AccountId: 011433970860
ContactId: 23177b47-127a-426c-9380-f223a901d5dd
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 689289 ms
Total Talk Time (AGENT): 213931 ms
Total Talk Time (CUSTOMER): 195990 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/06/23177b47-127a-426c-9380-f223a901d5dd_20250206T18:32_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling in for uh Palm Beach Orthopedic to get an additional information about a claim that has been denied. So please note that this call is recorded and monitored for quality and training purposes.
[AGENT][POSITIVE] OK, yeah, I could definitely check on a claim for you. uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] All right, thank you. And then do you have the policy number?
[CUSTOMER][NEUTRAL] So this member's ID is 02263086ML8.
[AGENT][POSITIVE] All right, thank you.
[CUSTOMER][NEUTRAL] And what was your name?
[AGENT][NEUTRAL] Uh, it's [PII]
[CUSTOMER][NEUTRAL] OK OK.
[AGENT][NEUTRAL] And then what was the
[AGENT][NEUTRAL] Right, um, what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] So this is under uh [PII] [PII].
[AGENT][NEUTRAL] All right, thank you for verifying that, [PII]. Do you have a claim number?
[CUSTOMER][NEUTRAL] Uh, on the UB it shows 3556172.
[AGENT][POSITIVE] OK, thank you one moment please.
[AGENT][NEUTRAL] OK, so I did find this claim, [PII]. uh, looks like we were unable to pay a benefit as office visits are not covered under this policy.
[CUSTOMER][NEUTRAL] So not a covered uh covered as per the insurance?
[AGENT][NEUTRAL] Right, this policy does not cover office visits.
[CUSTOMER][NEUTRAL] Uh, the last process date is on [PII].
[AGENT][NEUTRAL] What was that? I'm sorry.
[CUSTOMER][NEUTRAL] Was it processed on [PII]?
[AGENT][NEUTRAL] Uh, it was processed, uh, [PII].
[CUSTOMER][NEUTRAL] And you couldn't reprocess this?
[AGENT][NEGATIVE] No, it's office visits are just not covered under this policy. We were unable to pay a benefit.
[CUSTOMER][NEUTRAL] OK, that's good is not covered as of the moment. OK. Uh, your appeal address, can I have it?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that is in [PII], [PII].
[AGENT][NEUTRAL] Zip code is
[CUSTOMER][NEUTRAL] I'm just checking with that.
[AGENT][NEUTRAL] Oh sure.
[CUSTOMER][NEUTRAL] OK, [PII]
[AGENT][NEUTRAL] OK. [PII], yes.
[CUSTOMER][NEUTRAL] OK. C.
[AGENT][NEUTRAL] Yes, [PII] and [PII] is the state.
[AGENT][NEUTRAL] And then the uh zip code is,
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] OK, timely filing one year from the denial.
[AGENT][NEUTRAL] For an appeal that would be 180 days.
[CUSTOMER][NEUTRAL] 180 days from then on, OK.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] And we would need a letter uh stating of course that it is in for an appeal.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh just for documenting it I was collecting. So what's the reference number on this patient, I will give you the next member's ID.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, it would just be my first name, last initial, and today's date, uh, so my last initial is [PII], um, and you said there was another claim we needed to look at was for a different member?
[CUSTOMER][NEUTRAL] Yeah, I have 2 more games.
[AGENT][NEUTRAL] For different members though, correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, yes, one moment and the reference will be the same for all of them.
[CUSTOMER][NEUTRAL] Uh, OK.
[AGENT][NEUTRAL] Alright, one moment.
[AGENT][NEUTRAL] OK, I am ready for that next policy number.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, it's gonna be 022.
[CUSTOMER][NEUTRAL] 12396.
[AGENT][NEUTRAL] 6, OK. And then uh the name and date of birth for this number, please?
[CUSTOMER][NEUTRAL] So my name uh.
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Alright, thank you for that. Do you have this claim number as well?
[CUSTOMER][NEUTRAL] I'm trying to check.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] We have received an AUB. Hold on, it's loading. OK, 354-884-7.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] And only the denial code I'm checking on this, OK.
[AGENT][NEUTRAL] Um, what was that? I'm sorry.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] What is the denial reason I'm checking.
[AGENT][NEUTRAL] Yes, so for this policy we were unable to pay a benefit as the services were rendered after coverage was terminated. So this policy terminated uh [PII].
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So policy was not active during the date of service, right?
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] Termed on [PII].
[AGENT][NEUTRAL] Uh, uh, hold on just a moment. I just had it, uh, [PII], yes.
[CUSTOMER][NEUTRAL] [PII], OK. No other alternate coverage?
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right, this was the only policy they had with us.
[CUSTOMER][NEUTRAL] Even though we have received previous payments, still they couldn't reprocesses as well, right?
[AGENT][NEUTRAL] What was that? I'm sorry.
[CUSTOMER][NEUTRAL] Even though we have received previous payment, you still cannot reprocess it. Rather, we can appeal it with the address which you mentioned, right?
[AGENT][NEUTRAL] This policy did terminate um on [PII], so they did not have any active coverage during that date of service at least not with us if uh they might have had other coverage elsewhere but this is the only one I'm able to see.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Same my bill address I'm using one moment.
[CUSTOMER][NEUTRAL] OK, let's go on with the next patient.
[AGENT][NEUTRAL] OK, one moment please.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] OK, and I'm ready for that next one.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK. And then the uh name and date of birth for this number?
[CUSTOMER][NEUTRAL] So my name is [PII] [PII].
[AGENT][NEUTRAL] Alright, thank you for that and then uh did you have this claim number as well?
[CUSTOMER][NEUTRAL] Checking.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Do you have the last process date for the previous member which uh I gave you?
[AGENT][NEUTRAL] What was that? I'm sorry?
[CUSTOMER][NEUTRAL] Um, no. OK. Uh, let me finish this. Uh, it's 355-625-5.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] So for this one [PII], this is the same as the first um office visits are not covered under this policy, so we were unable to pay a benefit.
[CUSTOMER][NEUTRAL] OK, now the cover code as for your insurance, OK. I'll put that in and last process date, [PII].
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Yes, that's when this claim was processed correct.
[CUSTOMER][NEUTRAL] OK. For the previous member also same uh process date, right?
[AGENT][NEUTRAL] Um, I am not quite sure. I'd have to go back and double check. Give me just a moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Give me just a moment. OK, um, that one, the previous one processed, uh, [PII], so [PII].
[CUSTOMER][NEUTRAL] [PII]. OK.
[AGENT][NEUTRAL] Yes, yes.
[CUSTOMER][NEUTRAL] Uh, usually, how many claims for call you can assist after?
[AGENT][NEUTRAL] Um, it really depends on time of day, how busy you are and such. Did you have more for me to look at?
[CUSTOMER][NEUTRAL] Uh, no, no, no, only 3, just for, uh, basic information I was trying to inquire.
[AGENT][NEUTRAL] Oh sure, yeah, there's typically not a limit unless you know, like 50 or so at a time.
[CUSTOMER][POSITIVE] Um, OK, no issues. Thank you and have a great day. Thanks for assisting.
[AGENT][NEUTRAL] Yeah, was there anything else I can help you with?
[CUSTOMER][NEUTRAL] Uh, no, that's it. Thank you. Bye-bye.
[AGENT][POSITIVE] Alright well thanks for calling APL yeah have a great rest of your day.
[CUSTOMER][NEUTRAL] You too, bye bye.
[AGENT][NEUTRAL] Bye bye.