AccountId: 011433970860
ContactId: 10416d29-9b9a-4f69-ada5-90e365730dd0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 635270 ms
Total Talk Time (AGENT): 257983 ms
Total Talk Time (CUSTOMER): 252597 ms
Interruptions: 3
Overall Sentiment: AGENT=-0.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/10416d29-9b9a-4f69-ada5-90e365730dd0_20250429T18:22_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Um, yes, [PII], my name is [PII], and I work for Doctor [PII], [PII], and we have a patient that has, um, APL insurance, and we tried to submit it and it said that we, um, you guys were unable to find her in your system, and we did verify that she had benefits before we had the procedure so I'm just wondering if I could maybe have the wrong ID number.
[AGENT][POSITIVE] OK. Well, I can definitely um help you try to locate the policy and um provide the benefits and everything for you. And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] I believe the policy number she wrote down let's see 259-617-1.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Her, uh, first name is [PII]. Her last name is [PII], and let's see, her date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. So I am showing um that policy number that you gave, it pulls her policy, um, that's correct, that's the correct policy number.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] From
[CUSTOMER][NEUTRAL] OK, so, hm, weird. OK, um, I guess we will. I'm just wondering, I know that when we verified it said she didn't have oral surgery benefits so.
[AGENT][NEUTRAL] Oh, let me take a look at the benefits. Hold on one moment.
[AGENT][NEUTRAL] And you're looking, you said you're looking for oral surgery benefits?
[CUSTOMER][POSITIVE] That's correct.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, so the policy doesn't cover major expenses, which for us is endoic, periodontic, prosodontic, and oral surgery, um.
[AGENT][NEUTRAL] So there is no major coverage on the policy, but there is a policy here. It covers preventative, basic, and then the FMX and
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, then let me see if I have because so the letter we received says we recently received a claim for the patient listed in this letter we've notified the patient that we are unable to identify this individual as a plan member under any of our plans. Please verify you are sending this claim to your patient's current insurance carrier.
[CUSTOMER][NEUTRAL] Um, and then the letter or the information we have for her.
[CUSTOMER][NEUTRAL] Let's see, so your address we have in is [PII].
[AGENT][POSITIVE] Correct. Mhm.
[CUSTOMER][NEUTRAL] Is that
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hm, so I wonder why.
[AGENT][NEUTRAL] So you received a letter from us saying that there was that we received the claim but no policy was found?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Let's see, hold on one moment.
[AGENT][NEUTRAL] Let me try this one.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] What's the date on that letter?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] OK, wait a minute, [PII].
[AGENT][NEUTRAL] I'm gonna
[AGENT][NEUTRAL] I'm gonna say that and it was for dental?
[CUSTOMER][NEUTRAL] Mhm, yes.
[AGENT][NEGATIVE] Yeah, I'm gonna say to disregard that because she
[CUSTOMER][NEUTRAL] We
[AGENT][NEUTRAL] That policy number that you gave brought it right up and um she does have a policy, it just doesn't have major coverage. So maybe that could have been an error because even when I look um like under all the correspondence that we've like sent out to providers and to them, there's nothing here past [PII], so that may have been an error.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So we did, OK, so then we did um perform the procedure on [PII].
[CUSTOMER][NEUTRAL] And we did surgical extract the code that we did was 7210.
[AGENT][NEUTRAL] Now, the 727,210, I think that's a major code. Hold on one moment.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, that's a major code. Now, that code is not covered on the policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Because there's no major coverage.
[CUSTOMER][NEUTRAL] Yeah, yeah, and we had told her that when we came in we just, um, you know, still wanted to submit it to insurance that you guys have a record of it we just like I said, received the letter that you, yeah, so OK, so just disregard the letter.
[AGENT][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] Wait a minute, wait, wait, wait. So,
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I think this is uh.
[AGENT][NEUTRAL] Just to be on the safe side, let me reach out to a claims examiner because there's nothing here, but I don't, I mean, you received the letter, so I just want to double check.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey, [PII], this is [PII] on the care team. How are you doing?
[CUSTOMER][NEUTRAL] Fine, how are you?
[AGENT][NEUTRAL] I'm good. Um, I don't need a transfer. I really need, uh, can you look at this with me? It's a provider, um, it's 259-617-1.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Or uh [PII].
[AGENT][NEGATIVE] Yeah, the provider is saying that they received a letter from us saying that there was no policy. We received the claim, but there was no policy found.
[AGENT][NEGATIVE] But I don't see anything on base showing that we sent it to her. She said she received the letter or the date on the letter is [PII]. There's nothing in OnBase after [PII]. There's no note and she does, the policy came right up up with the policy number. I just didn't want to tell her to disregard it if it was something for real.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So she gave
[CUSTOMER][NEUTRAL] So, on the letter, it, it gave that policy number?
[AGENT][NEGATIVE] Yeah, on the letter, it gave the policy number that she gave me. No, no, no, there's no there's no there was no policy number on the letter. She has the member's ID card. She said the member came in and she um she called in the, the provider called in to verify benefits and we told her back in March that there was no major coverage, but they still submitted the claim, I guess just to get the denial and then they received that letter in return.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK, and the letter said that they, they couldn't locate that they had coverage?
[AGENT][NEGATIVE] Yeah, the letter said that we received the claim, but there's no, we were unable to locate a policy.
[CUSTOMER][NEUTRAL] Is that what?
[CUSTOMER][NEUTRAL] OK, so they must didn't, it was identifiable, so you wouldn't see anything in on base.
[CUSTOMER][NEUTRAL] Because we couldn't locate them. So either they didn't put the policy number on the claim or their social for us to locate them in the system. So when that happens they send that letter out and we don't have any identifying information to locate them in the system with coverage.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So tell her to resubmit.
[CUSTOMER][NEUTRAL] So I would advise him to resubmit the claim, yes, with the policy number indicated on it.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, got it. Thank you.
[CUSTOMER][POSITIVE] Mhm. You're welcome.
[AGENT][NEUTRAL] All right, bye bye.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you for holding. So, um, the examiner.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Um, just, she just explained, if they sent out that letter, then there's something missing either there wasn't the policy number or the patient's social, something to identify a policy for them. She said, but you can resubmit the claim, um, there's definitely a policy here, but that just means something, it was unidentifiable.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, can I maybe since I have you on the phone, can I go over what we have so um.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, wrong person here, so he.
[CUSTOMER][NEUTRAL] OK my system is being so.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] OK, so it, so the number is 259-617-1 and then I have a group number of 70,030.
[AGENT][NEUTRAL] Hold on 1 2nd.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK, and so I'm just wondering what else.
[CUSTOMER][NEUTRAL] I need for her.
[AGENT][NEUTRAL] I'm not sure, but as as long as you have that policy number.
[AGENT][NEUTRAL] On your claim, it'll they'll be able to locate it this time. Mhm.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And the group number yeah.
[AGENT][NEUTRAL] Was that on there previously?
[CUSTOMER][NEUTRAL] OK, OK, well I guess we will.
[CUSTOMER][NEUTRAL] Mhm yeah that was the number we had on there so I don't know why it's saying.
[CUSTOMER][NEUTRAL] That it didn't
[CUSTOMER][NEUTRAL] I know that um yeah I don't know why it would.
[AGENT][NEUTRAL] Yeah, I'm not sure either, but um you definitely can resubmit it um so that we can process and provide the denial.
[CUSTOMER][NEUTRAL] Why we can
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK perfect thank you.
[AGENT][POSITIVE] You're welcome. Was there anything else I can help you with today, [PII]?
[CUSTOMER][NEGATIVE] I don't think so thank you so much.
[AGENT][POSITIVE] You're welcome. Thanks for calling [PII]. I hope you have a great day.
[CUSTOMER][POSITIVE] Thank
[CUSTOMER][POSITIVE] Thanks you too bye.
[AGENT][NEUTRAL] Bye bye.