AccountId: 011433970860
ContactId: 2bbebe97-5c36-41a1-a47b-18fa9bfd0218
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 581669 ms
Total Talk Time (AGENT): 140661 ms
Total Talk Time (CUSTOMER): 211373 ms
Interruptions: 2
Overall Sentiment: AGENT=0.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/28/2bbebe97-5c36-41a1-a47b-18fa9bfd0218_20250128T15:17_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] and the initial to my last name is [PII]. I'm calling for the provider to check on an additional information about the claim that has been denied. Please note this call will be monitored and recorded for quality and training purposes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I can help you spell your name for me, please.
[CUSTOMER][POSITIVE] I can help
[CUSTOMER][NEUTRAL] Yeah. My name is [PII], which is spelled as [PII]
[AGENT][NEUTRAL] OK [PII], what's the policy number and claim number?
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] The policy number is 02496467.
[CUSTOMER][NEUTRAL] M as in Mike. L as in Lima, number 8.
[AGENT][NEUTRAL] And the claim number?
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] The claim number is 3547025.
[AGENT][NEUTRAL] OK, what's a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] The callback number is [PII]. It's a direct line.
[AGENT][POSITIVE] OK, thank you for that give me one moment to pull up the file.
[CUSTOMER][NEUTRAL] Mhm, yes.
[CUSTOMER][NEUTRAL] you.
[CUSTOMER][NEUTRAL] Very much.
[AGENT][NEUTRAL] And if you can verify the patient's name and date of birth for me, [PII].
[CUSTOMER][NEUTRAL] Have
[CUSTOMER][NEUTRAL] Yeah, sure. Patient's name is [PII]. Date of birth is on [PII].
[AGENT][NEUTRAL] I have policy 02496.
[AGENT][NEUTRAL] 46
[CUSTOMER][NEUTRAL] Yeah, yeah, that's the number 467 M as in Mike, L as in Lima, the number 8.
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] And I'm sorry, repeat the patient's name and date of birth again.
[CUSTOMER][NEUTRAL] Yeah. Patient's name is [PII]. Date of birth is on [PII]. When, uh, upon checking from my end, uh, this, uh, patient has been covered from their mother's insurance.
[AGENT][NEUTRAL] OK, but I'm showing a different last name.
[AGENT][NEUTRAL] Can you spell the last name for me?
[CUSTOMER][NEUTRAL] One.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Last name is [PII]
[AGENT][NEUTRAL] OK, that's the first name. What's the last name?
[CUSTOMER][NEUTRAL] Last name, which I have here [PII], the [PII].
[AGENT][NEUTRAL] Yeah, I'm showing something different for the first name.
[AGENT][NEUTRAL] You have a copy of the medical identification card?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Uh, no, I don't have any card with me. Well, one moment, let me just check if I have any different.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well we receive an EOB. Let me check on that one.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, on this one, are they.
[CUSTOMER][NEUTRAL] name which is spelled as [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, and I see that and what was your question regarding the claim?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, uh, I can see in the UB in which received, uh, the claim has been denied because the primary OB is not, uh, submitted with the claim. Well, upon checking from my end, uh, I can see we have submitted the primary OB.
[CUSTOMER][NEUTRAL] In the initial submission, so I just wanted to verify if the primary payer for the member on the date of service is I met.
[CUSTOMER][NEUTRAL] HMO
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You.
[AGENT][NEUTRAL] See
[AGENT][NEUTRAL] So now the claim was processed on the [PII], uh, the remark code that I'm showing on the claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, it says that the, the benefits were not.
[CUSTOMER][NEUTRAL] Oh what?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Uh, paid by the major medical they were denied.
[AGENT][NEUTRAL] And so whenever this happens this policy does not cover the benefit or the you know the charges either.
[CUSTOMER][NEUTRAL] OK. So this is not covered as per the patient's policy, right?
[AGENT][NEUTRAL] Well, I just read the remark code. So whenever it's denied by the primary insurance is not covered, it's not covered by this policy either.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So that's the reason for the denial.
[CUSTOMER][NEUTRAL] So the
[CUSTOMER][NEUTRAL] OK. Um, uh, upon checking from my end, we received the denial as the primary OB was not received. So I just wanted to make sure is um the primary, yeah, OK. And the primary payer is a matric.
[AGENT][NEUTRAL] We received it.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's what we're showing on our records. You can also check with the patient as well.
[CUSTOMER][NEUTRAL] OK sure.
[CUSTOMER][NEGATIVE] So this is denied because the primary insurance uh refused to pay, so secondary insurance will also refuse to pay this, that, that's the reason, right?
[AGENT][NEUTRAL] That's not what I said.
[AGENT][NEUTRAL] The primary insurance denied the charges.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] As not covered. It's not that they refuse to pay, they denied it is not covered. Whenever it's denied by the primary insurance, this policy does not cover.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. OK, sure. Just for the documentation purpose. Yeah.
[AGENT][NEUTRAL] And if you'd like, you can go on our website and download a copy of the explanation of benefits that was mailed uh to this office um the web address is secured.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII] and if you need me to help with creating that account, helping you create the account, I can do that as well. Uh you'll use my name in today's date as reference for today's call. [PII]t name is R as in Randy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, I just wanted to verify what is the mailing address and time limit. That's all.
[AGENT][NEUTRAL] It's the same as the claim mailing address, 180 days from the date of denial.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So this has been uh denied us on [PII], right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, then. uh, is there any attention while submitting uh appeal?
[AGENT][NEUTRAL] Make, make it to the attention of appeals.
[CUSTOMER][POSITIVE] OK, thank you. And that's all, that's all done.
[AGENT][NEUTRAL] And submit any supporting to provide any supporting documentation that you may have as to why the claim is being appealed. Anything else?
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][POSITIVE] OK. OK. No, that's all. And thank you for your assistance.
[AGENT][POSITIVE] All right, [PII], thank
[AGENT][POSITIVE] Thank you, [PII] for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] Yeah, bye.
[CUSTOMER][POSITIVE] Mhm. Have a good day. Bye.