AccountId: 011433970860
ContactId: 1a8eb33e-ce5a-4137-8b5d-2189ea947949
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1154969 ms
Total Talk Time (AGENT): 261675 ms
Total Talk Time (CUSTOMER): 320573 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/30/1a8eb33e-ce5a-4137-8b5d-2189ea947949_20241230T18:10_UTC.wav
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[AGENT][NEUTRAL] Good afternoon, thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi. So this is [PII], initial to my last name, [PII], calling for Clean State Medical Group of Kentucky PLLC. And I verified the EOB this call is made for additional information about the denial. Please note the call will be recorded and monitored for quality and training purposes.
[AGENT][NEUTRAL] Sure, Mr. [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, the callback number is [PII].
[CUSTOMER][NEUTRAL] And it's a direct line. And may I have your name one more time?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] My name is [PII]. That's [PII].
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You're welcome. And may I have the patient's policy number, Mr. [PII]?
[CUSTOMER][NEUTRAL] I have 0404.
[CUSTOMER][NEUTRAL] 08452.
[AGENT][NEUTRAL] Mm, OK, that's too many numbers to be one of our policy numbers. Do you have the copy of the card with APL?
[CUSTOMER][NEUTRAL] Um, no, I don't.
[AGENT][NEUTRAL] What information do you have on the member, Mr. [PII]?
[CUSTOMER][NEUTRAL] Member's first and last name and.
[CUSTOMER][NEUTRAL] I, I just received an EOB, uh, before just to make sure, so we submitted the claim and, and the payer name I have is 90 Degree Benefits multi-plan Eloyer group. I'm sorry.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, thank you so much for patiently waiting. After we submitting the claim, we did receive an EOB from American Public Life Insurance Company with the new policy, uh different policy number. I don't know which one should I.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so I go with that number, the number for APL.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, 02512211.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You're.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII]. The date of birth is [PII].
[AGENT][NEUTRAL] OK. What is the date of service or the claim number?
[CUSTOMER][NEUTRAL] The claim number I have 354-046-1.
[AGENT][NEUTRAL] OK, let me pull the image on that thing. OK, one moment.
[AGENT][NEUTRAL] I'm still waiting on the EV one moment.
[AGENT][NEUTRAL] This is for date of service [PII].
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] Right, so based on this EOB it looks like benefits payable under the certificate are limited to, um, so that it's not a cover service, that's what it is. It's not a covered service under this plan.
[CUSTOMER][NEUTRAL] Under the member's plan or the provider's contract?
[AGENT][NEUTRAL] The member's plan.
[CUSTOMER][NEUTRAL] One moment please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] On top of the EOB I do see a mailing address [PII], [PII], OK, and [PII]. That's the address for an appeal.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] That's correct, yes.
[CUSTOMER][NEUTRAL] And what about the timely filing limit to send an a pay.
[AGENT][NEUTRAL] We don't have timely final limits for appeals.
[CUSTOMER][NEGATIVE] So that is not OK.
[CUSTOMER][NEUTRAL] And may I get the call reference number for this claim?
[AGENT][NEUTRAL] We don't have reference number so you can use my name in today's date.
[CUSTOMER][NEUTRAL] OK, and shall we move on to the next line?
[AGENT][NEUTRAL] You have another member?
[AGENT][NEUTRAL] Is it a different number?
[CUSTOMER][NEUTRAL] Um, I'm, I'm actually have a total.
[CUSTOMER][NEUTRAL] Total number 4, but we completed one. I have 3 more left, so will you be able to assist me with the 3 more?
[AGENT][NEUTRAL] OK, um, sure, yes, I just need to make a note on each one, so they're gonna be different members.
[CUSTOMER][NEUTRAL] Yeah, each one of them is different.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] I'm ready whenever you whenever you are.
[AGENT][NEUTRAL] OK, bear with me. I'm making a note.
[AGENT][NEUTRAL] One moment, I need to recall the uh the information on the EOB.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, and what is the next policy number?
[CUSTOMER][NEUTRAL] So the policy number 024.
[CUSTOMER][NEUTRAL] 12467.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII], the date of birth is [PII].
[AGENT][NEUTRAL] Alright, and what is the date of service or the claim number?
[CUSTOMER][NEUTRAL] The claim number I have 354-0764.
[AGENT][NEGATIVE] All right, so this one was processed on [PII] and it was denied.
[AGENT][NEUTRAL] Um, let me see what's the reason.
[AGENT][NEUTRAL] OK, so our records indicate the premium for the date of service was not received. The policy has terminated. You need the termination date.
[CUSTOMER][NEUTRAL] So simply saying the policy is not active at the date of service.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] May I know the policy effective on term date?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, the effective date is [PII].
[AGENT][NEUTRAL] And it terminated [PII].
[CUSTOMER][NEUTRAL] After [PII] no.
[CUSTOMER][NEUTRAL] Oh, so that, uh, after [PII], it is not renewed later.
[AGENT][NEUTRAL] [PII], there's no other policies after that day.
[CUSTOMER][NEGATIVE] No renewal.
[CUSTOMER][NEUTRAL] A active.
[CUSTOMER][NEUTRAL] I see uh from.
[CUSTOMER][NEUTRAL] And no other policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So shall we move on, one moment please.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] You make it out.
[CUSTOMER][NEUTRAL] Yeah, shall we move on to the next?
[AGENT][NEUTRAL] You don't need any other, you don't need any other information on this one?
[CUSTOMER][NEGATIVE] Um, yeah, I got the denial and I don't see a payment after term date.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So all set we can go to the next.
[AGENT][NEUTRAL] OK, let me make the note. One moment.
[AGENT][NEUTRAL] OK, that's the next one.
[CUSTOMER][NEUTRAL] So the member's ID number.
[CUSTOMER][NEUTRAL] Starting with the prefix, A as in alpha.
[CUSTOMER][NEUTRAL] 604.
[CUSTOMER][NEUTRAL] 113 21.
[AGENT][NEUTRAL] Um, we don't have letters in our numbers. That's not our number.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK, so I have another member's ID, different, uh, for a different number, not for this number.
[AGENT][NEUTRAL] OK, go ahead with the number.
[CUSTOMER][NEUTRAL] This is the number.
[CUSTOMER][NEUTRAL] Give me one moment.
[CUSTOMER][NEUTRAL] Oh, no contacts. OK, so we'll.
[CUSTOMER][NEUTRAL] So the member's ID starts with a D.
[CUSTOMER][NEUTRAL] Policy.
[AGENT][NEUTRAL] That's gonna be IMAs. Do, do you have another number for this is like the one prior, so it's gonna start with a 0 followed by 7 digits.
[CUSTOMER][NEUTRAL] Let me take a look.
[CUSTOMER][NEUTRAL] Yeah, I have it here. It is 02381128.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Name and date of birth is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK, and do you have the claim number or the date of service?
[CUSTOMER][NEUTRAL] I have a claim number.
[AGENT][NEUTRAL] OK, go ahead.
[CUSTOMER][NEUTRAL] And it's 345, I'm sorry, 354-0540.
[AGENT][NEUTRAL] Let me put this on me.
[CUSTOMER][NEUTRAL] We sent an appeal for this.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Still waiting on the system.
[AGENT][NEUTRAL] And this was for um [PII]?
[CUSTOMER][POSITIVE] Yeah, that's correct.
[AGENT][NEUTRAL] OK, let's see I can find it here.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so it looks like the, we have not received an appeal. The original denial is that the maximum benefit for outpatients sickness has been exhausted for the year. So that's still the denial because we received the claim 3 times and it's the same information.
[CUSTOMER][NEUTRAL] OK. When was the last time you received?
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] The one that the one you provided to me, the 354-0540, that's the last claim. Let me see when it was received.
[AGENT][NEUTRAL] Um, um, it was received [PII], processed [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we submitted an appeal on [PII].
[CUSTOMER][NEUTRAL] Um, might be the one you received on [PII], that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I, I assume that one has a pillar also. Can you please check the attachment?
[CUSTOMER][NEUTRAL] The one you on [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] Yeah, the attachment only has the.
[AGENT][NEUTRAL] The 1500 form, that's all in the attachments.
[AGENT][NEUTRAL] It's just a claim.
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] So let me just confirm the mailing address. Uh, we mailed it to the [PII].
[CUSTOMER][NEUTRAL] Is that the correct mailing address?
[AGENT][NEUTRAL] For an appeal? No, for an appeal, you will send it to us. For an appeal, you will send it to the [PII] that is in the EOB.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And what is the denial description you mentioned? I'm sorry.
[AGENT][NEUTRAL] The maximum benefit for outpatient sickness rider has been exhausted for the calendar year.
[CUSTOMER][NEUTRAL] One moment please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Give me one moment please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. Just to, uh, just to make sure, let me repeat the description. You said maximum benefits for the outpatient sickness visit has been exhausted for the calendar year.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, the maximum benefit for the for the outpatient sickness writer has been exhausted for the calendar year. That's correct.
[AGENT][NEUTRAL] Hello, you still there?
[AGENT][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Oh, I'm sorry. I'm muted and I'm talking here. OK, so I got that. Uh, OK. So you haven't received an appeal so far. You only received a claim and that is also denied for the same reason.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Excuse me I'm sorry.
[CUSTOMER][POSITIVE] Um, so your name is the reference number. So yeah, that's all I have for today. And thank you so much for your assistance, by the way. Have a beautiful day and [PII] in another one, so.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] You're welcome. You're welcome.
[AGENT][POSITIVE] Thank you. [PII]. Thank you. Thank you. Bye-bye, Mr. [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Bye bye.