AccountId: 011433970860
ContactId: fb1128aa-73a2-40f3-947f-9f718e9a67a4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 401019 ms
Total Talk Time (AGENT): 177566 ms
Total Talk Time (CUSTOMER): 110473 ms
Interruptions: 1
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/27/fb1128aa-73a2-40f3-947f-9f718e9a67a4_20250127T16:00_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, good morning. My name is [PII] with Titus Regional Medical Center. I'm calling for a claim status and how do you spell your first name?
[AGENT][NEUTRAL] OK. My name is [PII]. That's [PII]. Last initial [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] You're welcome. And may I have a callback number just in case we get disconnected Miss [PII].
[CUSTOMER][NEUTRAL] It's, yes, it's [PII].
[AGENT][NEUTRAL] OK, thank you. And you said you would need claim status. All right, I'm sure I can assist you with that. And may I have the policy number Miss [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's 02421577.
[AGENT][NEUTRAL] OK. May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] It's [PII] and that's [PII].
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Thank you. And may I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] It is [PII], and that's $1,354.46.
[AGENT][NEUTRAL] OK, thank you. Let me check and see if we have it and that was [PII], correct?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me check on this one. And for future, you can check claim status online through our website at [PII] and that's just optional. You can always call and you said the amount is $1,654.46?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] $1,354.46.
[AGENT][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] I have the claim number.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] 202
[CUSTOMER][NEUTRAL] 501080112
[CUSTOMER][NEUTRAL] And actually there we submitted it twice so there's two claim numbers.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] What's the other one because that claim number is not ours.
[CUSTOMER][NEUTRAL] 202-409-090826.
[AGENT][NEUTRAL] OK, yeah, that's not ours either. All right, um.
[AGENT][NEUTRAL] Let me look at this document, bear with me.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this is for an ER visit?
[CUSTOMER][NEUTRAL] Um, let me check.
[CUSTOMER][NEUTRAL] Yes, it is.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] OK, I'm waiting on the explanation of benefits to pull up. It looks like we processed on the [PII] of this month.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] OK. So we did process on the [PII] [PII] and the claim was denied. The reason for this denial is the outpatient rider only allows payment for outpatient surgery. So there's no benefits for this for this claim, for this service.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] As policy only allows payment for outpatient services.
[AGENT][NEUTRAL] Based on the policy.
[AGENT][NEUTRAL] For outpatient surgery only.
[CUSTOMER][NEUTRAL] What else?
[CUSTOMER][NEUTRAL] For outpatient surgery. Emergency room not covered.
[AGENT][NEUTRAL] Not covered, correct.
[CUSTOMER][NEUTRAL] OK, so let me look at this patient's surgery. Let's see what they.
[CUSTOMER][NEUTRAL] OK. And so what are you showing her? So, and labs are not covered either, correct? If the labs are related to outpatient surgery, so ER and labs are not covered.
[AGENT][NEGATIVE] No, no.
[AGENT][NEUTRAL] Mm, no.
[CUSTOMER][NEUTRAL] OK, and what the patient is responsible for the entire amount.
[AGENT][NEUTRAL] This is a limited hospital indemnity plan. It is not a major medical. It is a limited policy. We don't know if they have any other policies out there, so it's up to the provider's discretion. We don't have any contractual involvement on the remaining.
[CUSTOMER][NEUTRAL] OK, OK, so.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and do you have a call reference number?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will. Do you need the spelling of my name or any other information, Miss [PII]?
[CUSTOMER][NEUTRAL] No, and then I noticed um I just wanna make sure those claim numbers that I gave to you, um, which one was correct?
[AGENT][NEUTRAL] Oh, those are not ours. I can give you the correct claim number with ours.
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK, the claim number for APL is 3553262.
[CUSTOMER][NEUTRAL] And where do those because I'm wondering where those claims come from you, you, you don't know where they came from. They just, and it could be that it could just through our clearing house our clearing house may be assigned those claim numbers.
[AGENT][NEUTRAL] More, more than likely it's gonna be through IMA. This particular policy is um they do the repricing through IMA and if there's like any preventative, they go ahead and process before we do and then they send it to us. So that's how they usually um work and that's probably why you have an explanation of benefits or a claim number for IMA.
[CUSTOMER][NEUTRAL] OK. Mhm. OK.
[CUSTOMER][NEUTRAL] And IMA is that that's not imagine correct?
[AGENT][NEUTRAL] No, I IMA is gonna be, um, it's, it's a different company, but they just handle preventative or repricing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, so I'll say I am a claim number. OK, OK, thank you so much, so you have been very helpful. I hope you have a great day.
[AGENT][NEUTRAL] I am mhm.
[AGENT][POSITIVE] You're welcome. No problem. You as well, Ms. [PII], and thank you for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] OK.