AccountId: 011433970860
ContactId: f394fad0-4632-4505-b9e2-43b4257e3f5c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 426119 ms
Total Talk Time (AGENT): 201489 ms
Total Talk Time (CUSTOMER): 170337 ms
Interruptions: 4
Overall Sentiment: AGENT=0, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/f394fad0-4632-4505-b9e2-43b4257e3f5c_20250429T17:17_UTC.wav
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[AGENT][NEUTRAL] Afternoon, thanks for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] on the care team. I've got a provider on the line that's having trouble understanding the claim denial on this policy.
[AGENT][NEUTRAL] OK, what is the policy number?
[CUSTOMER][NEUTRAL] Policy number is 358-084-1.
[CUSTOMER][NEUTRAL] Oh, I'm sorry, that's the claim. Let me give you the policy 257.
[CUSTOMER][NEUTRAL] 631-3. Sorry.
[AGENT][NEUTRAL] For [PII].
[CUSTOMER][NEUTRAL] Yeah, yeah, it's he's the um patient and then I'll give you the claim number.
[AGENT][NEUTRAL] OK, what's the claim number?
[CUSTOMER][NEUTRAL] 358-084-1.
[AGENT][NEUTRAL] It's for [PII] for $4,904.
[CUSTOMER][NEUTRAL] Yeah, I read her the denial code or denial reason verbatim that I also read from the plan policy, the language that says, you know, the surgery can be performed, um, we'll only pay the largest of the two, etc. but she's just not wanting to, um, listen.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me see what we got here. Give me a moment.
[CUSTOMER][NEUTRAL] Yes, they had 2 surgeries on the same day, but we paid.
[CUSTOMER][NEUTRAL] I guess the Lord we pay the.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] This claim is for the facility, not the surgeon.
[AGENT][NEUTRAL] Mm, so the surgeon's bill, let me see where we got the surgeon's bill for this one.
[CUSTOMER][NEUTRAL] OK, so then did we deny it wrong then?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEGATIVE] Yeah, we pay the surgeon's bill. This is for the facility, so it actually should have been denied based off the facility, not the surgery.
[AGENT][NEUTRAL] Yeah, it was processed incorrectly cause the surgeon's bill has already been paid. This is just for the surgery being, being performed at this facility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, um, uh, do we send out correct?
[AGENT][NEUTRAL] So the examiner, yeah, it'll need to be reprocessed, yeah.
[CUSTOMER][NEUTRAL] Explanation.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, uh, do you mind explaining that to her?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] I'll get her on the line and.
[AGENT][NEUTRAL] And what's her name?
[CUSTOMER][NEUTRAL] Her name's uh [PII] um and then I've got her callback number too if you want that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And [PII].
[AGENT][NEUTRAL] Yeah, I'll explain to her because the outpatient benefit does not cover, the outpatient benefit only covers for emergency room or urgent care or physician's office. It doesn't cover any outpatient facility under the outpatient benefit under this policy.
[CUSTOMER][NEUTRAL] OK, OK, I'm gonna introduce you and then I'll release her.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] OK, I've got uh [PII] on the line she's from our claim support services and she's gonna be able to help you on this claim, OK? Thank you, I appreciate your help.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Hi, this is [PII], and your name?
[CUSTOMER][NEUTRAL] Hi.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]? OK.
[CUSTOMER][NEUTRAL] Yes, uh-huh. [PII], yes.
[AGENT][NEUTRAL] OK, you, you had a question in regards to the facility claim, and that was for the [PII] data service.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] That is correct, uh huh.
[AGENT][NEUTRAL] OK. Under this particular policy for the outpatient benefit, the outpatient only covers for services rendered in a physician's office, urgent care or emergency room. So for these facility charges, that would not be a covered expense on the policy. So this claim will actually need to be reprocessed.
[CUSTOMER][NEUTRAL] OK, well, I'm sorry, so it only covers physicians, um, office, and what else?
[AGENT][NEUTRAL] Under the outpatients sickness benefit, it only covers for the physician's office.
[CUSTOMER][NEUTRAL] Uh huh.
[AGENT][NEUTRAL] Or emergency room or urgent care facility?
[CUSTOMER][NEUTRAL] So, what about ambulatory surgery center?
[AGENT][NEGATIVE] It does not cover that under the outpatient.
[AGENT][NEUTRAL] As far as hospital hospital, it only covers hospital confinement if they're confined in the hospital for at least 24 hours or more.
[CUSTOMER][NEUTRAL] Really? Because when we called, uh-huh.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] So what's gonna happen to our claim? Because when we call to check benefits, we were only told that for this plan, they will pay up to $2000 per procedure. It didn't say anything about not covering a surgery center.
[AGENT][NEUTRAL] It covers for the surgical procedure, for the actual surgical procedure and anesthesia up to that amount. However, it does not cover for the facility charges.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] As far as facility charges, they either had to be confined in the hospital at least 24 hours or more, or it has to be on the outpatient sick benefit in emergency room or physician's office or urgent care facility under the outpatient benefit.
[CUSTOMER][NEUTRAL] But then you mentioned right now that you can.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] So we're not gonna, you did mention something about you were gonna send the claim back to get reprocessed. Did I catch that correctly or?
[AGENT][NEUTRAL] Yes, to be processed correctly with the, with the correct denial code.
[CUSTOMER][NEUTRAL] So there's possibilities that the claim I get paid or?
[AGENT][NEGATIVE] No, it's not covered under the policy. It just was the incorrect denial code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I see. Oh, OK, I see what you're saying.
[CUSTOMER][NEUTRAL] So, in this case, will the patient be res uh-huh.
[AGENT][NEUTRAL] Yeah, the facility charges should have been denied, but not in regards to the actual surgeon's charges because it was denied based off the surgeon charges versus the facility charges.
[CUSTOMER][NEUTRAL] Got it. OK, OK.
[CUSTOMER][NEUTRAL] Um, so who would be responsible for this? I mean, would it be a complete write off or would the patient be responsible?
[AGENT][NEUTRAL] This is a limited indemnity policy, so it only covers what's outlined within the policy coverages. So since this is not a covered expense under the policy, we don't have any involvement of the handling of any remaining claim amounts. This is not a major medical plan.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, all right.
[CUSTOMER][NEUTRAL] Um, OK, can I get a claim number and a call reference number please?
[AGENT][NEUTRAL] Sure, the claim number is 358-084-1, and it would be just my name and that's [PII] Is there anything else I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Um, no, this would be it. Thank you so much for your help.
[AGENT][POSITIVE] You're welcome. Thank you for calling APO. You have a good day.
[CUSTOMER][POSITIVE] Thank you. You too. Bye-bye.
[AGENT][POSITIVE] You're welcome bye.