AccountId: 011433970860
ContactId: f2f9eae5-9643-4bcc-8e94-ce27fc2a380e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 485619 ms
Total Talk Time (AGENT): 197223 ms
Total Talk Time (CUSTOMER): 144818 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/31/f2f9eae5-9643-4bcc-8e94-ce27fc2a380e_20250331T17:46_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] and I'm calling from SSM Health and I was calling regarding
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Most questions about a medical claim as well as eligibility, I.
[CUSTOMER][NEUTRAL] I don't know. We'll look at it together, I guess.
[AGENT][POSITIVE] Well, I can help you with whatever you need.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII], what is that callback number please, ma'am?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you, [PII]. And what is the policy number for the patient?
[CUSTOMER][NEUTRAL] I have 01835781.
[AGENT][NEUTRAL] Thank you. And the patient's name and date of birth, please, ma'am.
[CUSTOMER][NEUTRAL] Her name is [PII] and the last name is [PII]
[CUSTOMER][NEUTRAL] IG and her date of birth is [PII].
[AGENT][NEUTRAL] All right, thank you. OK. So [PII], I do have [PII]'s policy pulled up.
[AGENT][NEUTRAL] And you said you were needing claim status, is that one thing you need?
[CUSTOMER][NEUTRAL] Yeah, cause it looks like we filed a claim to you guys, but when I look up the information, it looks like she had a colonoscopy, but
[CUSTOMER][NEUTRAL] It was at a um ambulatory surgery center.
[CUSTOMER][NEUTRAL] So I don't know if you guys would have covered that.
[AGENT][NEUTRAL] OK, well I can help you with that. Excuse me, what is the data service or if you have a claim number we can pull that up and look at it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The date of service is [PII] for $2,268.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] If you don't mind hanging on just a second for my computer.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Taking his sweet time.
[AGENT][NEUTRAL] Maybe I can pull it up this way.
[AGENT][NEUTRAL] And what was the um
[AGENT][NEUTRAL] Facility name.
[CUSTOMER][NEUTRAL] It's SSM Health Medical Group.
[AGENT][POSITIVE] Got you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I do see the claim.
[AGENT][NEUTRAL] Claim was received on [PII] and processed on [PII] and denied.
[AGENT][NEUTRAL] Was it a wellness colonoscopy?
[CUSTOMER][NEUTRAL] Uh, let me see.
[AGENT][NEUTRAL] It looks like what from the information we received, it was for a wellness, and the medical policy doesn't cover wellness.
[CUSTOMER][NEUTRAL] I don't know, I don't know how to determine if it's, well, yeah, because I think it's a zip code.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's the [PII].
[CUSTOMER][NEUTRAL] Encounter for screening for malignant neoplasm of colon. So usually when it's a Z code, I think it is considered preventive, preventative, but
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Well, yeah.
[CUSTOMER][NEUTRAL] I think it turned into medical because he saw something.
[AGENT][NEUTRAL] Let me get that claim pulled up. Let's take a look and see what's listed on that claim.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Cause they can always
[AGENT][NEUTRAL] Turn into diagnostic.
[CUSTOMER][NEUTRAL] I can change it when they go in there. Mhm.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Um, let me read her notes too.
[CUSTOMER][NEUTRAL] The providers notes.
[CUSTOMER][NEUTRAL] Do you guys cover if it's not a wellness?
[AGENT][NEUTRAL] Let me check that.
[AGENT][NEUTRAL] Actually, a colonoscopy is not a covered diagnostic test under this plan.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me check one other thing.
[AGENT][NEUTRAL] Cause it's a limited hospital indemnity policy, it's not major medical.
[AGENT][NEUTRAL] I'm gonna check one more thing.
[CUSTOMER][NEUTRAL] Now wouldn't you guys be secondary?
[AGENT][NEUTRAL] So this is just a limited indemnity policy. We're not major medical nor secondary.
[CUSTOMER][NEUTRAL] Or no?
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] It's just an indemnity policy to help provide benefits, covered procedures.
[AGENT][NEUTRAL] Let's take a look real quick.
[AGENT][NEUTRAL] Yeah, um,
[AGENT][NEGATIVE] Even with it being a diagnostic colonoscopy, it's just not gonna be covered under this policy.
[AGENT][NEUTRAL] The um covered diagnostic tests are limited to MRI, CAT scan, CT, PET scan, and thyroid.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Angiogram, arteriogram, lower GI upper GI, Myelogram, sleep study, nuclear test, and a TEE.
[AGENT][NEUTRAL] So it's not gonna be covered even if it is diagnostic.
[CUSTOMER][NEUTRAL] OK, question, um.
[CUSTOMER][NEUTRAL] Do you show that it's patient responsibility or is it just not covered?
[AGENT][NEUTRAL] It's just not covered now if you're a multi plan provider.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Uh, well, no, it's just not covered. This policy doesn't participate in multi-plan.
[AGENT][NEUTRAL] So it would be the uh facility.
[AGENT][NEUTRAL] The provider decision as to what to bill.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Well, if it's a non-covered benefit and it's an indemnity.
[CUSTOMER][NEUTRAL] That looks like it's patient responsibility.
[AGENT][NEUTRAL] We just can't determine what patient responsibility would be.
[CUSTOMER][NEUTRAL] To me
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] OK, let's see if I got another one in here.
[CUSTOMER][NEUTRAL] Oh, I don't, um, can you?
[CUSTOMER][NEUTRAL] Provide the claim number.
[AGENT][NEUTRAL] Absolutely, the claim number is 3,531,040.
[AGENT][NEUTRAL] And then [PII], if you need that EOB, we do have a provider portal at secured and that's [PII].
[AGENT][NEUTRAL] And you'd have instant access to that EOB.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] OK, alrighty and then do you give call reference numbe[PII] or just your name in today's date?
[AGENT][POSITIVE] The call reference number would be my name and today's date, and I spell my name [PII], it was a pleasure to assist you with that claim status. Anything else I can help you with today?
[CUSTOMER][NEUTRAL] Um, no, thank you, not at this time.
[AGENT][POSITIVE] OK and thank you for calling APL. I hope you have a wonderful day.
[CUSTOMER][NEUTRAL] OK, you too.
[AGENT][POSITIVE] Thank you, bye bye.
[CUSTOMER][NEUTRAL] Bye.