AccountId: 011433970860
ContactId: e99d4e69-219f-4e24-974b-b4d241118164
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 584000 ms
Total Talk Time (AGENT): 217542 ms
Total Talk Time (CUSTOMER): 175425 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/04/e99d4e69-219f-4e24-974b-b4d241118164_20250604T13:37_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. I'm calling from provider's office to check on the medical claim status.
[AGENT][POSITIVE] Sure, [PII], I can assist you with that. Can I have a callback number for you?
[CUSTOMER][NEUTRAL] Yeah, callback number is [PII].
[AGENT][NEUTRAL] And what is that policy number of the member that you're calling to check the status of a claim for today, [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 01988421 ML 8.
[AGENT][NEUTRAL] Can you verify that patient's name and date of birth, and I'll be able to assist you with your claim status.
[CUSTOMER][NEUTRAL] Yeah, patient's first name is [PII] Last name is [PII].
[AGENT][NEUTRAL] [PII] [PII]'s date of birth?
[CUSTOMER][NEUTRAL] I'm sorry, what?
[AGENT][NEUTRAL] What is the member's date of birth?
[CUSTOMER][NEUTRAL] The date of birth is [PII].
[AGENT][NEUTRAL] Thank you and what is the date of service that you're calling to check the status of a claim for?
[CUSTOMER][NEUTRAL] Yeah, it's [PII], I'm sorry, it's [PII].
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] I'm not showing a claim on file and this this policy has been active since [PII] and it's currently active.
[AGENT][NEUTRAL] Are you sure that's the correct date, [PII]?
[CUSTOMER][NEUTRAL] Yeah, like, uh, the bill amount is $969. There is no claim on, right?
[AGENT][NEUTRAL] Yes, that's correct. There's no claim on file for [PII], [PII].
[CUSTOMER][NEGATIVE] Yeah, but we have received, uh, uh, but I have received some uh denial as a service. This service are not covered under the claim number 3572235.
[AGENT][NEUTRAL] Let me see you said what's the claim number?
[CUSTOMER][NEUTRAL] I'm sorry, what?
[AGENT][NEUTRAL] Could you provide me with the claim number again?
[CUSTOMER][NEUTRAL] Yes, claim number 35.
[CUSTOMER][NEUTRAL] 7
[CUSTOMER][NEUTRAL] 223 5.
[AGENT][NEUTRAL] And you said that this claim was for [PII], right?
[CUSTOMER][NEUTRAL] Yes, this claim was for [PII] Last name is [PII]
[AGENT][NEUTRAL] So you're calling about [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So what is [PII]'s?
[AGENT][NEUTRAL] So what is [PII]'s date of birth because you gave me the information for [PII], the policy you gave me the information for [PII], the policy holder. So who are you calling to check the status of a claim for so we could be on the same of course so that I can assist you accordingly.
[CUSTOMER][NEUTRAL] I'm sorry, what?
[CUSTOMER][NEUTRAL] OK, I'm sorry. I think I provided the wrong information. Can I just check for this information which I'm providing right now?
[AGENT][NEUTRAL] Yes, so could you give me the pro the member's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, member's name is [PII] I'm sorry, [PII] Last name is [PII]
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[CUSTOMER][NEUTRAL] Member ID is 01.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Can you provide the member's ID?
[AGENT][NEUTRAL] I have the policy up. I just needed you to verify the member's name that you actually were calling to check the status of a claim for because you gave me the, the policy holder's information in the beginning of the phone call.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you're calling about claim number 3494596 which was received [PII].
[CUSTOMER][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] Once again.
[CUSTOMER][NEUTRAL] Can you spell once again?
[CUSTOMER][NEUTRAL] Received on?
[AGENT][NEUTRAL] So the data service is still the same, right?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] One second, data service.
[CUSTOMER][NEUTRAL] [PII] for the bid amount $969 ending with the claim number 35.
[AGENT][NEUTRAL] And then with the claim number of what [PII]?
[CUSTOMER][NEUTRAL] 3572235.
[AGENT][NEGATIVE] So the claim was received [PII]. It was processed [PII]. There was no payment on this claim because the policy per the policy, the member's benefits are not covered. Office visits are not covered under the member's policy.
[CUSTOMER][NEUTRAL] So, for this, what we need to do?
[CUSTOMER][NEUTRAL] You need to build the claim.
[AGENT][NEUTRAL] Well this is not a primary insurance company so I can't tell you what you have to do. I can only verify that we did not make a payment because the services are not covered under the policy for the policy, it does not offer office.
[CUSTOMER][NEUTRAL] OK. So, what is the resolution for the claim?
[AGENT][NEGATIVE] I mean, the only thing that I could tell you, [PII], is that we didn't make a payment. You sent the claim in for a bill amount and we did not make a payment on it because the benefits are not covered.
[CUSTOMER][NEUTRAL] OK. For this, we need to check with the patient or we need to check with the primary insurance?
[AGENT][NEUTRAL] Um, I don't, I'm not sure what you would have to do, [PII]. I can only verify that APL didn't make a payment.
[AGENT][NEUTRAL] Because we're not a primary insurance company, I can't tell you if it's the patient responsibility or not because we're not a primary. This is just a gap insurance and the policy does not cover the services provided. Is there anything else that I can assist you with today?
[CUSTOMER][NEUTRAL] Yeah, I have another one claim. Can you just provide the reference number for this claim?
[AGENT][NEUTRAL] But
[AGENT][NEUTRAL] The claim number is for the same member?
[AGENT][NEUTRAL] Or a different policy.
[CUSTOMER][NEUTRAL] No, it's
[CUSTOMER][NEUTRAL] Different policy. One second.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Can I provide the next member's ID?
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] Yeah, the next number ID starts with 01988421 M as in Mary, L as in Lima, 8.
[AGENT][NEUTRAL] This is the same policy. What is the member's name and date of birth?
[CUSTOMER][NEUTRAL] 1 2nd.
[CUSTOMER][NEUTRAL] Just a second.
[CUSTOMER][NEUTRAL] One second, I'm just loading.
[CUSTOMER][NEUTRAL] I'm sorry. I provided the incorrect member's ID. I'll repeat the member's ID. It starts with
[CUSTOMER][NEUTRAL] 2473446.
[AGENT][NEUTRAL] And what is this member's name and date of birth that you're calling to check the status of the claim for?
[CUSTOMER][NEUTRAL] Members first
[CUSTOMER][NEUTRAL] Yes, member's first name is [PII] Last name is [PII]
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][NEUTRAL] Thank you. And what is the date of service that you're calling to verify the status for for [PII]?
[CUSTOMER][NEUTRAL] Yeah, it's [PII] for the bill amount $336.
[AGENT][NEUTRAL] And what is your procedure code?
[CUSTOMER][NEUTRAL] Procedure code.
[AGENT][NEUTRAL] Mhm, what is the CPT code?
[CUSTOMER][NEUTRAL] CPT code is 99214.
[AGENT][NEUTRAL] So this claim was received [PII]. It was processed [PII]. There was no payment made on this claim because the benefits are not covered under the policy.
[AGENT][NEUTRAL] Benefits payable under this certification.
[AGENT][NEUTRAL] Certification are limited to those outlined on the schedule of benefits. This is not a covered loss under the plan. Therefore, no amount is payable for this expense.
[CUSTOMER][NEUTRAL] OK. Can I get the call reference number for the claims?
[AGENT][NEUTRAL] We don't provide reference numbers, however, you could use my name in today's date as a reference, [PII]. Let me know when you're ready for me to spell my name for you.
[CUSTOMER][POSITIVE] Yeah, I'm ready.
[AGENT][NEUTRAL] [PII] and today's date as a reference. Is there anything else that I can assist you with today?
[CUSTOMER][NEUTRAL] Yeah, what is the
[CUSTOMER][NEUTRAL] Yeah, I need to know the time limit for the claim.
[AGENT][NEGATIVE] There's no timely filing.
[CUSTOMER][POSITIVE] OK. Thank you so much.
[AGENT][POSITIVE] Have a good day. Thanks for calling APL. Goodbye.
[CUSTOMER][POSITIVE] Have a good bye.
[CUSTOMER][NEUTRAL] Bye.