AccountId: 011433970860
ContactId: e28980bf-1e00-49ed-9b24-ca4a1e8b2840
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 485200 ms
Total Talk Time (AGENT): 189035 ms
Total Talk Time (CUSTOMER): 61733 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/14/e28980bf-1e00-49ed-9b24-ca4a1e8b2840_20250414T14:47_UTC.wav
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[AGENT][NEUTRAL] Morning. Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yes, hi, my name is [PII] calling for CSI Health to check on our claim status.
[AGENT][NEUTRAL] Uh, yes, [PII], were you and I speaking a moment ago?
[CUSTOMER][NEUTRAL] Yes. Sorry, I was uh having some issues with my.
[AGENT][NEUTRAL] OK, I could no longer.
[AGENT][NEUTRAL] OK, so you were the one having the, OK, because I did try to call you back and the call would not go through.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] And you said your phone number is [PII]. Is that correct?
[CUSTOMER][NEUTRAL] [PII]. With the, yes, with the extension [PII].
[AGENT][NEUTRAL] Yes, sir. Extension.
[AGENT][NEUTRAL] OK. All right. Yes, sir, but the call would not go through. So, are you calling on the same policy that you called on a moment ago?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, just one moment and let me get that pulled back up, please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And again, uh, here, any information provided would be a verification of benefits and not a guarantee of payment. So if you could please verify the name of the patient again and their date of birth.
[CUSTOMER][NEUTRAL] Yes, patient's name is uh [PII] and date of birth of [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And what is the date of service and total bill amount, please?
[CUSTOMER][NEUTRAL] [PII] charges for $273.07.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so this claim was received. [PII], this claim was received on 12-9-2024.
[AGENT][NEUTRAL] It was processed and denied on 12-11-2024.
[AGENT][NEUTRAL] The claim number is 353.
[AGENT][NEUTRAL] 9654.
[AGENT][NEUTRAL] And the reason for the denial on this claim?
[AGENT][NEUTRAL] States the outpatient treatment benefit provides an indemnity amount when a covered person receives treatment.
[AGENT][NEUTRAL] In an emergency room, urgent care facility, physician's office, or a physical, speech or occupational therapy facility.
[AGENT][NEUTRAL] Treatment in an outpatient hospital less than 18 hours is not covered by this policy.
[AGENT][NEGATIVE] And the other denial remarks she does not provide a wellness expense benefit.
[AGENT][NEUTRAL] [PII], are you still there?
[CUSTOMER][NEUTRAL] Uh, yes, I'm still here. Uh, may I know the patient's policy name?
[AGENT][NEUTRAL] This is a hospital and limited benefit plan. This is not major medical insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] OK. So is there any possible ways for this claim to be appealed?
[AGENT][NEUTRAL] An appeal may be filed within 180 days from the date of the decision in writing to attention appeals department.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh may I know the uh mailing address or the fax number?
[AGENT][NEUTRAL] The mailing address is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] Attention appeals department.
[AGENT][NEUTRAL] The fax number is [PII].
[AGENT][NEUTRAL] Also attention appeals department.
[CUSTOMER][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] And if you need a copy of this explanation of benefits, [PII], we do have a portal now that you have the claim number that you should be able to print up from by going to secured.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, got it. So, finally, I would like to get a call reference number.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes sir, it would be my name along with.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And is there anything else, [PII], that I can help you with today?
[CUSTOMER][NEUTRAL] Uh, no, actually.
[AGENT][NEUTRAL] That's it.
[CUSTOMER][NEUTRAL] Mhm, yes.
[AGENT][POSITIVE] OK, well then, thank you so much for calling APL and I hope that you have a very nice day.
[CUSTOMER][POSITIVE] Yes, have a great day too.
[AGENT][POSITIVE] Yes sir, thank you.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] Yes, bye.
[CUSTOMER][NEUTRAL] Mhm.