AccountId: 011433970860
ContactId: f9f1fda1-4586-4fdb-8902-0b75f94f1a43
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 497290 ms
Total Talk Time (AGENT): 219887 ms
Total Talk Time (CUSTOMER): 220622 ms
Interruptions: 4
Overall Sentiment: AGENT=0.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/30/f9f1fda1-4586-4fdb-8902-0b75f94f1a43_20250130T16:07_UTC.wav
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[AGENT][POSITIVE] Good Morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Um, yes, my name is [PII]. I'm calling from the provider's office. I am just trying to inquire about, um, some claims that have denied.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] All right, sure, I can assist you with claims, Miss [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Mhm it's [PII].
[AGENT][NEUTRAL] Thank you. And what's the name of the provider?
[CUSTOMER][NEUTRAL] Um, it's Premier Medical Group is our group.
[AGENT][NEUTRAL] OK, thank you. And may I have the patient's policy number, Miss [PII]?
[CUSTOMER][NEUTRAL] Uh huh
[CUSTOMER][NEUTRAL] I've got 02290842.
[AGENT][NEUTRAL] OK, thank you, one moment.
[CUSTOMER][NEUTRAL] I've actually got 2 patients. It's granted it's 2 different ID numbers that I'm inquiring on.
[AGENT][NEUTRAL] Mm, OK.
[AGENT][NEUTRAL] Alright. Um, may I have, uh, the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII] um [PII].
[AGENT][NEUTRAL] OK, perfect, thank you. And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Um, [PII], um, and then the bill charges is 23805.
[AGENT][NEUTRAL] OK, um let me see if I can find this one.
[AGENT][NEUTRAL] And I just need to let you know that for future you can check claim status online through our website at [PII] and that's just optional.
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] Let this one.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And so this one was denied that office visits are not covered by the policy and then the rest of the charges, it looks like they were fully paid by the major medical.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Offices it's not covered by policy, OK.
[CUSTOMER][NEUTRAL] So just out of curiosity, um, just because I haven't really messed with this insurance hardly at all if ever to be honest with you, um, so like with it is, is it just like uh like our labs covered or X-rays? is it just that like medical services are not covered or?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Um, no, this one, let me pull the benefits really quick because they're all different, but this one in particular, let's see.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Oh, got you.
[CUSTOMER][NEUTRAL] Because I was just a little curious about because the I mean on the EOB it says product does not have a provider participation at work and I'm like huh.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, that's, that's definitely not our denial.
[AGENT][NEUTRAL] OK. So, um, yeah. So this one has like office treatment, it doesn't have an office treatment rider, which if there's any procedures done in the office, it will cover those, but if it's just the visit itself, which in this case is just the visit, the co-payment for the visit is not covered.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Got you.
[CUSTOMER][NEUTRAL] OK, OK, um, so like procedures if they had like a biopsy or something like that then that would be covered so it's like a so it's almost OK so I think I kinda, I think it kind of makes sense, um.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So like normal like everyday office visits are not covered but like major things such as biopsy because they're obviously like more expensive and stuff like that um would like MRIs or CTs be covered?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm. Yes, yes.
[CUSTOMER][NEUTRAL] OK, OK, so yeah, then that makes more sense um to me um can I give you another policy number and this might be the same thing, um.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Bear with me just a minute. Let me go ahead and finalize the note on this one and then we can move forward to the next one.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK and then um.
[CUSTOMER][NEUTRAL] Do you happen to have a reference number or is it gonna be the same for both?
[AGENT][NEUTRAL] Yeah, it's gonna be my name and today's date um we don't have numbers.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Uh-huh. OK.
[AGENT][NEUTRAL] And you already have the claim number, you don't need the claim number?
[CUSTOMER][NEUTRAL] Yes, yeah, I already have that like I said, I was just.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Confused
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK. It's all right. I understand.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. All right. What's the next policy number?
[CUSTOMER][NEUTRAL] Um, that is 02341128.
[CUSTOMER][NEUTRAL] And that's for an [PII] Blackford 72464.
[AGENT][NEUTRAL] OK. And what is the date of service on this one?
[CUSTOMER][NEUTRAL] Um, [PII] and the total charge is $201. It's for some lab work.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That was [PII] and [PII].
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] Of [PII].
[AGENT][NEUTRAL] OK, uh, let me look at the benefits on this one.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So this one doesn't have the office treatment writer.
[AGENT][NEGATIVE] So it was denied stating that the service rendered in office is not covered.
[CUSTOMER][NEUTRAL] OK, so like basic labs then and office visits are not covered. It's just like the other one it was procedures like CTs, MRIs those major stuff is covered, but normal like lab work's not.
[AGENT][NEUTRAL] Um, not exactly. Um, OK, so this one in particular, because, like I said, they're all different, that's why we have to call them because they're all different. But, um, this one in particular, I'm looking at it, this one doesn't have the office treatment riders, so that means that all the procedures and treatments are not going to be covered on this one, but this one does have an independent life facility rider.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Uh huh
[AGENT][NEGATIVE] So if the charges of the lab was in a third party like Quest or the lab corp or anything like that, it would have been considered but since it was in the office and it was charged by the office, it's not covered.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Oh, OK, so office labs are not covered for his, so we would have had to.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Any procedure done in the office will not be covered on this one.
[CUSTOMER][NEUTRAL] OK, so any, so as far as any procedure you're talking about like MRIs or CTs maybe?
[AGENT][NEUTRAL] Any
[AGENT][NEUTRAL] Anything done in office is not gonna be covered. If he needs an MRI, a CT scan or anything like that, he needs to go to an outpatient facility, correct. Yes. Mhm.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] We would have to send him somewhere else.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Yeah. So for this one, nothing. For the other one, yes.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Well,
[AGENT][NEUTRAL] But no office visit.
[CUSTOMER][POSITIVE] Well, that's interesting.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] All right, well, luckily this one's just from November the other one is from June.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So, all right then, well, I will definitely put those notes on the patient's account.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so we're if that that we can send out lab work and so then it'll be covered.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, yeah, this one from Miss [PII]. If it's sent to a, uh, independent lab, it will be considered, but if it's done in the office, it will not, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Got you alright well thank you.
[AGENT][NEUTRAL] You're welcome. Is there anything else I may help you with today, Ms. [PII]?
[CUSTOMER][NEUTRAL] No, that's it.
[AGENT][POSITIVE] OK, thank you for calling ATL. Have a good day, Ms. [PII]. You're welcome. Thank you. Bye-bye.
[CUSTOMER][POSITIVE] Thanks you too bye bye.