AccountId: 011433970860
ContactId: e2505d76-ecb9-4c1f-9fd6-0b602eea6b02
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 489769 ms
Total Talk Time (AGENT): 164327 ms
Total Talk Time (CUSTOMER): 101099 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/14/e2505d76-ecb9-4c1f-9fd6-0b602eea6b02_20250114T15:59_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII] speaking. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from the provider's office to check on a claim status. Uh, this will be president. I would like to inform you that this call is being recorded for quality and training purposes. Is that OK with you?
[AGENT][NEUTRAL] Sure, you said it was [PII]?
[CUSTOMER][NEUTRAL] That is right. And how do you spell your name, ma'am?
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] Last initial [PII].
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] Certainly, and [PII], can I have a callback number in case we should get disconnected and I can call you back please?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] What's the name of the provider or facility you're calling from [PII]?
[CUSTOMER][NEUTRAL] It is vital MD Group Holding LLC.
[AGENT][NEUTRAL] And what's the policy certificate or member ID please?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] 02319319 M as in Mary, L as in Lima, number 8.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And just give me one moment please [PII].
[AGENT][NEUTRAL] And may I please have you verify patient's name and their date of birth?
[CUSTOMER][NEUTRAL] The member's name is [PII].
[CUSTOMER][NEUTRAL] [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And what's the date of service and the amount on the claim please?
[CUSTOMER][NEUTRAL] The date of service is [PII] with the total amount of $5160 even 5160.
[AGENT][NEUTRAL] I'm sorry, did you say [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] [PII], 5160, is that correct?
[CUSTOMER][NEUTRAL] Yes
[AGENT][POSITIVE] OK, thank you, just give me one moment please.
[AGENT][NEUTRAL] OK, do not show a claim on file for [PII]. Would you like to verify any information, [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, just verify the mailing address for this one.
[CUSTOMER][NEUTRAL] Uh, is that [PII]?
[AGENT][NEUTRAL] Yes, just give me one moment please [PII]. I'm sorry, it looks like she has an updated policy number different from the one you provided, my apologies. Just give me one moment. That is the correct address though.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] OK, no problem.
[AGENT][NEUTRAL] So let me just check under here and see if I have that claim, sorry.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It looks like I do have that claim on file, just bear with me for one moment.
[AGENT][NEUTRAL] I'm gonna pull the claim image.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Just to be certain that's your claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 6690.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] I'm sorry my system's hanging up a little bit so just bear with me for just one moment please.
[CUSTOMER][NEUTRAL] That kind of
[CUSTOMER][POSITIVE] OK, no problem.
[AGENT][NEUTRAL] It looks like it's
[AGENT][NEUTRAL] Trying to work
[AGENT][NEUTRAL] My apologies.
[AGENT][NEUTRAL] OK, so I do have that claim on file. I'll give you the claim detail now. That claim was received on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] The claim process date is 12-31-2024.
[AGENT][NEUTRAL] The claim number is 35.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 46
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] 690.
[AGENT][NEUTRAL] And the claim was denied uh on that date, [PII] due to the, uh, this policy does not provide a benefit for uh wellness. So it must be a sickness or an injury diagnosis.
[AGENT][NEGATIVE] There's no wellness benefit under this policy.
[AGENT][NEUTRAL] So the claim was denied.
[CUSTOMER][NEUTRAL] OK, hold on.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] So the member's policy does not cover that?
[AGENT][POSITIVE] That's right.
[CUSTOMER][NEUTRAL] Uh, does not cover sickness and wellness, right?
[AGENT][NEUTRAL] No, it only covers for a sickness or injury diagnosis. So wellness or preventative diagnosis is not covered.
[CUSTOMER][NEUTRAL] So you mean to say that the diagnosis that we have billed is not covered as per the member's policy.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. Just allow me a moment, OK?
[CUSTOMER][NEUTRAL] And also, may I get the member's plan name?
[AGENT][NEUTRAL] The members plan name, it is a it it is a limited uh supplemental.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Benefit expense plan.
[CUSTOMER][NEUTRAL] Limited supplemental expense plan, OK.
[AGENT][POSITIVE] That's right.
[CUSTOMER][NEUTRAL] Uh, provide me the reference number for this call, Roxy.
[AGENT][NEUTRAL] You use my name and today's date?
[AGENT][NEUTRAL] Again it's R O X Y last initial L like love.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] Thank you so much for your assistance and you're really helpful. Have a great day ahead. Bye-bye. Take care.
[AGENT][POSITIVE] You too [PII] thank you for calling API. I hope you have a great rest of your day bye bye.