AccountId: 011433970860
ContactId: 0f508597-0573-4bd9-85ff-17474f116d36
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 280390 ms
Total Talk Time (AGENT): 128969 ms
Total Talk Time (CUSTOMER): 109111 ms
Interruptions: 4
Overall Sentiment: AGENT=1.3, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/12/0f508597-0573-4bd9-85ff-17474f116d36_20250212T16:01_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII] calling for Lake Area Medical Associates. I verified that UV and this call is made for additional information about the denial. Please note call will be recorded and monitored for quality and training purposes.
[AGENT][NEUTRAL] OK and so you're needing additional information on a claim that was denied, is that correct?
[CUSTOMER][POSITIVE] Yes, ma'am. You're right.
[AGENT][POSITIVE] Yes, I can help you with that. And what is your callback number, please?
[CUSTOMER][NEUTRAL] [PII] and it's a direct line?
[AGENT][NEUTRAL] And the member's policy number please, [PII]?
[CUSTOMER][NEUTRAL] Yes, it is for uh 02273700.
[AGENT][POSITIVE] Thank you, one moment please.
[CUSTOMER][NEUTRAL] OK, ma'am.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the information that I do provide for you, [PII] would be a verification of benefits and not a guarantee of payment. What is your patient's name, please, and their date of birth?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What is the data service and total bill amount?
[CUSTOMER][NEUTRAL] 1022 of 2024. And the total bill amount is $179 even. Primary was already paid to this claim and as you're the secondary, we submitted the, to the, the claim to you but you have denied this. Could you please tell me the reason, ma'am?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment. And what is the claim number you said that you had the EOB?
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] Loading one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm, the claim number I here I have is uh 3557322.
[AGENT][NEUTRAL] Yes, that is correct. And on page two of our explanation of benefits, [PII], it does have the remarks that go along with the reason for the denial and this claim was denied, office visits are not covered under this supplemental policy.
[CUSTOMER][NEUTRAL] So office, OK, yeah, office visit not covered that but the above me numbered policy you said. So
[AGENT][NEUTRAL] For the member plan, for the member's policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It is mentioned as a number, so that's the reason we're confused. OK. So as for the member plan, it is not covered. OK, ma'am. Uh, one moment, let me check is there any payment receipt. One second, sorry. Uh simple mistake.
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] Oh, that's OK. And
[CUSTOMER][NEUTRAL] OK. Sorry, ma'am. Once again, it's good. Uh yeah, one moment, ma'am. Let me check if there any payment receipt.
[AGENT][NEUTRAL] OK, and I know.
[CUSTOMER][NEUTRAL] Yeah, one second, please. Sorry. I'm, I'm just checking if there any payment. OK, got it. Thank you. And uh could you please tell me the reconsideration mailing address?
[AGENT][NEUTRAL] It is the same as for to file an appeal, you would use the same address as the claims and put it to attention appeals department and it must be submitted in writing within 180 days from the date of the decision.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. Uh mailing address if you don't mind.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Thank you. And is there any specific form to submit the recitation or we can use the general form?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] No, you just, it needs to be submitted in writing and sent to the appeals department with any additional documentation. There's, yes ma'am, I, no ma'am, there is not a specific form for an appeal.
[CUSTOMER][NEUTRAL] No, no, no. Is there any specific form?
[CUSTOMER][NEUTRAL] I don't know
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEGATIVE] But it must be clearly labeled as an appeal.
[CUSTOMER][NEUTRAL] OK. Call reference number.
[AGENT][NEUTRAL] And the call reference number would be my name in today's date and then also we do have a portal that you can in the future Angel have access to our explanation of benefits and claim status and that website for that is secured. [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you. You have a wonderful day. Bye-bye.
[AGENT][POSITIVE] You're welcome. Yes ma'am, I hope you do too, and thank you again for calling APL.