AccountId: 011433970860
ContactId: 40cd2c0e-5cea-48fa-a2aa-42ada241696e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 423690 ms
Total Talk Time (AGENT): 183118 ms
Total Talk Time (CUSTOMER): 129308 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/28/40cd2c0e-5cea-48fa-a2aa-42ada241696e_20250528T18:34_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] Hi, [PII], this is [PII] calling from Day and Night Pediatrics. I'm trying to check on a claim um for a patient of ours.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status, and [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] [PII] is the phone number and the policy number I'm calling about is 60801.
[AGENT][NEUTRAL] So that's our payer ID number. Do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] Give me a second.
[CUSTOMER][NEUTRAL] 5
[CUSTOMER][NEUTRAL] I have a group number of 18188. Does that make sense?
[AGENT][NEUTRAL] Yes, do you have the member's ID card available?
[CUSTOMER][NEUTRAL] Let me check because well no I'm doing this off of the information that I have. Give me a second, um.
[AGENT][NEUTRAL] OK, and you said it was 18188?
[CUSTOMER][NEUTRAL] The.
[AGENT][NEUTRAL] For the group number?
[CUSTOMER][NEUTRAL] So the 60801 does not exist, is that what you're saying?
[AGENT][NEUTRAL] No, it exists. That's our payer ID to submit electronic payments for claims. That's not a policy number.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The, the group number.
[CUSTOMER][NEUTRAL] OK, give me a second, give me.
[AGENT][NEUTRAL] OK, hold on one moment. I'm just trying to look in the system. The group number, did you say it was 18188?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 18188, yes.
[AGENT][NEUTRAL] OK, let me see.
[AGENT][NEUTRAL] Alright, and that group number is no longer active with us. OK, um, do you have the member's full social I can search with?
[AGENT][NEUTRAL] Their first and last name?
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Or the policy number.
[CUSTOMER][NEUTRAL] Give me a second. Give me a second, because if you look at the insurance card, APL APL group number is 18188. The social I do not have what I have is their first and last name, their birth date, and everything like that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you have their ID cards?
[CUSTOMER][NEUTRAL] How can we do this?
[CUSTOMER][NEUTRAL] I do. Mhm.
[AGENT][NEUTRAL] On the card, do you see anywhere that says in hospitals or outpatient policy cert number?
[CUSTOMER][NEUTRAL] Inhospital benefit certification or outpatient benefit certification?
[AGENT][NEUTRAL] Yes, the numbers are the same. The ML 7 or 8 at the end is different. I just need the numbers. That's the policy number.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] 02271365.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] First and last name is [PII].
[CUSTOMER][NEUTRAL] The mother's name is [PII].
[AGENT][NEUTRAL] Can you verify your patient's date of birth, please?
[CUSTOMER][NEUTRAL] Patient's date of birth is [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 for the claim?
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] And the total bills?
[CUSTOMER][NEUTRAL] 488.
[AGENT][NEUTRAL] 48
[AGENT][NEUTRAL] Alright, so just for the call, the information provided is a verification of benefits, not a guarantee of payment. So the active policy during your data services policy number 253.
[AGENT][NEUTRAL] 4038.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And I'm gonna check on that policy to see if there's a claim there. Hold on one second.
[AGENT][NEUTRAL] And what is the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Day and night pediatrics.
[CUSTOMER][NEUTRAL] Part of vital Group clothings.
[AGENT][NEUTRAL] Alright, so we received the claim on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 357.
[AGENT][NEUTRAL] 8545.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Um, code 99214 was denied because office visits are not covered on this policy.
[AGENT][NEUTRAL] Code 946-40 and 87,880 were both denied because the primary or I'm sorry, the primary insurance provided full benefits, so there are no benefits payable.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And then the A7015 was denied.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] Because durable medical equipment.
[AGENT][NEUTRAL] Um, it has to be non-disposable.
[CUSTOMER][NEUTRAL] Hm
[AGENT][NEUTRAL] So it just says that this um that code does not meet the definition of durable medical equipment under the contract.
[CUSTOMER][NEUTRAL] Can you send me the ELB on that?
[AGENT][NEUTRAL] Sure, what's a good fax number for you?
[CUSTOMER][NEUTRAL] Through fax?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And does that need to be
[CUSTOMER][NEUTRAL] And you said you, you you received that on March what? I'm sorry?
[CUSTOMER][NEUTRAL] The original received date um.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, and you got the fax number so you can send me that?
[AGENT][NEUTRAL] Yes, I wanted to confirm it with you. Um, it was [PII]. Did you need that to be attention, [PII]?
[CUSTOMER][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Um, attention billing, that's fine.
[AGENT][POSITIVE] Alright, so I'll go ahead and send this over to you now. Was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] No and if you could please give me a reference number for this call.
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][POSITIVE] OK, perfect. Thank you so very much and.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] We will, we'll, we'll see if we, well, how this can work out here for us. OK, thank you. OK, bye-bye.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] You too bye bye.