Modulate
Review Queue

Health member appeals denied MRI claim after urgent back pain referral

Customer
Support specialist
0:00
12:48
0:00
0:00

Behaviors

Speaker Behavior Model reasoning Confidence
Customer Service Representative Issue Not Resolved
The representative continues verification and account review, but does not provide a concrete follow-up commitment, ownership handoff, or confirmed resolution for the caller's issue.
Thank you, Mr. Mercer. For verification, can you confirm the phone number and email we have on file: 614-555-0198, and daniel.mercer82@protonmail.com? I see your plan is under policy number PPO-77-194402, and the primary care physician listed is Dr. Elena Ruiz at Buckeye Family Clinic, 903 East Main Street, Columbus, Ohio 43205. I was told the MRI appeal would be reviewed within two business days, but it has now been over a week and I still have no decision.
75%
Customer Complaints
The customer raises an unresolved claims and medication issue, giving corrected contact details while continuing to seek action from the support specialist.
Yes, that's right, although my new callback number is 380-555-4412, and my employer is Harrison Industrial Company at 2150 Fisher Road, Columbus, Ohio.
86%
Issue Not Resolved
The customer describes an unresolved claim and denied prescription, then continues supplying corrected information without receiving confirmation that either issue has been closed.
Yes, this is Daniel Andrew Mercer. The last four of my Social Security number are 4421, and my member ID is GVH-88394127. Yes, that's right, although my new callback number is 380-555-4412, and my employer is Harrison Industrial Company at 2150 Fisher Road, Columbus, Ohio. I see your plan is under policy number PPO-77-194402, and the primary care physician listed is Dr. Elena Ruiz at Buckeye Family Clinic, 903 East Main Street, Columbus, Ohio 43205.
82%
Coercion Manipulation
The customer applies pressure by linking corrected contact and employer details to the denied care issue, keeping the representative focused on the appeal path.
Yes, that's right, although my new callback number is 380-555-4412, and my employer is Harrison Industrial Company at 2150 Fisher Road, Columbus, Ohio.
71%

Transcript

0:00 Customer Service Representative Neutral English American accent

Thank you for calling Green Valley Health member services. This is Mina speaking on a recorded line. Can I confirm I'm speaking with Daniel Mercer, born July 18, 1982, and living at 4827 Willow Creek Drive, Apt 5B, Columbus, Ohio 43215?

0:18 Customer Calm English American accent

Yes, this is Daniel Andrew Mercer. The last four of my Social Security number are 4421, and my member ID is GVH-88394127.

0:32 Customer Service Representative Issue Not Resolved 75% Confident

Thank you, Mr. Mercer. For verification, can you confirm the phone number and email we have on file: 614-555-0198, and daniel.mercer82@protonmail.com?

0:47 Customer Complaints 86% Disappointed

Yes, that's right, although my new callback number is 380-555-4412, and my employer is Harrison Industrial Company at 2150 Fisher Road, Columbus, Ohio.

1:00 Customer Service Representative Issue Not Resolved 75% Interested

I see your plan is under policy number PPO-77-194402, and the primary care physician listed is Dr. Elena Ruiz at Buckeye Family Clinic, 903 East Main Street, Columbus, Ohio 43205.

1:24 Customer Disappointed

I was told the MRI appeal would be reviewed within two business days, but it has now been over a week and I still have no decision.

1:48 Customer Service Representative Neutral

The appeal is still pending in our system. I cannot confirm a review date or connect you directly with the clinical review team.

2:11 Customer Frustrated

This is the third time I have called. My physician marked the referral as urgent, and nobody has explained what is still missing.

2:36 Customer Service Representative Concerned

I can add another note to the case, but I do not have a confirmation number or a specific follow-up time to give you today.