AccountId: 011433970860
ContactId: 0bd5b0aa-9939-46c7-a5d9-0b3af708e2a7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1719780 ms
Total Talk Time (AGENT): 381109 ms
Total Talk Time (CUSTOMER): 336130 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/06/0bd5b0aa-9939-46c7-a5d9-0b3af708e2a7_20250506T19:12_UTC.wav
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[AGENT][NEUTRAL] Good afternoon thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello, this is [PII] calling from provider's office to check up on a claim status. Also, this call is being recorded for quality and training purposes. Are you OK with that?
[AGENT][NEUTRAL] Yeah and spell your name for me please.
[CUSTOMER][NEUTRAL] Yeah, it's [PII] would be [PII]. Also, can you spell out your name for me?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Uh.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] And [PII], what is your callback number? You're welcome.
[CUSTOMER][NEUTRAL] Yeah, it would be [PII].
[AGENT][NEUTRAL] Thank you. And you're needing claim status for one patient, is that correct?
[CUSTOMER][NEUTRAL] Oh yeah, actually I do have concern with this claim.
[AGENT][NEUTRAL] OK, so you already have the claim number, you just have a question regarding the claim, is that correct?
[CUSTOMER][POSITIVE] Yeah, that's right.
[AGENT][NEUTRAL] Yes, I can help you. And what is the policy number that you're calling?
[CUSTOMER][NEUTRAL] And I, I.
[CUSTOMER][NEUTRAL] And I do have 3 claims with me, but it's for the different members.
[AGENT][NEUTRAL] OK, so you're gonna use my name along with today's date as each of your call reference numbers, any information that I provide for you on any of the claims will.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Be a verification of benefits and not a guaranteed payment. And lastly, if you need a copy of any of the explanation of benefits, once you have the claim number, you can print them directly from our portal yourself by going to [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is your first patient's policy number Pirana?
[CUSTOMER][NEUTRAL] Yeah it's 018261.
[CUSTOMER][NEUTRAL] 70 M as in Mike L as in Lima 8.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Your member's name would be [PII] and the date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And what is the date of service and total bill amount for her place?
[CUSTOMER][NEUTRAL] It's [PII] and the total charge would be $3500 even.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, and the claim number?
[CUSTOMER][NEUTRAL] It's 356-450-9.
[AGENT][NEUTRAL] OK, thank you. So, yes, that claim was denied as a duplicate. This claim has been received multiple times.
[CUSTOMER][NEUTRAL] Yeah, actually, uh, initially it was denied for primary GOB, right?
[AGENT][NEUTRAL] Uh, yes, under claim number 3515509.
[CUSTOMER][NEUTRAL] Uh, yeah, and we have actually submitted primary UB to you on [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Also, once we received a denial from you stated uh claim has been paid to the provider.
[AGENT][NEUTRAL] Claim number?
[CUSTOMER][NEUTRAL] Yeah, just give me a moment. I'm just.
[CUSTOMER][NEUTRAL] Getting the claim number.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Yeah, the claim number was?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] 356-450-9 is the same actually.
[AGENT][NEUTRAL] That's denied as a duplicate. So we did receive the explanation of benefits that had previously been requested and that claim was processed under claim number 3541622.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] That EOB was received on [PII] and processed on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the benefit paid $200.
[AGENT][NEUTRAL] And that was paid on single trip. 20185557.
[AGENT][NEUTRAL] And if you could verify the address, please?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] The address is [PII].
[AGENT][NEUTRAL] That is the address.
[AGENT][NEUTRAL] You said, and you said there's a, what was the sweet again? I'm sorry.
[CUSTOMER][NEUTRAL] Uh, can I repeat the address?
[AGENT][NEUTRAL] I don't need the entire address. I need the suite number.
[CUSTOMER][NEUTRAL] Oh, it was [PII].
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK just a moment and let me look at something.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] It's still trying to load what I'm something.
[AGENT][NEUTRAL] OK, so.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So that is the address on the home, but the H1 is not on the claim form that we received.
[AGENT][NEUTRAL] There is no suite number on this claim.
[CUSTOMER][NEUTRAL] OK so.
[CUSTOMER][NEUTRAL] On
[CUSTOMER][NEUTRAL] Yeah, just give me a moment.
[CUSTOMER][NEUTRAL] Yeah, actually the address um.
[CUSTOMER][NEGATIVE] Then the address is actually incorrect as you said the suite number was not mentioned on the claim form.
[CUSTOMER][NEUTRAL] I have already gave you the correct address so can you just uh send the claim back for to.
[AGENT][NEUTRAL] Yes, ma'am, but
[CUSTOMER][NEUTRAL] Or reissue the check on the to the correct address.
[AGENT][NEUTRAL] I can, I can, OK. Again, the address on the claim does not have the suite number.
[CUSTOMER][NEUTRAL] Yeah, I've already gave you the suite number. It is [PII].
[AGENT][NEUTRAL] Yes, ma'am, but I can't just add that. Correct. I can't just add that in.
[AGENT][NEUTRAL] We would need to receive corrected information with the correct information on it.
[CUSTOMER][NEUTRAL] So the uh whole address is correct only the suite number was not mentioned in that, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK, um, just give me a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You said the claim has been paid on [PII]?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] OK, sure, no problem. Thank you so much.
[AGENT][NEUTRAL] OK, so do you want me to send a request to have this
[AGENT][NEGATIVE] Approved to void and reissue to the same address we issued it to before.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, do you mind letting me place you on a brief hold?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yes
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you very much Peron for holding. So do you want me to submit a request to our financial department to have this
[AGENT][NEUTRAL] Verify that it is still outstanding and void and reissue.
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK, so that's gonna take me a few minutes to do that. So just um bear with me.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] I'm still working on your request for [PII] to have this submitted for review.
[CUSTOMER][POSITIVE] Thank you. Uh, also, can you help me with the turnaround time?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Uh, you're gonna need to allow, it's still gonna take 7 to 5 to 7 business days.
[CUSTOMER][NEUTRAL] 527
[AGENT][NEUTRAL] Business days.
[AGENT][NEUTRAL] And then you wouldn't and if it's approved to be voided and reissued, then you would need to allow another 10 business days to be received.
[CUSTOMER][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] And do you need, I have just submitted that request. Do you need any additional information on this member's policy, Pirana?
[CUSTOMER][NEGATIVE] Uh, no thank you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And do you, what is your next patient's policy number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It would be 02.
[CUSTOMER][NEUTRAL] 046820
[CUSTOMER][NEUTRAL] M as in Mike. L as in Lima. 8.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And your patient's name and date of birth.
[CUSTOMER][NEUTRAL] Member's name is [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Data service and total bill amount, please.
[CUSTOMER][NEUTRAL] Data services [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The total charge is $1,872.47.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, and the claim number?
[CUSTOMER][NEUTRAL] Uh, actually I don't have a claim number with me.
[CUSTOMER][NEUTRAL] I need general claim status.
[AGENT][NEUTRAL] You need general claim status on this data service. OK, just a moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so this client was received on [PII].
[AGENT][NEGATIVE] It was processed and denied on [PII].
[AGENT][NEUTRAL] The claim number is 359.
[AGENT][NEUTRAL] 245 5.
[AGENT][NEUTRAL] And the reason for the denial on this claim?
[AGENT][NEUTRAL] States the above reference claim appears to be a duplicate of previously submitted expenses. Benefit payment has been made to the insured.
[CUSTOMER][NEUTRAL] OK, you mean to say the number was already built this claim to you?
[AGENT][POSITIVE] That is correct. It's
[CUSTOMER][POSITIVE] And it was paid as well.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so do you have any details like when was the member bill this claim or anything?
[AGENT][NEUTRAL] No
[AGENT][NEUTRAL] No, ma'am. I can't provide, yes, ma'am. It was prior to your claim being received. I can't provide any additional information. You would have to contact the member with any further questions.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] No problem, that's fine.
[AGENT][NEUTRAL] And do you need any other information for on this claim on this policy?
[CUSTOMER][NEUTRAL] Uh, no, not for this number.
[AGENT][NEUTRAL] OK. And you said that you had one more. Is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The next policy ID.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] S. 02.
[CUSTOMER][NEUTRAL] 2818
[CUSTOMER][NEUTRAL] 90 M as in Mike L as in Lima 8.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you, one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the date of service and total bill amount please.
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the total charges $905 even.
[AGENT][POSITIVE] Thank you. One moment.
[AGENT][NEUTRAL] OK, so this claim was received on [PII].
[AGENT][NEUTRAL] It was processed on [PII].
[AGENT][NEUTRAL] The claim number is 359.
[AGENT][NEUTRAL] 232 9.
[AGENT][NEUTRAL] And this claim has been denied at this point?
[AGENT][NEUTRAL] We need the primary insurance company's explanation of benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, sure. No problem. I can submit the prime view over to you. Uh, I just need to confirm the fax number. Is it [PII]?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Attention claims department.
[CUSTOMER][POSITIVE] OK, thank you so much for your help, [PII].
[AGENT][POSITIVE] You're welcome. Yes, ma'am. And is there anything else that I can help you with today?
[CUSTOMER][NEUTRAL] Uh, can you just help me with the information like, uh, if you have any appeals and the filing limit.
[AGENT][NEUTRAL] An appeal must be filed within 180 days from the date of the decision.
[AGENT][NEUTRAL] And it must be sent to the same address as claims but put to attention appeals department.
[CUSTOMER][NEUTRAL] 180 days from the determination date.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] From the determination date. Mhm.
[AGENT][NEUTRAL] From the decision date.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And is there any time filing limit?
[AGENT][NEUTRAL] Yes, they must be filed within.
[CUSTOMER][NEUTRAL] For the clean?
[AGENT][NEUTRAL] An initial claim does not have, there's no TSL for an initial filing. An appeal must be filed in writing within 180 days from the date of the decision and sent to the appeals department.
[CUSTOMER][POSITIVE] Sure, no problem. Thank you so much for your help. That's it for the day.
[AGENT][POSITIVE] OK. Well, if that is all that I can help you with, [PII], thank you again for calling APL and I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] Bye bye take care.
[AGENT][POSITIVE] Uh, you too. Bye-bye. Thank you.