AccountId: 011433970860
ContactId: 0e2fb970-aa87-4526-bfab-483647a46352
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 457980 ms
Total Talk Time (AGENT): 198359 ms
Total Talk Time (CUSTOMER): 142279 ms
Interruptions: 3
Overall Sentiment: AGENT=0.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/09/0e2fb970-aa87-4526-bfab-483647a46352_20250509T19:19_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], it's [PII]. How are you?
[AGENT][NEUTRAL] I'm, I'm fine. I'm sorry, what was your name?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] OK, moving. Thank you. And how can I help you today?
[CUSTOMER][NEUTRAL] Uh, I have a patient and I need to confirm the claim status. Could you help?
[AGENT][NEUTRAL] OK, you have one patient that you're needing to check claim status on, is that correct? Yes, I, yes, I can help you with that, Move, and what is your callback number?
[CUSTOMER][POSITIVE] Yes. Yes. Yes.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, thank you. And the member's policy number, please?
[CUSTOMER][NEUTRAL] It's 02505495.
[AGENT][NEUTRAL] OK, thank you, one moment.
[AGENT][NEUTRAL] And then any information that I can provide for you today would be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII]. Date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And what is the data service and total bill amount for her place?
[CUSTOMER][NEUTRAL] Data service is 723-2024 and total charge amount is $300.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, my, this is, this claim has been received more than once. The most recently received claim was denied as a duplicate. Do you need that information or the claim that was received initially prior to that?
[CUSTOMER][NEUTRAL] OK, uh
[CUSTOMER][NEUTRAL] I know about that. The initially claim was denied, but we have, uh, sent a corrected claim. So why the claim was denied due to duplicate.
[AGENT][NEUTRAL] We've received it 3 times.
[CUSTOMER][NEUTRAL] Uh, let me check that.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And the last time was denied just a duplicate. Mhm.
[CUSTOMER][NEUTRAL] Initially, the claim was denied.
[CUSTOMER][NEUTRAL] OK. Uh, you said you received this claim 3 times initially claim was denied. So could you confirm what the status for the 2nd time claim did you receive?
[AGENT][NEGATIVE] It is also denied.
[CUSTOMER][NEUTRAL] Uh, what's the reason for the second time denial?
[AGENT][NEUTRAL] And the 2nd time was the exact same reason as the 1st.
[AGENT][NEUTRAL] The policy, it states on here, I'm sorry, the denial reason states the outpatient treatment benefit provides an indemnity amount when a covered person receives treatment in an emergency room, urgent care facility, physician's office, or a physical speech or occupational therapy facility. Treatment in an outpatient hospital less than 18 hours is not covered by this policy.
[CUSTOMER][NEUTRAL] K
[CUSTOMER][NEUTRAL] You said less than 18 hour.
[CUSTOMER][NEUTRAL] Right.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK, sure. Uh.
[CUSTOMER][NEUTRAL] Could you provide me the updated claim number? So I'll send a corrective claim on that one. So did you provide me the updated claim number?
[AGENT][NEUTRAL] 353.
[AGENT][NEUTRAL] Mhm. 36167.
[CUSTOMER][NEUTRAL] 353
[CUSTOMER][NEUTRAL] OK, this one is updated claim number?
[AGENT][NEUTRAL] That is correct. And then the other claim number that was denied is a duplicate is 3,558,980.
[CUSTOMER][NEUTRAL] OK, uh, the thing is that.
[CUSTOMER][NEUTRAL] Uh, you have provided me the 353-6167, the claim number, and we have submit a credited claim on this one also on [PII]. So, could you confirm, did you receive that one?
[AGENT][NEUTRAL] So, that's the
[CUSTOMER][NEUTRAL] After [PII]?
[AGENT][NEGATIVE] That was denied as a duplicate.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] You provide me the claim number 3536167. On this claim um claim number, we already submitted a corrected claim number.
[AGENT][NEUTRAL] That's correct. That's the 2nd 1.
[AGENT][NEUTRAL] OK, and I was denied as a duplicate.
[CUSTOMER][NEUTRAL] This one is the 2nd 1 claim number.
[AGENT][NEUTRAL] Yes, sir.
[AGENT][NEUTRAL] The first claim was received under claim 352595-3.
[CUSTOMER][NEUTRAL] OK, what
[AGENT][NEUTRAL] The second claim was the 353-6167, and the most recent is 3,558,980.
[CUSTOMER][NEUTRAL] 355
[AGENT][NEUTRAL] 8980 is the most recent received and denied as a duplicate.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure. Uh, could you check that because, uh, we have changed the place of service in this claim. So why this claim was duplicate with previous one?
[AGENT][NEUTRAL] If you have any, if you would like to file an appeal, you have the option to do that and an appeal must be filed within 180 days from the date of the decision.
[CUSTOMER][NEUTRAL] OK, so could you confirm the last decision when you're taken?
[AGENT][NEUTRAL] I'm sorry, the last claim that was denied as a duplicate was on 23.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] 2320 25th.
[AGENT][NEUTRAL] And the second the other.
[CUSTOMER][NEGATIVE] It's already denied to TFL.
[AGENT][NEUTRAL] Mhm. That's the most recent received claim.
[CUSTOMER][NEUTRAL] OK, uh,
[CUSTOMER][NEUTRAL] Sure. Uh, could you provide, provide me the fax number where I send uh
[CUSTOMER][NEUTRAL] Appeal
[AGENT][NEUTRAL] It needs to be put to attention appeals department.
[AGENT][NEUTRAL] This must be sent to [PII].
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] That is correct.
[CUSTOMER][POSITIVE] Perfect. Could you spell your name, please?
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] And then if you need a copy, i[PII]'s my name and today's date, and if you need a copy moving of any of these claim numbers, you can go to our portal at [PII] and you should be able to print those.
[CUSTOMER][NEUTRAL] And what's the call reference number?
[CUSTOMER][POSITIVE] Perfect. And what's the call reference number?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] My name and today's date.
[CUSTOMER][POSITIVE] Perfect. Thank you. Have a good day.
[AGENT][POSITIVE] Well, you too, if that's all I can help you with. Thank you again for calling APO and I hope you have a nice weekend as well.
[CUSTOMER][NEUTRAL] You too. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye-bye.