AccountId: 011433970860
ContactId: 22ae85b5-3e79-4c5f-a954-dc94cf0861da
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 371929 ms
Total Talk Time (AGENT): 88130 ms
Total Talk Time (CUSTOMER): 223679 ms
Interruptions: 2
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/28/22ae85b5-3e79-4c5f-a954-dc94cf0861da_20250128T17:10_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APL. My name is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling from the provider's office and I have a question about a claim.
[AGENT][POSITIVE] I'd be happy to assist with the claim that they can drive. I can get a good call back number for you.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Going just to let um include things like.
[AGENT][NEUTRAL] And what is the policy number?
[CUSTOMER][NEUTRAL] 01227648
[CUSTOMER][NEUTRAL] The analysis say and the active courses.
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] The patient is [PII], [PII].
[AGENT][NEUTRAL] And what is the date of service for the claim?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Day of service is [PII].
[CUSTOMER][NEUTRAL] Like this. [PII]
[AGENT][NEUTRAL] And your tax ID.
[AGENT][NEUTRAL] Thank you for that information. OK, I'm showing the claim was denied because office visits are not covered under the policy.
[CUSTOMER][NEUTRAL] the
[CUSTOMER][NEUTRAL] OK, so because it looked like it denied originally or saying it denied because they couldn't identify the patient and I'm like, what does that mean?
[CUSTOMER][POSITIVE] Cause I looked and I'm like we can do this.
[AGENT][NEUTRAL] Well, what claim number do you have?
[CUSTOMER][NEUTRAL] Um, the claim number on this one is 3534808.
[CUSTOMER][NEUTRAL] The.
[AGENT][NEUTRAL] Well, where does it say that on the EOB?
[CUSTOMER][NEUTRAL] Well, that's what I'm not sure.
[AGENT][NEUTRAL] I'm showing that calls are for.
[AGENT][NEGATIVE] The denial cos I'm showing on there are um not covered in an office.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That
[CUSTOMER][NEUTRAL] OK, because the one I have, it says, it says patient insured health ID name and patient health insurer ID number name does not match cause I'm like I'm looking at the ID card. OK, it says who the policyholder is, but it says it's a family account, so I'm assuming that's what I was calling for to see if each person has because some insurances, each person may have a different account number or ID number rather.
[CUSTOMER][NEUTRAL] Explain
[AGENT][NEUTRAL] No, I don't know why it says that.
[CUSTOMER][NEUTRAL] OK, so then this
[AGENT][NEUTRAL] Let me pull up that EOB cause I'm, I don't know.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So start.
[CUSTOMER][NEUTRAL] OK, so that's.
[CUSTOMER][NEUTRAL] So let's just see.
[CUSTOMER][NEUTRAL] it.
[CUSTOMER][NEUTRAL] OK, what is this? Can I have this one here.
[CUSTOMER][NEUTRAL] fine.
[CUSTOMER][NEUTRAL] That.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, I'm looking at the EOB. I'm looking on page 2 on the remarks, and I see office visits are not covered by the above number policy. In the second denial, this service is not covered when performed in the doctor's office or clinic.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So, I'm not seeing that we sent anything about their eligibility.
[CUSTOMER][MIXED] It is funny because I have that denial, but I also have another claim number and the other claim number is denied.
[AGENT][NEUTRAL] Well, what's the claim number then?
[AGENT][NEUTRAL] What's that claim number?
[CUSTOMER][NEUTRAL] The other claim, the other one is 3547496.
[CUSTOMER][NEGATIVE] Now that plane number is denied for what you're telling me is denied for.
[CUSTOMER][NEUTRAL] Forensics.
[AGENT][NEUTRAL] OK, uh, that's confusing because the claim number that you gave me ending in 808. I'm, I'm looking, I'm looking at the EOB and.
[AGENT][NEUTRAL] I don't see any
[CUSTOMER][NEUTRAL] The
[AGENT][NEUTRAL] I don't see that. I'm sorry. Well, I don't know why they sent that and then sent you an EOB. If you couldn't find her, then how did you process the claim?
[CUSTOMER][NEUTRAL] That's what made me call because I'm like if the ID numbers don't match, how does this claim deny? And that's what made me call thinking maybe, and then when I looked when I looked at her ID card, the ID card has the policyholder's name on it, but it says it's a family plan and sometimes like I said, some insurances will give each person on the plan like a different number at the end will be 0120 you know 20304 for each person.
[CUSTOMER][NEUTRAL] And that's what I was calling to see if this plan required us to change the last digits to identify each patient on the account.
[CUSTOMER][NEGATIVE] I'm not sure, but I see, like I said, I have 2 claim numbers and I just noticed that it was 2 claim numbers. The first one denied saying that they couldn't identify, and the second one that I gave you was denied saying that non-covered visits, meaning that what you're saying the plan doesn't cover the office visits.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] That's really weird. OK, so I can go ahead and send this to the patient because then they would be responsible for this question. What is, if there's a reason for the office visit, not that it possibly can be, it's just not heard on their plane, but what is the turnaround time for if we haven't wanted to appeal anything? Is there a time for an appeal?
[AGENT][NEUTRAL] Um, it will be 60 days from the date of denial.
[CUSTOMER][POSITIVE] Perfect. That's what I needed to. All right, is there a reference number for our call today, [PII]?
[AGENT][NEUTRAL] It's just my name and today's date and time. Was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] Perfect. Thank you so much. That was, that was it. Thank you so much. You have a good one.
[AGENT][POSITIVE] Thank you for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] Bye bye.