AccountId: 011433970860
ContactId: 1735b2a7-8abc-4ab0-88f3-cedae3069159
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1341319 ms
Total Talk Time (AGENT): 394415 ms
Total Talk Time (CUSTOMER): 277250 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/09/1735b2a7-8abc-4ab0-88f3-cedae3069159_20250509T17:35_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] Hi, [PII]. This is [PII] calling from provider office. Before that, this call is being recorded for quality and training purpose. Is it OK with you, [PII]?
[AGENT][NEUTRAL] Yeah, that's fine.
[CUSTOMER][POSITIVE] Thanks, yeah, I want to check the claim status.
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status and from my notes, can you spell your first name for me please and provide a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII] initial SSM. It's spelled as [PII] SM. Callback number is [PII].
[AGENT][NEUTRAL] OK, hold on one second. Can you repeat the phone number slowly, please?
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and the member's policy number?
[CUSTOMER][NEUTRAL] Ma'am policy number 02493550.
[AGENT][POSITIVE] Thank you for that. Hold on one moment.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEGATIVE] I didn't get you.
[AGENT][NEUTRAL] I just said thank you and hold on one moment, I'm just pulling up the policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Alrighty, can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, ma'am my name, wait a minute.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] [PII], hello.
[AGENT][NEUTRAL] Yes, I'm here.
[CUSTOMER][NEUTRAL] Sorry, your voice is, wait a minute. Let me verify on my side.
[CUSTOMER][NEUTRAL] Hello. Is it OK for you now?
[AGENT][NEUTRAL] Yes, I can hear you.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] I'm just waiting for you to verify her name and date of birth.
[CUSTOMER][NEUTRAL] Yeah,
[CUSTOMER][NEUTRAL] Yeah. My name is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Thank you for that. And all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service?
[CUSTOMER][NEUTRAL] Sorry, but
[CUSTOMER][NEUTRAL] And I was is very hardly breaking. Wait a minute.
[CUSTOMER][NEUTRAL] Hello. Is it OK to for now?
[AGENT][NEUTRAL] Yes, I didn't hear anything, so let me know if it's OK on your end.
[CUSTOMER][NEUTRAL] Yeah, yeah, so.
[CUSTOMER][POSITIVE] Yeah, it's very perfect now. Now you are asking patients then, right?
[AGENT][NEUTRAL] I was giving you the disclaimer. All the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bills for the member's policy or claim, I'm sorry.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Date, date of service this [PII]. Bill amount $312 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yeah, the provider of his name is West Jefferson Physician Service.
[AGENT][POSITIVE] Thank you for that.
[AGENT][NEUTRAL] And hold on one moment.
[AGENT][NEUTRAL] So I'm showing the claim was received on [PII].
[AGENT][NEUTRAL] The claim number is 358.
[AGENT][NEUTRAL] 083 1.
[AGENT][NEUTRAL] And on [PII], the claim was denied as office visits are not covered on this policy. Hold on one moment. How did it switch like that?
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] OK, that's correct. Office visits are not covered on this policy, and then the other codes on here were denied. Let me get that reason for you.
[AGENT][NEGATIVE] The other codes were denied because there were no charges. Um, the policy does not provide a benefit for services in which no charges were incurred.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] And as you told, and now, this member does not have uh office visit services, right? In her in their policy, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. So may I know, and uh is this a limited benefit plan?
[AGENT][NEUTRAL] No, this is their secondary supplemental gap insurance policy. So it covers inpatient and outpatient facilities, um, but under outpatient, it does not cover the facility itself for office visits. There is the office treatment rider in which the treatment could be covered um up to the calendar year max.
[CUSTOMER][NEUTRAL] OK, you guys only covered uh inpatient and outpatient services but does not cover office visit, right?
[AGENT][NEUTRAL] If you, if you use code 99213 or 99214 as you have on this claim, that's a place of service code. So for the facility, there is no coverage, but the treatment in the office uses the office treatment rider.
[CUSTOMER][NEUTRAL] OK. So office treatment is covered, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Wait a minute. Let me make my note.
[CUSTOMER][NEUTRAL] OK. I have 1 more, 2 more claims.
[AGENT][NEUTRAL] How many claims do you have in total?
[CUSTOMER][NEUTRAL] Total 3 claim for different patients.
[AGENT][NEUTRAL] OK. Do you mind if I place you on just a brief hold so I can note this patient?
[CUSTOMER][POSITIVE] Yeah, take your time and you.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. And what is the next member's policy number?
[CUSTOMER][NEUTRAL] The next number policy number is 1260231.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] [PII]. Date of birth, [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the um data service and the total bills?
[CUSTOMER][NEUTRAL] Date of service is [PII] $314 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And for this one, do you mind if I place you on just a brief hold? There's a few claims for this data service.
[CUSTOMER][NEUTRAL] For $340 right?
[AGENT][NEUTRAL] That's what I'm checking for. We received multiple claims on this day, so I'm, I'm locating yours.
[CUSTOMER][NEUTRAL] OK, you can check.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, [PII].
[CUSTOMER][NEUTRAL] Yes, I'm there.
[AGENT][POSITIVE] All right, thank you so much for holding. I apologize for that wait. So, the claim was received on [PII]?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim number is 343.
[AGENT][NEUTRAL] 03
[AGENT][NEUTRAL] I'm sorry, 083 8.
[AGENT][NEUTRAL] So 343-083-8?
[CUSTOMER][NEUTRAL] Wait a minute. 343.
[AGENT][NEUTRAL] 0838.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim to the provider, a total of $80.
[CUSTOMER][NEUTRAL] OK, but I have a claim received as a denial. I have a claim number as 3453668.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Sorry, wait a minute, wait a minute. I have mistakenly provided the wrong date of service. But sorry for inconvenience, [PII].
[CUSTOMER][NEUTRAL] Are you there?
[AGENT][NEUTRAL] Yes, I'm here. I'm trying to get out of this claim. OK, so yes, that's a different data service. So,
[CUSTOMER][NEGATIVE] No, sorry.
[CUSTOMER][NEUTRAL] Yeah. That date of service is [PII], right?
[AGENT][NEUTRAL] Correct. So which one did you need?
[CUSTOMER][NEUTRAL] OK. [PII].
[AGENT][NEUTRAL] So [PII] is the one that you need?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one second.
[AGENT][NEUTRAL] So we received this claim on [PII].
[AGENT][NEUTRAL] Um, you have the claim number there, 3453668.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because the benefits payable under this contract are only limited to those listed on the schedule of benefits, so this is not a covered.
[AGENT][NEGATIVE] Um, loss under the plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. As you're trying to say, this service is not covered under the member's plan, right?
[AGENT][NEUTRAL] Yes, that's what I'm saying.
[CUSTOMER][NEUTRAL] OK, but the same CPD has been paid as you, as you have given the claim number. You can check the same CPD is there and the same service was provided under the date of service.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEGATIVE] There, OK, I don't understand what you're saying. This claim, the whole claim was denied.
[AGENT][NEUTRAL] Are you saying on the February, I'm asking for clarity, just allow me to speak. For [PII], are you saying that there was a claim on that date that paid one of the codes that are on [PII]?
[CUSTOMER][NEUTRAL] As, as
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] And same diagnosis are below that also.
[AGENT][NEUTRAL] OK, let me take a look at these 3, these two claims. Hold on one moment, OK?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Yes, I'm there.
[AGENT][POSITIVE] All right, thanks again for holding. So I do see you're right on um
[AGENT][NEUTRAL] Policy or claim number 343-0838, the 99214 was paid and that is an error. So I can go ahead and send this back so that we can reprocess and ask for a refund for that because there should not if the most it should have been was $25.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] If they were going to pay out on it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So I can send that back for reprocessing.
[CUSTOMER][NEUTRAL] OK. And what will the turnaround time for this?
[AGENT][NEUTRAL] Um, the turnaround time to request the refund?
[AGENT][NEUTRAL] I think it should be about the 7 to 10 business days.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Which is
[CUSTOMER][NEUTRAL] Ma, I want to know the claim, I was asking the claim which is paid, paid in error I'm trying to say?
[AGENT][NEUTRAL] Yes, that's what I'm saying. So the $80 that you pointed out, it was paid in error. The maximum for that, um, for the benefit is $25 per visit for a physician's office with a max of $4 per calendar year. So this is paid $80. So if it was going to pay, it should have paid no more than $25. So I'll send them both back so that they can reprocess both and request the refund.
[CUSTOMER][NEUTRAL] OK. So, so you are sending both claim for reprocess, right?
[AGENT][NEGATIVE] Right, I'm sending the claim that was denied for reprocessing because they do have the $25 per visit, um.
[AGENT][NEGATIVE] Of course, they'll have to see if they've used any of it and then they'll they'll give you the explanation, the explanation of benefits. So the one that was denied, I'm going to send back and the one that was paid, I'm going to send back because it should not have been paid $80.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. After 14 business, I have to follow up for this thing, right?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] After how many days should I follow up for this claim?
[AGENT][NEUTRAL] I'm gonna say the 7 to 10 business days, that's the amount of time to process the claim.
[CUSTOMER][NEUTRAL] OK, thanks. Can we go for another claim?
[AGENT][NEUTRAL] Um, hold on one moment, let me finish this one.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So it's this one.
[AGENT][NEUTRAL] OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] The next member ID is
[CUSTOMER][NEUTRAL] 001
[CUSTOMER][NEUTRAL] 89614701
[AGENT][NEUTRAL] 189614701
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] That's too many numbers. Um, do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] Wait a minute.
[CUSTOMER][NEUTRAL] Let me check if I have an insurance card or not.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I found the insurance card.
[CUSTOMER][NEUTRAL] The member ID is 018.
[CUSTOMER][NEUTRAL] 96147
[AGENT][NEUTRAL] Does it have an ML 8 or 7 at the end?
[CUSTOMER][NEUTRAL] Yes, 7 at the end.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII].
[CUSTOMER][POSITIVE] A glad, date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and again, just for the call, all the information provided is a verification of benefits, not a guarantee of payment. For this claim, or for this policy, the claims are processed through web TPA. Um, I can provide you with their phone number and transfer you over for claim status.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, which one would you prefer?
[CUSTOMER][NEUTRAL] You can provide me the call number and also you can transfer me. And before that, you can provide me the call reference number.
[AGENT][NEUTRAL] OK, that
[AGENT][NEUTRAL] The phone number is [PII].
[AGENT][NEUTRAL] 975.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And there's no call reference number, but you can use my name in today's date.
[CUSTOMER][NEUTRAL] OK. No thanks. You can pardon, transfer me to FDPA.
[AGENT][NEUTRAL] Thank you for calling APL. Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Welcome to Web TPA, the administrator for the limited benefit health insurance.