AccountId: 011433970860
ContactId: 294fd03f-561a-4380-9676-67e020ced385
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 756719 ms
Total Talk Time (AGENT): 218602 ms
Total Talk Time (CUSTOMER): 161354 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/27/294fd03f-561a-4380-9676-67e020ced385_20250127T15:08_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from provider's office checking on a claim status.
[AGENT][NEUTRAL] OK, sure, I can assist you with claim status Msneaky. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yeah, sure. That is [PII]. And can I have your name? Can you please spell your name?
[AGENT][NEUTRAL] Sure. Yes. My name is [PII]. That's [PII]. Last initial [PII].
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] Yeah, thankfully.
[AGENT][NEUTRAL] You're welcome. And may I have the patient's policy number, Miss [PII]?
[CUSTOMER][NEUTRAL] Uh yeah, sure. That is 25921.
[AGENT][NEUTRAL] Is that all the numbers you see?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. Yeah, that's not enough numbers. Do you have the copy of the card?
[CUSTOMER][NEUTRAL] This copy of the account, just give me a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, it looks like I don't have the uh copy of.
[CUSTOMER][NEUTRAL] The card?
[AGENT][NEUTRAL] OK. All right. um, we can do a name search, Ms. [PII]. What is the spelling of the last name?
[CUSTOMER][NEUTRAL] Just give me a moment.
[CUSTOMER][NEUTRAL] So the patient's last name is [PII]
[AGENT][NEUTRAL] OK, and what's the spelling of the first name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK. And may I have the date of birth?
[CUSTOMER][NEUTRAL] Oh sure. The date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. I found them right and may I have the date of service and the amount of the claims?
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh, sure. The total service is [PII] and the total charge amount, $10,000 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, let me see if I can find this claim for you, and that was [PII], correct?
[CUSTOMER][POSITIVE] Yes, correct.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you say it was [PII]?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] We don't have anything for [PII].
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] OK, is the patient active for this, um.
[AGENT][NEUTRAL] Mhm. Yes, um, the, yes, the effective date on the policy is [PII] and it is active at the moment and this is one of our secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] The service?
[CUSTOMER][POSITIVE] OK, thanks for that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm, can you please provide me the payer ID?
[AGENT][NEUTRAL] OK. The payer ID is 60801. Again, that's 60801. Now this is a secondary supplemental plan to the major medical, so we need this claim to be sent by fax or mail because we need the explanation of benefits from the primary insurance attached to it.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, thanks for that. And uh can you please provide me the fax number?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Sure, the fax number is [PII].
[CUSTOMER][POSITIVE] Thanks for that. And how about the mailing address?
[AGENT][NEUTRAL] Um, mailing address is [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Thanks for that. And what will be the timely spending limit?
[AGENT][NEGATIVE] There's no timely filing limits.
[CUSTOMER][NEUTRAL] Thanks for that. And the call reference number?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will. Do you need the spelling of my name or any other information?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah. Actually, I have another uh patient to check.
[AGENT][NEUTRAL] A different one or a different member?
[CUSTOMER][NEUTRAL] Yeah, the different one. Yes.
[AGENT][NEUTRAL] OK, let me make a note on this one so we can move forward to the next one. OK, one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you say you're calling from which provider Miss [PII]?
[CUSTOMER][NEUTRAL] Uh, I'm calling from, hold on.
[CUSTOMER][NEUTRAL] I'm calling from Gastro Health LLC.
[AGENT][NEUTRAL] That's true.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, I'm almost done, bear with me.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, go ahead with the next policy number.
[CUSTOMER][NEUTRAL] The policy number here 02430719.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah, the patient's first name is [PII] and the last name is [PII]
[AGENT][NEUTRAL] OK, what's the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] The date of service is um [PII] and the total charge amount $16,600 even.
[AGENT][NEUTRAL] OK. Can you verify the date of birth for Ms. [PII] one more time?
[CUSTOMER][NEUTRAL] Oh, sure. My date of birth is [PII].
[AGENT][NEUTRAL] Thank you. All right, so you said the date of service was [PII]?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me pull the explanation of benefits on this 11 moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it looks like we um received a claim on [PII] process on [PII].
[AGENT][NEGATIVE] And it looks like it was denied. The reason for this denial is the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, just give me a moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, um, thanks for that. And can you please verify whether, um, the service, as you said it is not covered. It is under patient plan or for the provider's plan.
[AGENT][NEUTRAL] Patients plan.
[CUSTOMER][NEUTRAL] OK, uh, can you also please verify what patient can has like patient has HMO or PPOR?
[AGENT][NEUTRAL] This is a secondary supplemental plan to the major medical and a TP or an H more as a commercial.
[CUSTOMER][POSITIVE] OK, thanks for that.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Just give me a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, thanks for that, and, uh, can I, uh, submit an appeal?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Yes, you have 180 days from the decision date to submit any appeals.
[CUSTOMER][NEUTRAL] Decision date uh which means, um, the process date or?
[AGENT][NEUTRAL] Mhm. Um, on this case, the decision, yeah, the process date [PII]. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what will be the fax ID?
[AGENT][NEUTRAL] The fax number?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's gonna be the same one I gave you previously, which is [PII]. Mhm.
[CUSTOMER][NEUTRAL] Oh, OK, thanks.
[CUSTOMER][POSITIVE] OK. Thanks for the information.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Uh, just give me a moment.
[CUSTOMER][NEUTRAL] Yeah, thanks for that. And what will be the call reference number?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will. Do you need the spelling of my name or any other information?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Uh well, no, I have, yeah, that's all. Thanks for the assistance. Have a good day. Bye-bye.
[AGENT][POSITIVE] You as well thank you for calling APR. Have a good day.