AccountId: 011433970860
ContactId: 2537c251-842c-477b-8e1d-65f84cd0b2a9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 804210 ms
Total Talk Time (AGENT): 218678 ms
Total Talk Time (CUSTOMER): 262527 ms
Interruptions: 3
Overall Sentiment: AGENT=0.9, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/30/2537c251-842c-477b-8e1d-65f84cd0b2a9_20250130T18:51_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good. Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling from provider's office. This call is regarding a clarification or denied claim. Could you be able to assist me?
[AGENT][NEUTRAL] OK, did you say your name is [PII]?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] And you're needing clarification [PII] on a denied claim, is that correct?
[CUSTOMER][NEUTRAL] Yeah, and
[CUSTOMER][POSITIVE] Exactly.
[AGENT][POSITIVE] Yes, I can help you with that, and [PII], what is your callback number?
[CUSTOMER][NEUTRAL] That is going to be [PII].
[CUSTOMER][NEUTRAL] One moment, I'll get the new number.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] There is an extension number [PII].
[AGENT][POSITIVE] Thank you and the member's policy number, please, [PII].
[CUSTOMER][NEUTRAL] That is going to be 01644021.
[AGENT][NEUTRAL] Thank you one moment while I get the member's information loaded.
[AGENT][NEUTRAL] And uh then any information that I do provide for you today will be a verification of benefits and not a guarantee of payment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] What is your patient's name, please, and their date of birth?
[CUSTOMER][NEUTRAL] Yeah, I'll give you that one moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, the patient's name is, it's [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, and what is the date of service fiving and total build amount please?
[CUSTOMER][NEUTRAL] OK, so here the date of service is going to be?
[CUSTOMER][NEUTRAL] [PII] and the total charge is $1100.93. And could you be able to spell your name for documentation purpose?
[AGENT][NEUTRAL] [PII] And you said that the
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Amount is $1100.93 is that correct?
[CUSTOMER][NEUTRAL] Um, I said $1100.93.
[AGENT][NEUTRAL] Yes, that's what I said and what is the claim number?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, sorry for that um claim number is going to be one moment.
[AGENT][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] One moment please, I'll give you the claim number.
[AGENT][POSITIVE] Oh, you're fine. Mhm. No worries.
[CUSTOMER][NEUTRAL] 3551222
[AGENT][NEUTRAL] 3551222. Is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. One moment.
[AGENT][NEUTRAL] OK, so, um, how can I help you with this particular claim?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, so I found this claim actually got denied for non-covered charges, the non-covered expenses.
[AGENT][POSITIVE] That is correct. Mhm.
[AGENT][NEUTRAL] First off, office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] Is that the
[AGENT][NEGATIVE] But this member's plan, office visits are not covered.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the other codes were not covered because it states the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What.
[CUSTOMER][NEUTRAL] Could you please provide me the process date of the claim?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEGATIVE] What is so denied recently you said it was made for non-covered charges.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] That is correct. Is it non-covered charges and the patients plan or product plan?
[AGENT][NEUTRAL] Yes, sir. I stated that it was the member's plan. The patient's plan does not cover office visits or treatment within the office setting.
[CUSTOMER][NEUTRAL] the
[CUSTOMER][POSITIVE] OK, I'm sorry.
[CUSTOMER][NEUTRAL] What's this.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So patients.
[CUSTOMER][NEUTRAL] As for the patient's plan, uh, it does not cover charges. Um, one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, CPT.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, so this no call you said it is on culture the patient's plan. Do you have any specific guidelines?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] This supplemental policy does not cover office visits or treatment within the office setting.
[CUSTOMER][NEUTRAL] This.
[AGENT][NEUTRAL] It is not a covered service under this policy.
[CUSTOMER][NEUTRAL] For
[CUSTOMER][NEUTRAL] So the supplemental policy will not cover patients responsibility like coy coins is deductible.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] On this, this supplemental policy does not cover those areas that I explained to you.
[AGENT][NEUTRAL] And we do not determine patient responsibility, that would be up to the provider.
[CUSTOMER][NEUTRAL] And do you have any policy guidelines?
[AGENT][NEUTRAL] We are not a major medical insurance company. We are a supplemental policy only.
[CUSTOMER][NEUTRAL] We
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Supplement policy.
[CUSTOMER][NEUTRAL] Mhm. So because it's a supplement policy.
[CUSTOMER][NEUTRAL] Um, uh, I'm so sorry for the inconvenience. I just wanted to clarify, uh, it's because of the supplement policy will not cover the patient's co-insurance.
[AGENT][NEUTRAL] That is correct. That's not a cover benefit under this policy that she has with us.
[CUSTOMER][NEUTRAL] Uh, patient's coinsurance amount.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] Since it's an uncovered service of the patients, can we bill patient for the school?
[CUSTOMER][NEUTRAL] For these charges?
[AGENT][NEUTRAL] I explained that we do not determine patient responsibility, that would be up to the provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] And if you and if you need a copy of that explanation of benefits from myself and you can go to our portal and print that by going to [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And one last question.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And here is also the same situation.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So shall we move on to the next state of service for the same patient?
[AGENT][NEUTRAL] Oh, I'm so sorry, but you had not indicated that there was more than one day of service. How many dates of service do you have?
[CUSTOMER][NEUTRAL] Uh, this is the last one that I have.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK, what is the next stage of service and total bill amount?
[CUSTOMER][NEUTRAL] So the next state of services.
[CUSTOMER][NEUTRAL] [PII] and the total charge is $313.31.
[AGENT][NEUTRAL] 3 1331, is that correct for the same date of service?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] That is, that is correct.
[CUSTOMER][NEUTRAL] The, the date of [PII]. Mhm.
[AGENT][NEUTRAL] Mhm, same data service? OK.
[CUSTOMER][POSITIVE] Exactly, yes.
[AGENT][NEUTRAL] And do you already have that claim number?
[CUSTOMER][NEUTRAL] Is that 3551216?
[AGENT][POSITIVE] Yes, sir, that is correct.
[AGENT][NEUTRAL] And this claim was denied his office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] policy
[CUSTOMER][NEUTRAL] Uh, wait does.
[CUSTOMER][NEUTRAL] One moment please. I have one doubt here, um, just for the checking the documentation.
[CUSTOMER][NEUTRAL] OK, half is no cover.
[CUSTOMER][NEUTRAL] So, may I get the
[CUSTOMER][NEUTRAL] Will not covered office supplement policy will not cover office visit.
[AGENT][NEUTRAL] And this was also processed on [PII].
[CUSTOMER][NEUTRAL] Mm, yeah, yeah, so it's also process 114 and the claim got denied for the same reason like uh office visit will not covered by.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The Medicare supplement plan.
[AGENT][NEUTRAL] This is not a Medicare supplement plan.
[CUSTOMER][NEUTRAL] Make it sorry, um, supplement plan.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] May I know what guidelines you guys are following?
[AGENT][NEUTRAL] We do not, we're not a major medical insurance company, [PII].
[AGENT][NEUTRAL] We are a supplemental insurance only, and this would be secondary to her primary private healthcare insurance, her major medical insurance.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, [PII], um, if you don't mind, could you please provide me the contact claims mailing address?
[AGENT][NEUTRAL] I'm sorry, what address do you need?
[CUSTOMER][NEUTRAL] [PII] client's mailing address.
[AGENT][NEUTRAL] It would be the same address as the other.
[CUSTOMER][NEUTRAL] It would be
[AGENT][NEUTRAL] And if you're filing an appeal, you would need to put it to attention appeals department and that must be filed within 180 days from the date of the decision.
[CUSTOMER][NEUTRAL] and I
[CUSTOMER][NEUTRAL] Is the address is [PII]?
[AGENT][NEUTRAL] And the zip code?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah, I'll give you that. [PII].
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Uh, on the on the timely filing limits.
[AGENT][NEUTRAL] An appeal must be filed within 180 days from the date of the decision in writing to attention appeals department.
[CUSTOMER][NEUTRAL] They
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, here.
[CUSTOMER][NEUTRAL] Now, kindly provide me the call reference number, please.
[AGENT][NEUTRAL] My name and today's date.
[CUSTOMER][POSITIVE] All right, that's all for it. Thank you so much. Bye-bye. Take care.
[AGENT][POSITIVE] Well, you're welcome, [PII], and thank you again for calling APL and I hope you have a nice rest of your day as well.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Um