AccountId: 011433970860
ContactId: 20b66b1f-1f0d-4c57-a2c1-c62df616539d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 705020 ms
Total Talk Time (AGENT): 326638 ms
Total Talk Time (CUSTOMER): 256321 ms
Interruptions: 2
Overall Sentiment: AGENT=1.5, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/27/20b66b1f-1f0d-4c57-a2c1-c62df616539d_20250227T16:35_UTC.wav
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[AGENT][POSITIVE] Morning, thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] calling from [PII]'s office to check on a claim status.
[AGENT][POSITIVE] [PII], it would be a pleasure to assist you with that claim status. What is the callback number?
[CUSTOMER][NEUTRAL] Callback number is [PII]. That's a direct line.
[AGENT][NEUTRAL] Thank you, [PII]. And what is the policy number for the patient?
[CUSTOMER][NEUTRAL] Policy number is
[CUSTOMER][NEUTRAL] 01
[CUSTOMER][NEUTRAL] 887.
[CUSTOMER][NEUTRAL] 351 M as in Mike, L as in Lima, 8.
[AGENT][NEUTRAL] Thank you, [PII] and the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Patient name is [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Alright thank you and it would be a pleasure to assist you with that claim status. What is the data service?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And what is the bill amount?
[CUSTOMER][NEUTRAL] $4,195 even.
[AGENT][NEUTRAL] I'm checking on that, bear with me.
[CUSTOMER][POSITIVE] Sure, take your time.
[AGENT][NEUTRAL] [PII], what is the facility name?
[CUSTOMER][NEUTRAL] Uh, facility name is Pediatrics Medical Group of Florida.
[AGENT][POSITIVE] All right, thank you.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] [PII], I'm showing that we did receive that claim on [PII]. It was processed.
[AGENT][NEUTRAL] I'm sorry, it was received on [PII] and processed on [PII].
[CUSTOMER][NEUTRAL] Mhm. Yeah.
[AGENT][NEUTRAL] And the CPT 99214 was denied as office visits are not covered by the patient's plan.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then the subsequent procedures were denied as the insurance.
[AGENT][NEUTRAL] Excuse me, primary insurance provided full benefits. There are no benefits payable.
[CUSTOMER][NEUTRAL] OK, fine. So is there any allowed amount for the remaining CBD codes?
[AGENT][NEUTRAL] So we don't reprice uh claims and no contractual involvement, we're secondary to the major medical. We don't determine patients' responsibility.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, fine. So and then I do one for the office, is it, uh it's not covered under the member benefit plan, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. May I know the patient's plan name and the plan type?
[AGENT][NEUTRAL] It is a secondary Medlink gap policy.
[CUSTOMER][NEUTRAL] Re
[CUSTOMER][NEUTRAL] Yeah, OK, uh, plan type is it HMO or PPO some, uh, like EPO.
[AGENT][NEUTRAL] No, it's like a, no, sir, it's like a secondary gap policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. Thank you for that information.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK, thank you for that. And if you could, uh could you please send us a copy of the UB through fax?
[AGENT][NEUTRAL] Now, excuse me, I do apologize [PII], our faxes are, I mean our EOBs are available on our provider portal.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And that is a self-registration.
[CUSTOMER][NEUTRAL] Um, is it a self registered portal?
[AGENT][POSITIVE] It is, and I can assist you with creating that account to get that EOB automatically.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, OK, could you uh help me with that?
[AGENT][POSITIVE] It would be my pleasure. If you will go to [PII], that's [PII]
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, yeah.
[AGENT][NEUTRAL] You're gonna go in as a new user.
[CUSTOMER][NEUTRAL] OK, that's OK.
[AGENT][NEUTRAL] And you're going to choose the last option. You are a medical or dental provider.
[CUSTOMER][NEUTRAL] OK, just give me a second, and you have to sign in, right?
[AGENT][NEUTRAL] Yes, so you're gonna go in as a new user to create an account and you're gonna use a tax ID number. When you get to that patient account number if you'll let me know, I'll give that to you.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Uh, OK, I have that tax ID number. I have to enter it that, right, OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Tax ID is [PII].
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] And for the patient account if you are creating an account for different tax IDs, the the patient account number is always listed in box 26 on the HIA uh but I do have it in front of me, so that account number is 009.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 600.
[AGENT][NEUTRAL] 493.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] 643.
[CUSTOMER][NEUTRAL] Yeah, OK then, and it's OK, you want me to create.
[AGENT][NEUTRAL] Mhm if you'll just create that username and password, yes sir.
[CUSTOMER][NEUTRAL] Username and password.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, OK. I have completed all the informations.
[AGENT][NEUTRAL] OK, so once you sign back in.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] If, if you go to the claim status option one.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Yeah, it's, it was, yeah, that's right.
[AGENT][NEUTRAL] OK, then you're gonna put in the patient's name and date of birth.
[AGENT][NEUTRAL] And then the claim number, and I'm gonna give you that claim number.
[CUSTOMER][NEUTRAL] OK. Patient's name.
[CUSTOMER][NEUTRAL] And date of birth?
[CUSTOMER][NEUTRAL] OK, may I know the claim number?
[AGENT][NEUTRAL] Claim number is 352.
[AGENT][NEUTRAL] 7 911.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Excuse me.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Such.
[CUSTOMER][NEUTRAL] Yeah, OK. I got the claim number.
[AGENT][NEUTRAL] And now that you have an account or even if it's for a different um tax ID number, you know how to create the account, and you have 24/7 access to claim status, EOBs, and you can also submit claims online as well.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, get your file. OK, I just need to click on the hyperlink which is shown as claim number, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] To get the job. OK.
[CUSTOMER][POSITIVE] Just downloading. OK, and thank you for this assistance and yeah, I really appreciate.
[AGENT][POSITIVE] Yeah, that's a lot quicker than waiting for a fax back, isn't it?
[CUSTOMER][POSITIVE] Yeah, that's right, that's right. It's great. OK. Yeah, OK, actually I do have another one more client to discuss, so will you be able to assist?
[AGENT][POSITIVE] I would be happy to assist you, [PII]. Is it for the same patient or a different patient?
[CUSTOMER][NEUTRAL] Uh, double check.
[CUSTOMER][NEUTRAL] It's for the same patient only different data servers.
[AGENT][NEUTRAL] OK, and what is that data service?
[CUSTOMER][NEUTRAL] The data service is [PII].
[AGENT][NEUTRAL] And that bill amount?
[CUSTOMER][NEUTRAL] The amount is $884 even.
[AGENT][NEUTRAL] OK, and I can help you with that claim information now if you had not called and on that portal you could have used option 2 for claim status.
[CUSTOMER][POSITIVE] OK, thank you for that.
[AGENT][NEUTRAL] So, just be aware that that's available for you too as well. But
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] This claim was received.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEGATIVE] On [PII] and processed on [PII], and denied as office visits not covered.
[CUSTOMER][NEUTRAL] OK, it's the same offices are not covered under the member benefit plan. OK, so, uh, can we, can we build the patient for this tonight?
[AGENT][NEUTRAL] Mhm. And if you need that.
[AGENT][NEUTRAL] That would be determined by the provider. We don't determine patient responsibility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But it's a complete patient responsibility, right?
[AGENT][NEUTRAL] Oh, we don't determine patient responsibility. If there's just no benefits payable on the APL policy.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Mm mm, OK, got it. Thank you for that. And uh could you please check whether have you received any um reconciliation?
[AGENT][NEUTRAL] You
[AGENT][NEUTRAL] We have not. Now we will need a formal excuse me, I do apologize. It's just that there are no benefits for an office visit and that is per the policy guidelines.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, and no reconsideration on file as well, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. So can you submit an appeal through portal or do we need to submit uh via Pay?
[AGENT][NEUTRAL] You can submit it through the portal now. We will need a formal appeal letter. Actually, it has passed the appeal time timely filing. Appeal timely filing is 180 days from the date of denial.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Firm bit of denial.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, got it, thank you for that. OK.
[AGENT][NEUTRAL] And let me give you that claim number if you need that EOB, you can get that EOB.
[CUSTOMER][POSITIVE] Yeah, I, uh, actually, I learned how to get a DOP. May I know how to submit an appeal?
[AGENT][NEUTRAL] So you would create the appeal if by
[AGENT][NEUTRAL] A formal appeal letter stating the reason that you are appealing the claim decision, save it to the computer and then upload it that's um do you see where it says would do you need to file a claim?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's where you'll upload the appeal letter in the policy.
[CUSTOMER][NEUTRAL] Uh, OK. OK, thank you for that information. OK, so.
[AGENT][NEUTRAL] And if not you can fax it to our claims department.
[CUSTOMER][NEUTRAL] OK. May I know the fax number?
[AGENT][NEUTRAL] Yes, sir. Our fax number is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Thank you for that. I really thank you for your assistance. And that's all for today. [PII], and really thank you for your assistance. And may I know the call reference number?
[AGENT][POSITIVE] It's been a pleasure.
[AGENT][POSITIVE] The call reference number is my name and today's date, and I spell my name [PII], and [PII], it was a pleasure to assist you with that claim status. Thank you for calling APL and I hope you have a wonderful day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah, you too. Have a wonderful day. Bye-bye.
[AGENT][POSITIVE] Thank you, [PII]. Bye bye.
[CUSTOMER][NEUTRAL] OK