AccountId: 011433970860
ContactId: e74ed8af-a5ea-4825-a4cf-500f2d32d010
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 362059 ms
Total Talk Time (AGENT): 132513 ms
Total Talk Time (CUSTOMER): 145060 ms
Interruptions: 2
Overall Sentiment: AGENT=1.3, CUSTOMER=1.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/14/e74ed8af-a5ea-4825-a4cf-500f2d32d010_20250514T15:51_UTC.wav
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[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Thank you [PII]. This is [PII]. I'm calling from the provider's office. How you doing?
[AGENT][POSITIVE] I'm doing well. How are you?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Doing great thank you. We are a dentist's office and I need to check some uh information about a claim.
[AGENT][POSITIVE] OK, you're welcome.
[AGENT][NEUTRAL] OK, I can definitely help you with your dental claim, and [PII], may I have a good contact number in case we're disconnected and the member's policy number?
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] 8642354848
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the policy number whenever you're ready. Oh, sure.
[CUSTOMER][NEUTRAL] [PII], can you hold for me?
[CUSTOMER][NEUTRAL] Yeah, can you hold for me 10 seconds please?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, yeah, let's get that number and we're gonna send that. Uh, I have an insurance, right, um, I'm back there, um, this, um, what do you need, please? I'm sorry.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] The policy number, it's OK.
[CUSTOMER][NEUTRAL] Policy is 02559376.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] That that's, it isn't really on the decision.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, the patient is, uh, [PII].
[CUSTOMER][NEUTRAL] And let me see if I can find his uh date of birth here.
[CUSTOMER][NEUTRAL] It's uh [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim and the total bills?
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The day of service was [PII], [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] No
[AGENT][NEUTRAL] And that was 043.
[AGENT][NEUTRAL] Here it is. Alright, hold on one moment.
[CUSTOMER][NEUTRAL] It's just
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] All right. And um can you verify the name of the facility?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] So I'm sure we received the claim on [PII]?
[CUSTOMER][NEUTRAL] Yes ma'am.
[AGENT][NEUTRAL] The claim number, hold on, let me make sure I didn't get it right. Oh, the claim number is 359.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 7666.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because the policy does not
[CUSTOMER][NEUTRAL] And what was the reason for?
[AGENT][NEUTRAL] The policy does not provide benefits for any procedure or service not listed.
[AGENT][NEUTRAL] On the covered dental services and procedures.
[CUSTOMER][NEUTRAL] Yeah, but the thing is on the list is showing that it is 7140, which is the simple extraction this were to wisdom teeth, yeah, we use the 70 to 10 then, um, do we have to do a 7140 because on the wisdom tooth we can do the 7140 to get paid but technically by the American, yeah.
[AGENT][NEUTRAL] Hold on one second.
[AGENT][NEUTRAL] Let me put
[AGENT][NEUTRAL] Let me look at the fact that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So the code that was billed was 07210, which is not a listed code on the fax bag.
[CUSTOMER][NEUTRAL] 00 OK, alright.
[AGENT][NEUTRAL] Yeah, 07210 is what was, what is on this, what was billed to us for 21 and 16.
[CUSTOMER][NEUTRAL] Let me go here.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, alright, let me, uh, is this the 7 to 10 coverage?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] No, that's what I'm saying to you. The 07, the 7210 is not covered on this member's policy, so that's why this claim was denied.
[CUSTOMER][NEUTRAL] Yeah, but
[CUSTOMER][NEUTRAL] Yeah, but you guys changed the D as in dentist to a 0. I just want to ask you is D because we're talking about dental and you guys switched to 0.
[AGENT][NEUTRAL] Whether you
[AGENT][NEUTRAL] Whether you put D 07210 or you put 07210, the code is still 7210, so it's, it's, that's a technicality. It doesn't, however you enter it's the same code.
[AGENT][NEGATIVE] Which is not covered on this policy.
[CUSTOMER][NEUTRAL] Tech technicality, yeah, technicality, uh, the uh D 7140, it is covered.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Yes, 7140 is a simple extraction, which is covered under basic on this policy.
[CUSTOMER][POSITIVE] Alright, thank you, ma'am.
[AGENT][POSITIVE] You're welcome. Was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] You have a great day.
[CUSTOMER][POSITIVE] That will do it bye bye thanks.
[AGENT][POSITIVE] Thanks for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] Bye bye