AccountId: 011433970860
ContactId: 265598ab-ae86-41b9-a5a0-060fc493d04d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1974239 ms
Total Talk Time (AGENT): 487226 ms
Total Talk Time (CUSTOMER): 491156 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/265598ab-ae86-41b9-a5a0-060fc493d04d_20250429T18:38_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello, [PII]. My name is [PII] calling from the provider's office. How are you doing today?
[AGENT][POSITIVE] I'm doing well. How are you?
[CUSTOMER][POSITIVE] Yeah, I'm doing great.
[CUSTOMER][NEUTRAL] Mm thank you for asking. And before proceeding the call, I would like to inform you that this call is being recorded for the quality and training purpose. Would you like us to continue with recording?
[AGENT][NEUTRAL] Yes, that's fine.
[AGENT][NEUTRAL] And for my notes, can you, you're welcome. For my notes, can you spell your first name for me and provide a good contact number in case we're disconnected?
[CUSTOMER][POSITIVE] Yeah, thank you for calling.
[CUSTOMER][NEUTRAL] Yeah, and my name is [PII]. It's spelled as [PII]. And initially, the last name is [PII], and the callback number is [PII].
[AGENT][POSITIVE] Thank you for that. And how may I assist you today, [PII]?
[CUSTOMER][NEUTRAL] Uh, actually, I'm checking on the status of a claim.
[AGENT][NEUTRAL] OK, and how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Oh, it's all 6 claims.
[CUSTOMER][NEUTRAL] 6 to 7 claims.
[AGENT][NEUTRAL] And they're for one person?
[CUSTOMER][NEUTRAL] No, it is for different persons.
[AGENT][NEUTRAL] OK, may I have the first member's policy number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It is 01655031 ML 8.
[AGENT][NEUTRAL] Can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah. The member first name is [PII] and the last name is [PII]. And the date of birth is on [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] Yeah. The service is on [PII] and the bill amount is $2,375 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] I'm not showing any claims on file for [PII] for um [PII].
[CUSTOMER][NEUTRAL] Oh sorry. It is on [PII].
[AGENT][NEUTRAL] February, hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It is skin and Cancer Associates.
[AGENT][NEUTRAL] and again, just for the call, all the information provided is a verification of benefits, not a guarantee of payment. I'm sure you received the claim on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That claim number is 357.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] 1771.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And on [PII], we paid out on the claim a total of $467.18.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] With that payment, um, it maxed out the um outpatient benefits for the calendar year, so that was all they had left for the year.
[CUSTOMER][NEUTRAL] Oh, this payment, the payment which I received $467.18 is for the line item 13131. Am I right?
[AGENT][NEUTRAL] No, it's for 17311.
[CUSTOMER][NEUTRAL] And for the line item 13131.
[AGENT][NEGATIVE] It was denied because when we
[CUSTOMER][NEUTRAL] May I know the status?
[AGENT][NEGATIVE] It was denied because when we paid the 17311, that maxed out the benefits for the year, so we couldn't pay out on anything else.
[CUSTOMER][NEUTRAL] OK. Just a moment. Let me check.
[CUSTOMER][NEUTRAL] Uh, may I know like how many units are allowed for the year?
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] So the benefit is up to $500 per calendar year. So what this claim is saying to you is when your claim came in, they only had the 400, I'm in another screen, hold on one moment. They only had the amount that was paid towards this claim left, so they had other claims that paid out and they had a, the rest of the total was applied to this claim. So they have used all $500 for $2025.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can you please help me with the call reference number?
[AGENT][NEUTRAL] The call reference number for the entire call is going to be my name and today's date, which is [PII].
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Uh, can I place you on hold for a moment?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Hello, [PII].
[AGENT][NEUTRAL] Yes, I'm here.
[CUSTOMER][NEGATIVE] Yeah. Thank you for being on hold. Uh, actually, the line item 13131 was denied as the max, like as it maxed out the benefits for the year you told, right?
[AGENT][NEUTRAL] Once, say that one more time.
[CUSTOMER][NEUTRAL] The line item 13131.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, it was denied as the benefits has been backed out for the year and you stated that the allowed is $500 per day.
[CUSTOMER][NEUTRAL] For calendar year.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] But upon checking that from my end, the DHC has processed $143.97 only.
[AGENT][NEUTRAL] I'm sorry, can you repeat that again?
[CUSTOMER][NEUTRAL] And it is below 500, right?
[CUSTOMER][NEUTRAL] Oh, from upon checking from my end, I see that the primary insurance that has processed up to $143.97 which is below $500 right?
[AGENT][NEUTRAL] Primary policy and secondary policy are two different policies. So what primary applied we see, but our policy has its own benefits.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, can we, uh, is it, uh, towards patient responsibility?
[AGENT][NEUTRAL] We don't determine patient responsibility because we're not the major medical, um, it would be whatever your, uh, policies are on remaining or outstanding balances.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Can I go with the another claim?
[AGENT][NEUTRAL] Sure, what's the next um policy number?
[CUSTOMER][NEUTRAL] It is 02153626 ML 8.
[AGENT][NEUTRAL] 02153626
[CUSTOMER][NEUTRAL] ML 8. Yes. Yes.
[AGENT][NEUTRAL] Is that correct?
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, the first name is [PII] and the last name is [PII].
[CUSTOMER][NEUTRAL] Date of birth is on [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service and the total bill for the claim?
[CUSTOMER][NEUTRAL] Yeah. It is of [PII].
[CUSTOMER][NEUTRAL] And the bill amount is $456 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And would it be the same provider or a different provider on the claim?
[CUSTOMER][NEUTRAL] It is for the same provider.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Alright, so I'm shall receive the claim on [PII].
[AGENT][NEUTRAL] The claim number is 3579088.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Code 99213 was denied because office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] OK. It is not covered by the policy, right?
[AGENT][NEUTRAL] Code 1
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, whether it is under patient policy or the provider's policy.
[AGENT][NEUTRAL] The patient's policy.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Did you need the status for the other code?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] 17,110 was denied because the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] It was denied as non-covered as it is under doctor's policy, right?
[AGENT][NEUTRAL] Not covered when performed in a doctor's office or clinic for the patient's policy.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Do you have any other claims for this member or this policy number?
[CUSTOMER][NEUTRAL] Uh, just a minute. Let me check from my end.
[CUSTOMER][NEUTRAL] Uh, I just want to confirm that, uh, the line item 17,110 was denied as a non-covered as it was performed in the doctor's place under the policy, right?
[AGENT][NEUTRAL] The denial reason is the the claim.
[AGENT][NEUTRAL] Well, let me go back to it. Hold on one second.
[AGENT][NEUTRAL] It's not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a moment. Can I place you on hold for a moment?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Hi, [PII]. Thank you for being on hold.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yeah. Can we bill patient for this line item 17,110?
[AGENT][NEUTRAL] We don't determine patient responsibility.
[AGENT][NEUTRAL] And [PII], are you ready to move on to the next member?
[CUSTOMER][NEUTRAL] Yeah, just a moment.
[CUSTOMER][NEUTRAL] Yeah, I'm online. Thank you for being on hold.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yeah, and the call reference is your name and today's state. Am I right?
[AGENT][NEUTRAL] Yes, for the entire call.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Uh, can I move to the another one?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Just a moment. Let me pull the details of the other one.
[CUSTOMER][NEUTRAL] And the next member ID is 01699452ML8.
[AGENT][NEUTRAL] Thank you. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] The member's first name is [PII] and the last name is [PII]. Date of birth is on [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] It is on [PII].
[AGENT][NEUTRAL] And the total bill amount?
[CUSTOMER][NEUTRAL] $898 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] Alright, so the active policy on that data service is policy number 247.
[AGENT][NEUTRAL] 3003.
[AGENT][NEUTRAL] And this policy has been active since [PII].
[AGENT][NEUTRAL] Hold on one moment. I'm gonna check this policy and see if there's a claim here.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, so we only have one claim for that data service. It is from your provider, but it is a different total bill. Could it, could there be any other total bills?
[CUSTOMER][NEUTRAL] Oh, is it $350?
[AGENT][NEUTRAL] Um, hold on one moment.
[AGENT][NEUTRAL] You said $150?
[CUSTOMER][NEUTRAL] No, 350.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Uh, uh, I could only see it is of $890.
[AGENT][NEUTRAL] OK. Well, if that's the case, then we do not have your claim on file, but this policy was active on the data service, so you can file the claim if you like.
[CUSTOMER][NEUTRAL] Oh, just a moment. Uh, can you please check with the bill amount of $197?
[AGENT][NEUTRAL] Yes, that's the amount that I saw. Hold on one moment.
[AGENT][NEUTRAL] We received that claim on [PII].
[AGENT][NEUTRAL] The claim number is 357.
[AGENT][NEUTRAL] 6654.
[AGENT][NEUTRAL] And on [PII], the claim was denied because office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] OK. Is it under patient policy or like provider's policy?
[AGENT][NEUTRAL] That office visits are not covered?
[CUSTOMER][NEUTRAL] Yes. Uh, but it is on a patient policy.
[AGENT][NEUTRAL] The patient's policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, is member having any other policies?
[AGENT][NEUTRAL] This is the only active policy.
[CUSTOMER][NEUTRAL] Like we need the coverage.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we can bill patient under this as it is not covered under the policy, right?
[AGENT][NEUTRAL] Again, we do not determine patient responsibility at APL.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And the next member's policy number whenever you're ready.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And the next member ID is 01678145.
[AGENT][NEUTRAL] And the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] The member's last name is [PII] and the first name is [PII]. Date of birth is on [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] Yeah, date of service is on [PII] and the bill amount is $602. Uh just a minute.
[CUSTOMER][NEUTRAL] It is of $277 even.
[AGENT][NEUTRAL] Thank you for that. And again, just for the call, all the information provided is a verification of benefits, not a guarantee of payment. So I'm showing that this claim was received on
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The claim number is 3573847.
[AGENT][NEUTRAL] And on [PII], the claim was denied because office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] I just want to confirm it is on the patient policy or provider's policy?
[AGENT][NEUTRAL] This will all be for the patient's policy.
[CUSTOMER][NEUTRAL] OK, thank you. And is there any other active coverage or other policies?
[CUSTOMER][NEUTRAL] For the members?
[AGENT][NEUTRAL] I mean, are you asking if they had any policies prior to the one that was for the data service?
[CUSTOMER][NEUTRAL] Uh, no. Uh, for the date of service, is member having any other active coverage or any other active policies?
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] No, this is the only medical policy that they have active.
[AGENT][NEUTRAL] With APL.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Can I go with the another one?
[AGENT][NEUTRAL] Um, hold on one moment. Let me note this policy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh, and one more thing, can you please fax the EOB?
[AGENT][NEUTRAL] For just this policy or will you need it for all?
[CUSTOMER][NEUTRAL] With attention to my name.
[CUSTOMER][NEUTRAL] For this policy and the previous one.
[AGENT][NEUTRAL] OK, hold on one moment, let me note this policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What's a good fax number for you?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] And it needs to be attention, [PII]
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. And the next member's policy number when you're ready?
[CUSTOMER][NEUTRAL] Yeah. And I also want to will be for the previous claim which is Robert Aller for the member.
[AGENT][NEUTRAL] So just send the explanation of benefits for the claims that we've gone over today.
[CUSTOMER][NEUTRAL] OK. And the next is for the same.
[AGENT][NEUTRAL] I'm asking.
[AGENT][NEUTRAL] I'm asking if that's what
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Yes, I'm asking you if you'd like me to send the explanation of benefits for the claims we go over today.
[CUSTOMER][POSITIVE] Yes, yes, please call.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And you said the next claim is for the same member?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] How many days of service does this member have?
[CUSTOMER][NEUTRAL] Oh, and this one.
[AGENT][NEUTRAL] The one that we went over and the one that you're about to give me?
[AGENT][NEUTRAL] I'm just asking for notes. OK, what's the next data service?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the total bills?
[CUSTOMER][NEUTRAL] $277 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] So I'm trying to received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 3573852.
[AGENT][NEUTRAL] And on [PII], we um denied the claim because office visits are not covered on this policy.
[CUSTOMER][NEUTRAL] I just want to confirm it is on the patient policy, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. And there is no other coverages or?
[CUSTOMER][NEUTRAL] Policy for this number.
[AGENT][NEUTRAL] This is the only, um, this was the only active policy with the insured.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] And also, can you please fax it before this claim also?
[AGENT][NEUTRAL] Yes, I'll be faxing them for all the claims we go over.
[CUSTOMER][NEUTRAL] Yeah. Can I go with the another one?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. And the next member ID is 023 consecutive 4790ML8.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah. The member, last name is [PII] and the first name is [PII]. Date of birth is on [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] Date of service is on [PII]. And the total bill amount is 5 $4 504 dollars even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So I shall receive the claim on [PII]?
[AGENT][NEUTRAL] Claim number is 3573992.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim a total of $48.02.
[CUSTOMER][NEUTRAL] Oh, I just want to know like how much the claim was paid.
[AGENT][NEUTRAL] $48.02.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] I just want to confirm, is it for the line item?
[AGENT][NEUTRAL] Line item 11102 was billed at $48.02 so we paid that full total.
[AGENT][NEUTRAL] Code 996
[CUSTOMER][NEUTRAL] OK. And for the line item 24.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Would you like me to proceed?
[CUSTOMER][NEUTRAL] Yeah, please go ahead.
[AGENT][NEUTRAL] 99214 was denied because office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] And it is on the patient policy, right?
[AGENT][NEUTRAL] Yes, this would be all due to the patient's policy.
[CUSTOMER][NEUTRAL] OK. Uh, does the member has any other coverages or policies?
[AGENT][NEUTRAL] Um, not with APL.
[CUSTOMER][NEUTRAL] Yeah, you stated that there is no other policies on, right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK. Thank you. And the call reference number is your name and today's date, right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Oh thank you. Uh, can you please fax the EOB for this claim also?
[AGENT][NEUTRAL] Yes, we'll be faxing for each claim we went over today.
[CUSTOMER][POSITIVE] Yeah. Thank you. Thank you for that. Thank you and uh have a great day. Bye-bye.
[AGENT][POSITIVE] You're welcome, buddy. You also, was there anything else I could assist you with today?
[CUSTOMER][NEGATIVE] No, I'm, I'm done with it.
[AGENT][POSITIVE] Alright, well, thanks for calling APL and I hope you have a great day.
[CUSTOMER][NEUTRAL] Bye bye.