER][POSITIVE] Uh, no, that was it. Thank you.
[AGENT][POSITIVE] OK. You're welcome and thank you for calling APL. Have a good day.
[CUSTOMER][POSITIVE] Thanks you too bye bye.