AccountId: 011433970860
ContactId: 3d5b1d75-c477-4fd1-bef6-5f864b66cd91
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1631849 ms
Total Talk Time (AGENT): 609501 ms
Total Talk Time (CUSTOMER): 361144 ms
Interruptions: 5
Overall Sentiment: AGENT=0.6, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/08/3d5b1d75-c477-4fd1-bef6-5f864b66cd91_20250508T20:28_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII], initial of my last name, [PII], calling from provider's office to check on a claim status. But before I proceed, kindly note that this call is being recorded for quality assurance. Are you OK with that?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That is fine. And could you spell your first name for me, please?
[CUSTOMER][NEUTRAL] It is [PII]. Initial of my last name is [PII].
[AGENT][NEUTRAL] Thank you, [PII]. And what is your callback number?
[CUSTOMER][NEUTRAL] [PII] with the extension of [PII].
[AGENT][POSITIVE] Thank you. And how can I help you today, [PII]?
[CUSTOMER][NEUTRAL] Uh, like I have claims that we have sent the primary UB. I just need the status of that.
[AGENT][NEUTRAL] OK. How many claims do you need status on?
[CUSTOMER][NEUTRAL] Like how much can you uh provide me?
[AGENT][NEUTRAL] How many do you have? How many do you have?
[CUSTOMER][NEUTRAL] I have like 2344 to 5.
[AGENT][NEUTRAL] I can help you with that and [PII], you will use my name that I gave you along with today's date as your call reference number for each one. Also any information [PII]?
[CUSTOMER][NEUTRAL] Uh, your name is?
[CUSTOMER][NEUTRAL] Can you please spell out your name for me?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And [PII], any information that I provide for you today will be a verification of benefits and not a guarantee of payment. And lastly, if we do have the claims on file and you need a copy of the explanation of benefits, once you have the claim number, you can print those yourself by going to our portal located at [PII].
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm, OK.
[AGENT][NEUTRAL] Alright, and what is your first patient's policy number?
[CUSTOMER][NEUTRAL] It is 02003072.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And your patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Yes, it is [PII].
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] What's the data service and total bill amount that you're calling about today [PII]?
[CUSTOMER][NEUTRAL] It is [PII], 2024 with the bill amount of $900 even.
[AGENT][NEUTRAL] OK, thank you. So the policy number that you gave me, [PII], is not the correct policy number. That is an old policy number that was not active for your data service.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, that policy number that you provided for me actually terminated [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The policy number that you should have now.
[AGENT][NEUTRAL] Is 02.
[AGENT][NEUTRAL] 46.
[AGENT][NEUTRAL] 7710.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And when it has an effective date of [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And give me just a moment to get that information pulled up, please.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And you said the data services 10-16 2024 for $900 is that correct?
[CUSTOMER][NEUTRAL] Yeah, right.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, [PII], so do you already have the claim number for that data service?
[CUSTOMER][NEUTRAL] Yeah, I
[CUSTOMER][NEUTRAL] Mhm I have.
[AGENT][NEUTRAL] OK, and this does still, it does show that we are still in need of the primary insurance's explanation of benefits. It does not show that that has been received.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Like, uh, we have recently, uh, sent the primary on [PII].
[AGENT][NEGATIVE] It was not received.
[CUSTOMER][NEUTRAL] Mm, like I have, uh, more claims that we have already sent the UV.
[AGENT][NEUTRAL] Yes, so I'm just letting you know, I'm not sure what happened, but we did not receive the explanation of benefits for this claim.
[CUSTOMER][NEUTRAL] Uh, like.
[CUSTOMER][NEUTRAL] OK. So, mhm.
[CUSTOMER][NEUTRAL] Your fax number is [PII]. Is it correct?
[AGENT][NEUTRAL] Uh-huh. Attention claims department.
[CUSTOMER][NEUTRAL] OK, and this claim received on?
[AGENT][NEUTRAL] The original claim was received [PII] and denied the same day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] And the next one is.
[AGENT][NEUTRAL] OK just a moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and what is your next patient's policy number?
[CUSTOMER][NEUTRAL] It is 22392.
[CUSTOMER][NEUTRAL] Patient name is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That's not a policy number? No, so that's not a policy number, that's a group number. What's her policy number?
[CUSTOMER][NEUTRAL] Date of birth is.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Actually I have that only. Do you want the name or date of birth to?
[AGENT][NEUTRAL] I can't search by date of birth, just one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What is the last name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And the first name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And what is her date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So the policy number that you should have and to submit with the claim is 01611565 and this policy has an effective date of [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is the date of service and total bill amount for her, please?
[CUSTOMER][NEUTRAL] The service is [PII]. Bill amount is $750 even.
[AGENT][NEUTRAL] 750, is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so this claim was received on [PII].
[AGENT][NEUTRAL] And it was processed on [PII].
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] The claim number is 3567433.
[AGENT][NEGATIVE] This claim was denied.
[AGENT][NEUTRAL] Uh, one of the remarks states.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] That it is a duplicate of previously submitted expenses that was on code 99213.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it had been previous initially denied as office visits are not covered under the policy. The member's policy does not cover office visits.
[CUSTOMER][NEUTRAL] Uh, actually for
[AGENT][NEUTRAL] And the other code 76,830 that was denied stating we have received a primary explanation of benefits that was submitted with your claim. However, the explanation of benefits received does not list the amounts applied to the deductible, co-pay, or co-insurance.
[CUSTOMER][NEUTRAL] Mhm, yeah.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] Please submit a more detailed explanation of benefits that shows these amounts for further consideration of your claim.
[CUSTOMER][NEUTRAL] OK, so we have to send again.
[AGENT][NEUTRAL] We need a detailed explanation of benefits showing the amounts applied to the co-pay, deductible, or co-insurance.
[CUSTOMER][NEUTRAL] Right?
[CUSTOMER][NEUTRAL] OK. And the latest number is?
[AGENT][NEUTRAL] The latest claim number that it was reviewed under is 3567433.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And do you need any other information on this number?
[CUSTOMER][NEUTRAL] No, that's it. We have to send the primary right? and uh.
[AGENT][NEUTRAL] But I did, we received a primary EOB but it did not have specific things on it, so we do need a detailed EOB. That is correct.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm, yeah.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] OK, so moving into next next uh.
[CUSTOMER][NEUTRAL] The claim num uh yeah, the next member ID mhm.
[AGENT][NEUTRAL] What is the policy number?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Is 022.
[CUSTOMER][NEUTRAL] 557
[CUSTOMER][NEUTRAL] 79
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] It is [PII].
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And let's see, the data service and total bill amount for her place.
[CUSTOMER][NEUTRAL] Yeah, the data service is [PII]. The amount is $400 even.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so the most recently received claim, let's see.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Most recently received information on this number. One moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Was received on [PII].
[AGENT][NEUTRAL] And it was processed and denied on [PII].
[CUSTOMER][NEUTRAL] Hm
[AGENT][NEUTRAL] The claim number is 353-2356.
[AGENT][NEUTRAL] And this claim was denied as a duplicate of previously submitted expenses.
[CUSTOMER][NEUTRAL] OK, sir, it is duplicate.
[AGENT][POSITIVE] I'm so sorry.
[CUSTOMER][NEUTRAL] So you need like the primary for this one also primary UV.
[AGENT][NEUTRAL] Oh
[AGENT][NEGATIVE] The original claim was denied.
[AGENT][NEUTRAL] Under claim number 352.
[AGENT][NEUTRAL] 3037.
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] And that was denied as this service is not covered when performed as a, in a doctor's office or clinic. Again, under the member's plan, the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] And do you need any other information on this one, [PII]?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEGATIVE] No, that's it. No.
[CUSTOMER][NEUTRAL] Next one, just a moment.
[AGENT][NEUTRAL] One moment. Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, the next member ID is.
[CUSTOMER][NEUTRAL] 022
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 105.
[CUSTOMER][NEUTRAL] 75.
[CUSTOMER][NEUTRAL] At Miami at Lima.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Ah
[CUSTOMER][NEUTRAL] It is [PII].
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Data service and total bill amount please.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] The amount is $1560 even.
[AGENT][NEUTRAL] OK, so the date of service is [PII]. Is that correct?
[CUSTOMER][POSITIVE] Yeah, right. Yeah, yeah. Correct.
[AGENT][NEUTRAL] And the billed amount is 1560. Is that correct?
[CUSTOMER][NEUTRAL] 60. Mhm yes.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so this claim was received on [PII].
[AGENT][NEUTRAL] And it was processed on [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 3577845.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Just one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So on this one it shows there was a benefit paid in the amount of $90.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] And that was on track number 2033884.
[AGENT][NEUTRAL] And that was paid on code 76,830.
[AGENT][NEUTRAL] The other codes were denied [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And one moment and I can provide you that information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And it does show that that check cleared on 42.
[AGENT][NEUTRAL] OK, so on code.
[AGENT][NEUTRAL] 99396.
[AGENT][NEUTRAL] That was denied as benefits not payable for condition other than sickness or injury.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] Um, the next one for
[AGENT][NEUTRAL] 99212 was denied as office visits are not covered by this policy. The member's plan does not cover office visits.
[AGENT][NEUTRAL] And the last code, which was 76856, was, was denied on here. It states insured's major medical coverage provided full benefits, no benefits payable for this procedure.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 76801.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, moving into the next one.
[AGENT][NEUTRAL] Uh just a moment, please.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] 018.
[CUSTOMER][NEUTRAL] 233.
[CUSTOMER][NEUTRAL] 39
[CUSTOMER][NEUTRAL] Um miami L Lima 8.
[AGENT][POSITIVE] Thank you, one moment.
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] It is [PII].
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And what is the date of service and total bill amount, please?
[CUSTOMER][NEUTRAL] D of service is [PII].
[CUSTOMER][NEUTRAL] Bill amount is $1200 even.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And for this one also we have already sent the primary UB so do you have status of that?
[AGENT][NEUTRAL] I don't have the information pulled up yet to know that. Just one moment, [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But this was received on [PII].
[AGENT][NEUTRAL] It was processed on [PII].
[AGENT][NEUTRAL] The claim number is 3533105.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] what about you?
[AGENT][NEUTRAL] There was a benefit paid in the amount of $500.
[AGENT][NEUTRAL] And that was paid on single check [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that check did clear on [PII].
[AGENT][NEUTRAL] And the remark with this payment states with this check.
[AGENT][NEUTRAL] The maximum benefits payable for this state of service has been met.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Next benefit.
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So the remaining balance is
[CUSTOMER][NEUTRAL] PTR or?
[AGENT][NEUTRAL] We
[AGENT][NEUTRAL] We do not determine patient responsibility. That would be up to the provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Uh, yeah, the last one.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] Yeah. It is 024.
[CUSTOMER][NEUTRAL] 501
[CUSTOMER][NEUTRAL] 02
[CUSTOMER][NEUTRAL] At Miami at Lima 7.
[AGENT][NEUTRAL] OK, thank you. One moment, please.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And your patient's name please and date of birth?
[CUSTOMER][NEUTRAL] It is [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And the date of service and total bill amount for her place?
[CUSTOMER][NEUTRAL] The service is [PII] bill amount is $1600 even.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so this claim was received on 224-2025?
[AGENT][NEUTRAL] It was processed on 227-2025.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] There was a benefit paid in the amount of $80.
[AGENT][NEUTRAL] That was on check number 2030053.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And just one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I just need.
[CUSTOMER][NEUTRAL] Uh, for procedure code.
[AGENT][NEUTRAL] And that check also cleared?
[CUSTOMER][NEUTRAL] 99213 only because yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so for 99213, that was denied.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEGATIVE] And that is denied because office visits are not covered.
[AGENT][NEUTRAL] By this policy, the member's plan does not cover office visits.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] OK. This is not good. And the uh patient insurance name is?
[AGENT][NEUTRAL] This is Med the, the name is our company name is APL.
[CUSTOMER][NEUTRAL] And patient, OK CPA.
[AGENT][NEUTRAL] This is a supplemental policy. Yes, this is a supplemental policy. It is not major medical insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Claim number is
[AGENT][NEUTRAL] 356.
[AGENT][NEUTRAL] 9090.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 9090.
[AGENT][NEUTRAL] Yes, again, the claim number is 3,569,090.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] So, yeah. Thank you, [PII], for your assistance and
[AGENT][POSITIVE] Oh, you're very welcome. You're welcome. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] No, that's it. Thank you.
[AGENT][POSITIVE] OK, well then thank you [PII] for calling APO and I hope that you have a great rest of your day today.
[CUSTOMER][NEUTRAL] Yeah bye.