AccountId: 011433970860
ContactId: 0077feb8-580f-4254-8238-5631b07ab458
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 865859 ms
Total Talk Time (AGENT): 217367 ms
Total Talk Time (CUSTOMER): 158475 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=-0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/01/0077feb8-580f-4254-8238-5631b07ab458_20250401T19:42_UTC.wav
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[AGENT][POSITIVE] Thank you for calling
[AGENT][NEUTRAL] This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII]. Last name initial is [PII] calling from provider's office to check up on a claim denial. Could you help me with that?
[AGENT][NEUTRAL] Uh yes [PII], I can help you with the claim. Can you please give me your callback number, sir?
[CUSTOMER][NEUTRAL] Sure, his callback number is [PII] direct line.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Thank you, sir. And then what is the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] We
[CUSTOMER][NEUTRAL] Patient's name is [PII]. Date of birth is [PII]. Policy number is 1426388 M as in Mike, L as in Lima 8.
[AGENT][NEUTRAL] OK, let me pull that policy up real quick.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, and then can you please give me the date of service?
[CUSTOMER][NEUTRAL] The service is [PII]. The amount is $2642 even.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] $264 even.
[CUSTOMER][NEUTRAL] No, $2,0642 even.
[AGENT][NEUTRAL] OK, and then what's the charge amount after the primary insurance paid their part?
[CUSTOMER][NEUTRAL] Sure. After the primary insurance pay the part.
[CUSTOMER][NEUTRAL] Uh, it's, it's the same.
[AGENT][NEUTRAL] OK. And what is the name of the facility you're calling from?
[CUSTOMER][NEUTRAL] Are you
[CUSTOMER][NEUTRAL] Pediatrics Medical Group of Florida INC.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] OK, I'm gonna put you on a brief hold while I look this claim up [PII] and I'll be right back with you.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][POSITIVE] Thank you, sir.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 3.
[AGENT][NEUTRAL] [PII], you mentioned that the claim was denied. Do you have the claim number?
[CUSTOMER][NEUTRAL] Uh, sure, the claim number is going to be 3497503.
[AGENT][NEUTRAL] OK, let me look that up because I'm not showing any active policies for this insured at this time, but let me check real quick.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Oh, I'm gonna put you on a brief hold again. I'll be right back.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 243-072-4.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, [PII], this is [PII] back with you again. Let me give you the good policy number that claim is on.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It is 243.
[AGENT][NEUTRAL] 0724.
[CUSTOMER][NEUTRAL] 243-0724 yeah I got it.
[AGENT][NEUTRAL] Yes, sir. And as you know, the claim was denied and the claim was denied because office visits are not covered for the patient's policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And both um.
[CUSTOMER][NEUTRAL] And for this we sent them a bill.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, for this we sent an appeal on [PII]. Could you check the status of the appeal?
[AGENT][NEUTRAL] And did you send the appeal for that policy number that I just gave you?
[AGENT][NEUTRAL] Or did you send the appeal for the OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Alright, let me look.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And what day did you send it?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, let me look.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK. It looks like the appeal is still in process.
[AGENT][NEUTRAL] I don't have any remarks that I can see about the appeal.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] But upon checking, we got an uphill letter that was uphelled.
[AGENT][NEUTRAL] OK, so you're saying that you guys sent in an appeal, but I don't have any remarks about the appeal that I can see. So what I'm going to need to do is um I can get the lady that does the appeals to give you a call back.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] If you can give that that phone number.
[CUSTOMER][NEUTRAL] That's fine. OK, could you fax me, could you fax the EOB?
[AGENT][NEUTRAL] Yeah, I can fax you the EOB.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What is your fax number?
[CUSTOMER][NEUTRAL] 954333.
[CUSTOMER][NEUTRAL] 354 3
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold while I get that um EOB faxed over to you. I'll be right back.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK, thank you for holding for me [PII]. I've got that EOB on the way to you now.
[CUSTOMER][NEUTRAL] OK, when will it reach?
[AGENT][NEUTRAL] It's been sent, so it should be there probably in the next 5 or 10 minutes. Just give it a chance to go through.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][POSITIVE] Sure, thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] I have uh one more claim for different member. Could you check that claim?
[AGENT][NEUTRAL] OK, let me put my notes on this one and then we'll move on to the next one.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, what's the next member's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Member's name is going to be [PII]. Date of birth is.
[CUSTOMER][NEUTRAL] [PII]. Yeah, policy number is 018.
[CUSTOMER][NEUTRAL] 45835.
[AGENT][NEUTRAL] OK, let me pull up that policy real quick.
[AGENT][NEUTRAL] OK, and then what is the date of service and the charge amount?
[CUSTOMER][NEUTRAL] Actually, uh.
[CUSTOMER][NEUTRAL] Charge amount is 613 date of service is [PII]. The amount is $93.85 even.
[AGENT][NEUTRAL] OK, and then what's the charges after the primary insurance paid their part?
[CUSTOMER][NEUTRAL] Uh, the charge amount is $232 even.
[AGENT][NEUTRAL] $232 and that's before primary or after primary paid?
[CUSTOMER][NEUTRAL] That's the full charge amount before and after primary.
[AGENT][NEUTRAL] OK, it's not, it's not $93.85.
[CUSTOMER][POSITIVE] Yes, correct.
[AGENT][NEUTRAL] OK. All right. And what's the name of the facility?
[CUSTOMER][NEUTRAL] Pediatrics Medical Group of Florida INC.
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold while I look up that claim. I'll be right back sir.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding for me, [PII]. I have the claim for you. The claim number is 3491912.
[AGENT][NEUTRAL] And the claim was denied because the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Thank you. So for this kind of denials, how many appeals can be sent?
[AGENT][NEUTRAL] You send one appeal.
[AGENT][NEUTRAL] And then it goes through the appeal process, but per the patient's policy, the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Thank you. So, yeah, that's all from my end. Uh, what's the call reference number?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Yes sir, you can use my name [PII] and today's date.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] Thank you, [PII]. Have a great day.
[AGENT][POSITIVE] You too, [PII]. Thank you for calling APL. I hope you have a good day also. Bye bye sir.