AccountId: 011433970860
ContactId: 0c01db27-5862-4800-bdf7-1d75ea76c3b2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1448239 ms
Total Talk Time (AGENT): 311022 ms
Total Talk Time (CUSTOMER): 389521 ms
Interruptions: 2
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/31/0c01db27-5862-4800-bdf7-1d75ea76c3b2_20250331T18:41_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII] and I'm calling for the provider, Morgan time to check on a claim status. Please be informed this call has been recorded and monitored for training and quality purposes. May I know if I can help you with the patient's information or the provider's information?
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Um, yeah, OK, so I can definitely check a claim for you [PII]. Uh, can I first get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]. It's a direct line or extension.
[AGENT][NEUTRAL] OK, thank you and then uh did you have that policy number?
[CUSTOMER][NEUTRAL] I I do that.
[CUSTOMER][NEUTRAL] Policy number?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] No, uh, do you mean to say the claim number?
[AGENT][NEUTRAL] Um, if you have a claim number I can look that way as well.
[CUSTOMER][NEUTRAL] All right. That is E as in Echo.
[CUSTOMER][NEUTRAL] 500
[CUSTOMER][NEUTRAL] 907
[CUSTOMER][NEUTRAL] 315908.
[AGENT][NEUTRAL] OK, uh, that's that's gonna be way too long to be one of our claim numbers then, um, do you have this member's social security number? I can try searching for them that way.
[CUSTOMER][NEUTRAL] Can you search with the member ID?
[AGENT][NEUTRAL] The member ID?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] It's 025.
[CUSTOMER][NEUTRAL] 09909.
[AGENT][NEUTRAL] OK, and what was the name and date of birth for this number?
[CUSTOMER][NEUTRAL] The patient name is [PII].
[CUSTOMER][NEUTRAL] Last name [PII] and the date of birth?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that. Alrighty, uh what was the date of service for this claim?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that bill out, please?
[CUSTOMER][NEUTRAL] Sure, one moment. OK, I will give you.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] It's $1,203 550 cents.
[AGENT][NEUTRAL] That was $1,205.50.
[CUSTOMER][NEUTRAL] $1,203.50. 120,350.
[AGENT][POSITIVE] Got it thank you one moment.
[AGENT][NEUTRAL] What was the name of the provider's office this was with then?
[CUSTOMER][NEUTRAL] Provider's name is Morgan [PII].
[AGENT][NEUTRAL] Do you have that tax ID?
[CUSTOMER][NEUTRAL] Sure, [PII].
[CUSTOMER][NEUTRAL] 329
[CUSTOMER][NEUTRAL] 907.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] It's the same part.
[CUSTOMER][NEUTRAL] for
[CUSTOMER][NEUTRAL] Are you
[AGENT][NEUTRAL] OK, I appreciate your patience then. The only claim that I have for this state of service for this number, it is from the same provider. Uh, however, that bill amount is $1,103 even.
[CUSTOMER][NEUTRAL] $1,103.
[AGENT][NEUTRAL] Correct. That's the only claim I have on file for this member for that date of service.
[CUSTOMER][NEUTRAL] See you
[CUSTOMER][NEUTRAL] All right, let me check.
[CUSTOMER][NEUTRAL] Yes, ma'am. I'm looking for, for the same claim. $1,103.
[AGENT][NEUTRAL] OK, so this is the correct claim. OK, got it, one moment.
[AGENT][NEUTRAL] OK, so for this claim, we were unable to pay a benefit as this policy provides no benefits for the treatment of conditions other than a sickness or an injury.
[AGENT][NEUTRAL] If you'd like, I can send you a copy of this EOB.
[CUSTOMER][NEUTRAL] So this claim is denied, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] As uh no benefits for the treatment of condition other than sickness or an injury.
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] All right, thanks so much. One moment.
[CUSTOMER][NEUTRAL] All right, thank you for the line. So, as it, it is uh not covered under the patient's policy or the provider's contract.
[AGENT][NEGATIVE] It's not covered under this patient's policy.
[CUSTOMER][POSITIVE] All right. Thank you so much. Just one moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So as claim is denied, that the uh it is not covered under the patient's policy. So could you help me with the received date and the denied date?
[AGENT][NEUTRAL] Yes, this claim was received [PII].
[AGENT][NEUTRAL] And it was processed [PII].
[CUSTOMER][NEUTRAL] And they are on the same day, right?
[AGENT][NEUTRAL] Uh, it was, yes, uh, uh, processed and denied on the [PII].
[CUSTOMER][POSITIVE] Alright, thank you so much. One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right. Thank you for holding the line. So, ma'am, as for checking my file, so I, I see that, you know, the claim is denied for policy provider not benefit for the treatment or condition other than sickness or injury.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I just need uh the detailed clarification. So, one moment.
[CUSTOMER][NEUTRAL] All right, one moment, OK.
[AGENT][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] All right. So, uh, thank you for holding the line. I'm really sorry, ma'am. OK. And which CPT code is not covered as per patient's policy?
[AGENT][NEUTRAL] That's OK.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] So may I know which CPD code is not covered and as per patient's policy?
[AGENT][NEUTRAL] All of the codes that were listed.
[AGENT][NEUTRAL] Under this, as it's not a result of a sickness or an injury.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] All the codes are denied, right?
[AGENT][NEUTRAL] Correct. Uh none of them were due to a sickness or an injury.
[CUSTOMER][NEUTRAL] All right, one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right. And what is the time you filing to submit a corrected claim?
[AGENT][NEUTRAL] Um, appeals have to be submitted within 180 days of the process date.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] 10 days from the processed date.
[AGENT][NEUTRAL] 180 days.
[CUSTOMER][NEUTRAL] For both, uh, corrected claim as well as appeal, right?
[AGENT][NEUTRAL] For an appeal, yes.
[CUSTOMER][NEUTRAL] No, no, I'm asking you what is timely filing to submit a corrected claim.
[AGENT][NEUTRAL] Yes, uh, so a corrected claim, there's no timely filing limit if it's for an appeal, that's 180 days.
[CUSTOMER][NEGATIVE] No timely filing for corrected claim.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] All right. And what is the mailing address to submit a corrected claim?
[AGENT][NEUTRAL] That is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that is in [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][POSITIVE] Alright, thank you so much for the information.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hi my name is
[AGENT][NEUTRAL] If you submit an appeal, you have to have a letter included, uh, stating that it is for an appeal.
[CUSTOMER][NEUTRAL] All right. So the address is [PII].
[CUSTOMER][NEUTRAL] All right. And the mailing address to submit a corrected claim would be [PII].
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And for mailing address to submit an appeal would be the same.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] All right. And is there any specific form for appeal?
[AGENT][NEUTRAL] No forms if it's for an appeal, we just need a letter stating that it is indeed an appeal.
[CUSTOMER][NEUTRAL] And is the dinner will be required while you submitting the claim?
[AGENT][NEUTRAL] I'm sorry, what was that?
[CUSTOMER][NEUTRAL] Is it denied explanation of benefit is required while he submitting the claim? Is it mandatory?
[CUSTOMER][NEUTRAL] Where does the dinner you be?
[AGENT][NEUTRAL] Uh, for the appeal? For the appeal, you mean?
[CUSTOMER][NEUTRAL] To submit a claim?
[AGENT][NEUTRAL] Yes, we do need the primary EOB for these claims.
[CUSTOMER][NEUTRAL] All right, one moment.
[CUSTOMER][NEUTRAL] All right. Could you help me with the claim number as well?
[AGENT][NEUTRAL] Yes, that claim number is 3556668.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] 3556668, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] All right, one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right. Could you help me with the next uh
[CUSTOMER][NEUTRAL] Call as well, the claim as well.
[AGENT][NEUTRAL] Is this going to be for the same member?
[CUSTOMER][NEUTRAL] No, it's for a different member.
[AGENT][NEUTRAL] OK, give me just a moment I'll let you know when I'm ready for that next one.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, I'm ready for that next policy number when you are done.
[CUSTOMER][NEUTRAL] The member ID?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] 021
[CUSTOMER][NEUTRAL] 947
[CUSTOMER][NEUTRAL] 52 M as in Mike, L as in Lima, the number 8.
[AGENT][NEUTRAL] OK and then what was the name and date of birth for this number?
[CUSTOMER][NEUTRAL] Name is [PII].
[CUSTOMER][NEUTRAL] Uh the last name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that. What was the date of service for this claim?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that building amount please.
[CUSTOMER][NEUTRAL] Mhm. One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] $382 even, 382.
[AGENT][NEUTRAL] OK thank you one moment.
[AGENT][NEUTRAL] Was this with the same provider?
[AGENT][NEUTRAL] Or is this a different provider?
[CUSTOMER][NEUTRAL] No, it's for a different provider.
[AGENT][NEUTRAL] OK. Do you have that tax ID?
[CUSTOMER][NEUTRAL] 2 to 3
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 487
[CUSTOMER][NEUTRAL] 984.
[AGENT][POSITIVE] OK, thank you for that one moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, so again I don't have a claim for that amount exactly [PII]. I do have one from this provider for that date of service for $369 even.
[CUSTOMER][NEUTRAL] No problem. One moment, let me check.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Uh, was it $369 even?
[AGENT][NEUTRAL] It was a $369 even.
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] All right, one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] There was the claim uh split it because uh
[CUSTOMER][NEUTRAL] I have $13 as well.
[AGENT][NEUTRAL] OK, um, then that claim may be incomplete. This is the only claim I have for this state of service from this provider, and it is for the amount of $369.
[CUSTOMER][NEUTRAL] All right, ma'am.
[CUSTOMER][NEUTRAL] So I just need a payment clarification on this claim.
[AGENT][NEUTRAL] Um, for whatever is missing, um, and I, I can send you this EOB that we have so you can review that.
[CUSTOMER][NEUTRAL] No, no, one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm sorry. I, I'm, I'm really sorry. I was looking for a uh claim status for this claim.
[AGENT][NEUTRAL] Yes, I can still give you the the status for this one. I just wanted to make sure this was the correct claim, um, so we were unable to pay a benefit on this one as well as charges incurred in an independent lab are not covered under this policy.
[CUSTOMER][NEUTRAL] Under the patient policy?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So this denied as per the previous claim, right?
[AGENT][NEUTRAL] Um, it's a different denial reason. Um, this one is, uh, charges incurred in an independent lab are not covered. It's not a covered outpatient facility.
[CUSTOMER][POSITIVE] All right. Thank you so much. One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right, thank you for holding the line. Could you help me with the received it and denied date?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, this claim was received [PII], and it was processed [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And under uh fix CPT code is not covered as per patient policy.
[AGENT][NEUTRAL] Charges incurred in an independent lab are not covered under this policy. It's not a covered outpatient facility.
[CUSTOMER][NEUTRAL] Ma'am, may I know which CPT code is not covered?
[AGENT][NEUTRAL] None of the charges, none of the codes were covered as they were in an independent lab and that's not covered under this policy.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] One moment, OK? I'll just quickly make a note of it.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Right, uh, thank you for holding the line. And the time you calling to submit a corrected claim will be the same as for the previous claim.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEGATIVE] No timely filing period for corrected claim, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] All right, one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I just.
[CUSTOMER][NEUTRAL] And the mailing address would be the same as for the previous claim, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] And you need uh the primary UP, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Alright, could you help me with the claim number for this claim?
[AGENT][NEUTRAL] Um, yes, that claim number is 3581234.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][POSITIVE] Thank you so much. One moment. I have more 3 claims to discuss today.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Could you repeat that? I'm sorry.
[CUSTOMER][NEUTRAL] I have more 3 claims to discuss today. Could you help me with that also?
[AGENT][NEUTRAL] Yeah, so they're for uh different members as well.
[CUSTOMER][NEUTRAL] Yes, it's for a different members.
[AGENT][NEUTRAL] OK, uh, did you need any further information for this claim?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, uh, give me just a moment. I'll let you know when I'm ready, um, to proceed with uh.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Sure.