AccountId: 011433970860
ContactId: 4c61b6c6-fe35-48ac-9db9-5484a937d34b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 728210 ms
Total Talk Time (AGENT): 263968 ms
Total Talk Time (CUSTOMER): 188366 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/09/4c61b6c6-fe35-48ac-9db9-5484a937d34b_20250509T20:04_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yes, hi. My name is [PII]. I'm calling from NYU, the provider's office. Today, I'm calling for the claim status. Could you provide me?
[AGENT][NEUTRAL] OK, sure. I can assist you with claim status. And you say you're calling from NYU?
[CUSTOMER][NEUTRAL] NYU, N as in November, Y for Yankee, U umbrella. Can you spell out your name for me?
[AGENT][NEUTRAL] OK. Thank you. My name is [PII]. That's [PII].
[AGENT][NEUTRAL] And may I have a callback? You're welcome. May I have a callback number just in case we get disconnected?
[CUSTOMER][POSITIVE] Thank you so much, sir.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number, Miss [PII]?
[CUSTOMER][NEUTRAL] The member ID D as in Delta 49000095.
[AGENT][NEUTRAL] Um, do you see a policy certificate number? It's gonna start with the 0 followed by 7 digits. That's gonna be our number, that the number is for IMA. It's not for us.
[CUSTOMER][NEUTRAL] I have the social security number. Can you check with that number?
[AGENT][NEUTRAL] OK, bear with me just a second. Let me pull another system to use the social, OK? One moment.
[AGENT][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Uh, go ahead with the social.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mm, let me have that one more time.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Remember, SSN is [PII].
[AGENT][NEUTRAL] OK, let me try one more time.
[AGENT][NEUTRAL] OK, and again, that's [PII], correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEGATIVE] I have no one pulling up with that Social Security.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you have like a claim number from us or any other information that might help locate the member?
[CUSTOMER][NEUTRAL] Yes, the claim number 359.
[CUSTOMER][NEUTRAL] 2749.
[AGENT][NEUTRAL] 49. OK, 3592749.
[CUSTOMER][NEUTRAL] 9274983592749.
[AGENT][NEUTRAL] OK. Bear with me just a second. Let me pull the image of that EOB.
[AGENT][NEUTRAL] What's the name of the patient?
[CUSTOMER][NEUTRAL] the member.
[CUSTOMER][NEUTRAL] The member name [PII]. Last name [PII]
[AGENT][NEUTRAL] What's the date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. All right. And let's see, so what is the date of service and the amount of the claim, Miss [PII]?
[CUSTOMER][NEUTRAL] [PII] and double the amount, $782 even.
[AGENT][NEUTRAL] Mm OK.
[AGENT][NEUTRAL] OK, so it looks like um we processed this claim on [PII] and the claim was denied, indicating that our records indicates that the premium for the date of service was not received, therefore benefits are not payable.
[CUSTOMER][NEUTRAL] So this is denied for non-cover charge, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And non covered by patient plan or provider plan?
[AGENT][NEUTRAL] No, um, it's not really not payable. It's, uh, OK, let me read out what it says on the EOB, OK, because it's not really a non-covered service, it's just that we have not received premiums and that's why we cannot pay because there's no um benefits for that week. So our the denial is indicating our records indicate that the premium for the date of service was not received.
[AGENT][NEUTRAL] Therefore, benefits are not payable.
[CUSTOMER][NEUTRAL] OK, but I said that you will be denied for non-covered charges for the claim number whatever I provided to you.
[AGENT][NEUTRAL] That's not the that's not the denial. The denial reason is the one that I'm giving you.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Your records premium that for the date of service not received for the benefits of payable.
[AGENT][NEUTRAL] Again, let me, let me read it again. One moment. Let me go back to it. Our records indicate that the premium for the date of service was not received.
[AGENT][NEUTRAL] Therefore benefits are not payable.
[CUSTOMER][NEUTRAL] For the date of service, not for the date of service not received for the benefits of payable, right?
[AGENT][NEUTRAL] Therefore, benefits are not payable.
[CUSTOMER][NEUTRAL] OK. Just only one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And may I know the denial date?
[AGENT][NEUTRAL] OK, that is on [PII].
[CUSTOMER][NEUTRAL] 2.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes, 25 years.
[AGENT][NEUTRAL] 25 years, yeah. Uh-huh. It's gonna be [PII].
[CUSTOMER][NEUTRAL] May I know which policy you would need for this one?
[AGENT][NEUTRAL] I'm sorry, can you repeat?
[CUSTOMER][NEGATIVE] And this is denied, you stated, right? May I know the reason that denied me, which policy you denied this one?
[AGENT][NEUTRAL] Which policy I deny this one. I'm not really sure exactly what's your question now. The policy that we have for this member is a limited hospital indemnity plan. I'm not sure if that answers your question.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Limited Hospital.
[AGENT][NEUTRAL] Indemnity policy.
[CUSTOMER][NEUTRAL] Intermetic.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And this is by the patient plan?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] May I know the patient have which plan, PPO or HMO?
[AGENT][NEUTRAL] It's not a PPO and HMO it's a commercial plan.
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And may I know patient have which plan? It's a PPO or HMO or EPO?
[AGENT][NEUTRAL] It's a commercial plan.
[CUSTOMER][NEUTRAL] And just only one moment, uh, Sol.
[AGENT][NEUTRAL] Mm sure.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Yes, thank you.
[CUSTOMER][NEUTRAL] 6415.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, may I know the call reference number and the claim number, whatever I brought it to, that's the correct one for this one, right?
[AGENT][NEUTRAL] Yeah, it's the same one.
[CUSTOMER][NEUTRAL] OK may I call reference.
[AGENT][NEUTRAL] We don't have reference numbers you can use my name in today's date.
[CUSTOMER][POSITIVE] Thank you so much sir for assisting me today and you stated received on [PII] and denied on [PII], right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And the need for the patient plan, it's indicated that for benefits are payable, right?
[AGENT][NEGATIVE] denied because the premium was not received and the benefits are not payable.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much for assisting me today. And before that, can you provide me the
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Perfectly mailing address.
[AGENT][NEUTRAL] The address is going to be [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII] City, [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] Sorry, spell out that name.
[AGENT][NEUTRAL] Spell out [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, that is [PII] [PII].
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] You're welcome. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] And the ZIP code?
[CUSTOMER][NEUTRAL] May I know the ZIP code?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Sorry, [PII].
[AGENT][NEUTRAL] [PII]. Mhm.
[CUSTOMER][NEUTRAL] [PII]. Mhm.
[CUSTOMER][NEUTRAL] Yeah I know the timely filing limit for the corrected one.
[AGENT][NEUTRAL] We don't have timely filing limits for correct the claim. Now, if you need to submit an appeal, it's 180 days from the decision date.
[CUSTOMER][POSITIVE] OK. Thank you so much for assisting me today. Have a good day and bye for now.
[AGENT][POSITIVE] Yes sir. Thank you for calling APL bye.