AccountId: 011433970860
ContactId: 186a431e-2249-456f-927e-57b949e6e874
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1157119 ms
Total Talk Time (AGENT): 452954 ms
Total Talk Time (CUSTOMER): 395555 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/12/186a431e-2249-456f-927e-57b949e6e874_20250312T18:32_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. I'm calling from office. I want to check the claim status.
[AGENT][NEUTRAL] OK, can I think you're needing claim status, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, I can help you with that. And what is your callback number, please?
[CUSTOMER][NEUTRAL] [PII] with [PII].
[AGENT][NEUTRAL] Thank you. And how many claims, [PII], do you have to check status on?
[CUSTOMER][NEUTRAL] I have 4.
[AGENT][NEUTRAL] For the same patient or one data service for 4 different patients?
[CUSTOMER][NEUTRAL] Different, uh.
[AGENT][NEUTRAL] One data service for 4 patients each.
[CUSTOMER][NEUTRAL] No, no, it's a different, uh, different patient and different data service.
[AGENT][NEUTRAL] And one date of service for each patient?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][POSITIVE] Yes, I can help you with all of that, [PII]. So you will use my name.
[AGENT][NEUTRAL] And today's date as your call reference number for each. Also, any information that I provide for you on any of the claims will be a verification of benefits and not a guarantee of payment. And lastly, if we do have the claims on file and you need a copy of the explanation of benefits, you may print that by going to our portal.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] And our portal website is secured.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes, I have that.
[AGENT][NEUTRAL] OK. So if you need a copy of the EOB, you can print it from there. And what is the first patient's policy number?
[CUSTOMER][NEUTRAL] 01832520. M as in Mike Lima, and the number 7.
[AGENT][POSITIVE] Thank you, one moment.
[AGENT][NEUTRAL] And what is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And what is the date of service and total bill amount for her place?
[CUSTOMER][NEUTRAL] OK. It's uh [PII] and the total charges is $354.42.
[AGENT][NEUTRAL] 354.42.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you. One moment.
[AGENT][NEUTRAL] And you did say the date of service is [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, there is no claim on file.
[AGENT][NEUTRAL] And when you do file the claim with [PII], you will also need to include a copy of her primary insurance company's explanation of benefits as well.
[CUSTOMER][NEUTRAL] OK. OK. Uh, yeah, [PII], uh, could you please tell me whether this member has the active policy and when it was, uh, like so effective?
[AGENT][NEUTRAL] Policy is active with an effective date of [PII].
[CUSTOMER][NEUTRAL] Still current, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] And could you please tell me the payer ID?
[AGENT][NEUTRAL] 60801.
[CUSTOMER][NEUTRAL] 60801. OK.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, thank you. And then, OK, if the claim is not on file, could, could we, uh, like, we can go for the next claim? Uh.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] And the next member's policy number?
[CUSTOMER][NEUTRAL] Yes, uh, it's.
[CUSTOMER][NEUTRAL] 02003104
[CUSTOMER][NEUTRAL] M as in Mike, Lima, and the number 8.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And the date of service and total bill amount for him, please?
[CUSTOMER][NEUTRAL] OK. It's [PII]. And the charges is $27.87.
[AGENT][NEUTRAL] And you did say data service 7-23-2024?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, uh, for this claim, uh, I, yeah, before, uh, like, while we are pulling up the claims. For this claim, uh, we call on this on
[CUSTOMER][NEUTRAL] January, no, yeah, [PII]. And we spoke, uh,
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So you already have the claim number?
[AGENT][NEUTRAL] You do have the claim number for this claim? OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, it's 3552713.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] So, um, yeah, the claim is denied for, as per the previous uh rep, the claim is denied for diagnosis, the excort. So, yeah, we send an appeal for this claim. So do we, like, do you have the appeal or you have, you haven't received the appeal yet or not?
[AGENT][NEUTRAL] Mm, no, sir. And the the reason for the denial on this claim states policy provides no benefits for the treatment of conditions other than a sickness or injury as defined by the policy.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That is the denial reason on this claim.
[CUSTOMER][NEUTRAL] OK. But as per, as per uh like the users that uh one of my friend who has uh work on this claim, it's written, the claim has denied for diagnosis, it's not for injuries.
[CUSTOMER][NEUTRAL] Therefore, not payable for CBD 39,010. OK.
[AGENT][NEUTRAL] OK. Again, the specific remark reads as follows. Policy provides no benefits.
[AGENT][NEUTRAL] For the treatment of conditions.
[AGENT][NEUTRAL] Other than a sickness or injury as defined by the policy.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] So that means it is not included in this, uh, in the policy of, is it a member's plan, right?
[AGENT][NEUTRAL] The member's plan.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So in this case, uh like we can be to patient, right?
[AGENT][NEUTRAL] We do not determine patient responsibility. That would be up to the provider, [PII].
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Mhm. And do you need any other information on this number?
[CUSTOMER][NEGATIVE] No, no, no.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, then we can go for the next claim uh. Uh I'm.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK, and the next policy number?
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] OK. It's 246-497-8.
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh, so what.
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, maybe I misheard.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, maybe I misheard the policy number, OK, give me just one moment. 246.
[CUSTOMER][NEUTRAL] Sorry?
[CUSTOMER][NEUTRAL] 49.
[AGENT][NEUTRAL] 4973.
[CUSTOMER][NEUTRAL] 78.
[AGENT][NEUTRAL] 78.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] And the other didn't he also didn't.
[AGENT][NEUTRAL] OK. And again, the, I'm sorry, the name and date of birth?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK. And what type of it? Do you already have some claim information on this one that you're needing additional information on?
[CUSTOMER][NEUTRAL] OK, for this, uh, let me just well.
[AGENT][NEUTRAL] Or do you
[CUSTOMER][NEUTRAL] Yeah, we have the, I have the claim number and yeah.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] What is the data service and total bill amount?
[CUSTOMER][NEUTRAL] OK, the date of service is uh
[CUSTOMER][NEUTRAL] [PII] and the total amount is $91.80.
[AGENT][NEUTRAL] 91.80. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you, one moment.
[AGENT][NEUTRAL] OK, so the, we've received this claim.
[AGENT][NEUTRAL] OK, give me, let me look at one thing please.
[AGENT][NEUTRAL] OK, so this claim has been received more than once. The most recent received claim was denied as a duplicate of previously submitted expenses. Are you needing the original claim information?
[CUSTOMER][NEUTRAL] OK. And what I have and what you have, is it, uh, any difference? Let me just, uh, review it for you, OK? Like the allowed amount is $15.55 right?
[AGENT][NEUTRAL] The benefit paid $15.55.
[CUSTOMER][NEUTRAL] And that is the allowed amount and the pet amount, right? It is same.
[AGENT][NEUTRAL] That is because this is a supplemental policy, yes. This is a supplemental policy that helps with the co-pays, deductibles and co-insurance amounts.
[CUSTOMER][NEUTRAL] OK, so there is no patient responsibility for this claim, right?
[AGENT][NEUTRAL] Again, we do not determine any form of any patient responsibility that is always up to the provider.
[CUSTOMER][NEUTRAL] No, uh, [PII], I have a little confusion here. What I'm asking is the paid amount and the allowed amount is $15.55 and it's already paid.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] And that is what was paid.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, thank you. And recently, you received the claim and it is denied for duplicate, right?
[AGENT][NEGATIVE] The 2nd time, yes, we did receive the same bill again and it was denied as a duplicate of previously submitted expenses.
[CUSTOMER][NEUTRAL] OK. OK, thank you. And here, uh.
[AGENT][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] I have the last claim and
[AGENT][NEUTRAL] So, do you need any other information on this?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] No, no.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK, and I'm ready for the next policy number, Kennedy.
[CUSTOMER][NEUTRAL] 01871735 M as in Mike Lima, and the number 8.
[AGENT][NEUTRAL] OK, thank you, one moment.
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] And the date of service and total build out for her, please.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the total charges is $476.13.
[AGENT][NEUTRAL] Thank you. And do you already have the claim number on this?
[CUSTOMER][NEUTRAL] No, I just want to know whether this claim is on file or not.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Maybe
[AGENT][NEUTRAL] OK, so this claim was received, [PII]. This claim was received on [PII].
[AGENT][NEUTRAL] Processed and denied on [PII].
[AGENT][NEUTRAL] The claim number is 355-0489.
[AGENT][NEUTRAL] And the reason for the denial on this claim is that office visits are not covered under this policy.
[AGENT][NEUTRAL] The member's plan does not cover office visits.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I have, I have a query, uh, that is stressing, why, why we can't pull up the claim in the portal, that is APO uh portal that without the claim number. Why?
[AGENT][NEUTRAL] I'm not able to, I really, I'm not sure. Sometimes people can, sometimes you can't. If you have all of the other information and it matches what we have, you should be able to, Kennedy, so I'm sorry that it occurs where you can't, but with the claim number, you definitely should be able to pull that up.
[CUSTOMER][NEUTRAL] Uh, I try, I try. There's uh two portion that is, uh, without claim number.
[AGENT][NEUTRAL] For example, yes, so for example, if we do not have the social security number for the member you're calling on in the system, I know it asks for you to enter that information.
[AGENT][NEUTRAL] Um, then it's not going to find it.
[CUSTOMER][NEUTRAL] But yeah, I do have the social security number, but I cannot pull up any claims. That, that's why I called you up for this.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] And that's fine that you call us, but you should be able to.
[AGENT][NEUTRAL] But a lot of times you
[CUSTOMER][NEUTRAL] Yeah, just for
[CUSTOMER][POSITIVE] Sorry to interrupt you. You can, uh, you can, uh, yeah, continue.
[AGENT][NEUTRAL] No, no, that's OK. No, you should be able to access it. So why you're not able to, I don't know if maybe that has something, uh, I don't know, honestly, you know, so I don't wanna try to speculate.
[AGENT][NEGATIVE] On why you can't access it.
[CUSTOMER][NEUTRAL] Yeah, I, just for the claim number, we have to call you guys, uh, like we have to call you like American Public Life. So I'm just, I'm just curious, uh whether it is possible. Is there any possible way to pull up without calling or not?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, sir. If it's not a, if you can't enter the patient's name, date of birth,
[CUSTOMER][POSITIVE] Thank
[AGENT][NEUTRAL] The social and the now when you're entering the provider's patient account number.
[AGENT][NEUTRAL] Is that, are you trying to enter the APL policy number or the account or the patient account number that's on like box 23 or 26 on the claim form?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah, we use that one, yeah.
[AGENT][NEUTRAL] OK, yeah, because some people, some people try to use their APL policy number and that is not what that is asking for.
[CUSTOMER][NEUTRAL] We use the, yeah.
[AGENT][NEUTRAL] And if we don't have a claim on file, it also would not find anything.
[AGENT][NEUTRAL] So we have to, you know, so that could be another reason that it is not, you know, won't access it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][POSITIVE] OK. Uh uh thank you so much, [PII], and that's all for now. Yeah, thank you so much for the information that you have provided. Have a nice day. Bye-bye.
[AGENT][NEUTRAL] Well, you say, yes, and again, and one more thing like on this one, for example, just using as an example, when it asks for the last four digits, OK, so it asks for the patient's first name.
[AGENT][NEUTRAL] Right. And then the patient's date of birth, and then it asks for the last four digits of the primary insured's social. So that may not always be your patient. Like this time, this was for a dependent. So you have entered the dependent's name and the dependent's date of birth, and then the last four socials of the subscriber.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So if you don't have, you know, all of that information, yes, that would be another reason that I wouldn't find it.
[CUSTOMER][NEUTRAL] OK, I got it.
[CUSTOMER][POSITIVE] OK. Thank you so much.
[AGENT][NEUTRAL] Well, you're welcome. So again, is there anything else that I can help you with this afternoon, [PII]?
[CUSTOMER][NEUTRAL] No, that's all for now.
[AGENT][POSITIVE] OK, well, thank you very much then for calling APO and I hope you have a very nice rest of your day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Ah, thank you. Bye bye.
[CUSTOMER][NEUTRAL] You know.