AccountId: 011433970860
ContactId: e492fb57-76a2-413f-82be-4eae170db0fe
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 339480 ms
Total Talk Time (AGENT): 165957 ms
Total Talk Time (CUSTOMER): 81528 ms
Interruptions: 2
Overall Sentiment: AGENT=0, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/22/e492fb57-76a2-413f-82be-4eae170db0fe_20250422T18:47_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Um, yes, I was calling to get claim status on a claim, please.
[AGENT][NEUTRAL] OK, sure, I can assist you with claim status. May I have your name?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] OK. And may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure it's [PII].
[AGENT][NEUTRAL] And may I have the name of the facility you're calling from from my location?
[CUSTOMER][NEUTRAL] Yes, it's uh SSM Health Medical Group.
[AGENT][NEUTRAL] OK, thank you. And may I have the patient's policy number, Miss [PII]?
[CUSTOMER][NEUTRAL] Yes, I have 01835781.
[AGENT][NEUTRAL] OK, thank you. What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII] and date of birth is [PII].
[AGENT][NEUTRAL] OK. And may I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yes, and the date of service is [PII], and the amount is for $341.
[AGENT][NEUTRAL] Yeah, OK, let me see if I can find this claim, and that was [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and for the future, you can check claim status online through our website at [PII] and that's just optional. You can always call and let's see. Let me pull this EOB and see if this is your claim, OK? One moment.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] I'm still waiting on you bear with me.
[AGENT][NEGATIVE] OK, 3:41, this is it. OK, so it looks like we processed the claim on [PII] and the claim was denied. Um, the reason for this denials, and there's several denials, um, it looks like the policy does not provide wellness suspense, so that's one of the denials. Uh, another denial is that any puncture is not covered by the policy.
[AGENT][NEUTRAL] And see, another denial is that vaccine and immunizations administration of the injections are not covered.
[AGENT][NEUTRAL] And then for there's one code that it was denied stating that the calendar year maximum for outpatient office visit has been exhausted for the year.
[AGENT][NEUTRAL] You need the claim number?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK. Claim number is 3536469.
[AGENT][NEUTRAL] Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, can you, um, just, can you go over that just one more time? I'm gonna make sure that I got everything correct.
[AGENT][NEUTRAL] OK, and I'm just gonna give you the shorter version, OK? So basically, the policy does not.
[CUSTOMER][NEUTRAL] For my notes.
[CUSTOMER][NEUTRAL] Sure, sure. That's fine.
[AGENT][NEUTRAL] OK. The policy does not cover wellness, me puncture, vaccines, or immunization, and for the office visit, the maximum has been exhausted for the calendar year.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah, OK, that's what I got. I just wanted to be sure that I get that's what I got.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, cause I tried writing that down and sometimes my notes, they, they don't look right. I just wanted to be sure and I, uh, I thought I got everything done right. Sometimes it looks like chicken scratch.
[AGENT][NEUTRAL] Just
[AGENT][NEUTRAL] Yeah, it's just, it was a lot.
[AGENT][NEUTRAL] Yeah, this one was a lot. You only see usually one denial. This one is like 1234 denial, so I'm like, OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, that's actually all I needed to know. And what was your name again, hon?
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][POSITIVE] OK, great. Thank you so much for all your help. I appreciate it. Uh do you have a reference number for this call by chance?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] We don't have reference numbers you can use my name in today's date.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm. I'm there.
[CUSTOMER][POSITIVE] All right perfect thank you so much I appreciate it.
[AGENT][POSITIVE] You're welcome and thank you for calling APO. Have a good afternoon, Ms. [PII].