AccountId: 011433970860
ContactId: 4eb55266-79b3-4bbe-9a4c-b212a0448e2d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1467569 ms
Total Talk Time (AGENT): 404719 ms
Total Talk Time (CUSTOMER): 438185 ms
Interruptions: 3
Overall Sentiment: AGENT=0.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/29/4eb55266-79b3-4bbe-9a4c-b212a0448e2d_20250129T16:45_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey, hi, this is [PII]. Last name initial [PII] [PII], calling from provider's office to check on claim status and to get our explanation of benefits.
[AGENT][NEUTRAL] OK, I can check the status for you, um, and you can download the ELB from the online service center if it's been processed. What's the policy number?
[CUSTOMER][NEUTRAL] The policy number is D as in Delta 42005319.
[AGENT][NEUTRAL] OK, so that's not our policy number. Do you have the card, the ID card?
[AGENT][NEUTRAL] Or the claim number?
[CUSTOMER][NEUTRAL] Uh, it is, uh, IMA claim and we called IMA and IM is the first.
[CUSTOMER][NEUTRAL] Uh, suggested to call APL.
[AGENT][NEUTRAL] Yeah, that D number is unique to IMA. Uh, what's the patient's first and last name if you could spell that out for me please?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Patient's name is [PII]. The first name spells [PII].
[CUSTOMER][NEUTRAL] And the last name?
[CUSTOMER][NEUTRAL] Spells as [PII].
[AGENT][NEUTRAL] And what's a good phone number [PII] in case we're disconnected?
[CUSTOMER][NEUTRAL] Callback number is [PII]. And you can use the extension [PII] to reach me directly.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes, right.
[AGENT][NEUTRAL] OK, OK. And what's the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII].
[AGENT][NEUTRAL] Oh, you gave me that. I'm sorry. Hold on a second. Let me search for the policy number.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 7
[AGENT][NEUTRAL] And is this a medical or dental claim?
[CUSTOMER][NEUTRAL] Medical client.
[AGENT][NEUTRAL] And what's the date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, let me give you the policy number for APL. Let me know when you're ready.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Uh, and before the policy ID number. Can I get your name, please?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] T O N I
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] T T O N Y A.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Thank you. And may I know the APR member ID?
[AGENT][NEUTRAL] 1814655
[AGENT][NEUTRAL] And if I can get the date of service and the total charge?
[CUSTOMER][NEUTRAL] Date of service is on [PII], total charge on $141 even.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Pro
[AGENT][NEUTRAL] And what's the procedure code on the claim?
[CUSTOMER][NEUTRAL] Uh, so I was on the procedure code is 99213.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] So the claim was received [PII], processed [PII].
[AGENT][NEUTRAL] Uh, there was no payment made on the claim?
[CUSTOMER][NEUTRAL] The
[AGENT][NEUTRAL] It says the calendar your maximum for outpatient office visits.
[AGENT][NEUTRAL] Um, has been meant for this calendar year.
[AGENT][NEUTRAL] Let me know when you're ready for the claim number.
[AGENT][NEUTRAL] And then I can give you the website and assist you with creating an online account to download the ELB that was also mailed when the claim was processed to the uh address on the claim.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] OK, I'm ready for the claim number.
[AGENT][NEUTRAL] You ready for it, the claim number? It's 339-876-0.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] 339-876-0, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] All right. Can you please ask me for the website?
[AGENT][NEUTRAL] OK, so it's secured [PII].
[AGENT][NEUTRAL] U R E D
[AGENT][NEUTRAL] Dot
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Letter A as in apple, letter M, Mary.
[AGENT][NEUTRAL] P Peter U.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I can help you create that account if you would like.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Could you please
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Yeah, please assist me further.
[AGENT][NEUTRAL] OK, so when you get to the home page, it should say online service [PII] welcome.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and so to the right there's gonna be two tabs one that says log in and one that says new user.
[AGENT][NEUTRAL] Click the new user tab.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and then you
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It required asked me to.
[CUSTOMER][NEUTRAL] Choose the role which best describes you, all right, OK.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] All right, and it pops up me to the next step and suggested, and it asked me the tax ID and the patient's account number.
[CUSTOMER][NEUTRAL] So I can provide it with this patient account number, right?
[CUSTOMER][NEUTRAL] Are you still there?
[AGENT][NEUTRAL] Yes, I'm here. Uh, the patient, of course, the tax ID number is the provider's tax identification number, and then the patient account number is the number that's on inbox 26 of the claim that was sent to us.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] So it's not our policy number, it's the patient account number assigned by the office.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] All right, after hitting the patient's account number, it's
[CUSTOMER][NEGATIVE] It shows that no user was found with the information that was entered.
[AGENT][NEUTRAL] OK, so what we need to verify is if you can out loud give me the tax ID number entered and the patient account number that you entered because what you enter has to match what we have in our system. So can you verify those two items for me out loud?
[CUSTOMER][NEUTRAL] Tax ID [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the patient's account number is [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right, yeah, yeah, now it's popped up. I, I just entered him, uh, in my tax ID. I do apologize.
[AGENT][NEUTRAL] OK, hold on one second.
[CUSTOMER][NEUTRAL] 910
[CUSTOMER][NEUTRAL] 8
[AGENT][NEUTRAL] 2 more minutes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Date of birth
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Just a few more minutes.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah, I, uh, for your information, I created that one.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Yes, I created that one and I just found how to download the UOB and I got the AOB yeah.
[AGENT][NEUTRAL] Did you
[AGENT][NEUTRAL] OK, you were able to find it. What did you do different than the first time?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I informed you, right, that my, I just hit the incorrect tax ID.
[AGENT][NEUTRAL] OK, OK, and I see it online too that's what I was looking for because I see it in my system on my end as well so it should be online but you did retrieve it but that's how you can actually check claim status, [PII], and then if you need a copy of the explanation of benefits, that's how you can download it from our website as well.
[CUSTOMER][NEUTRAL] I, I just entered 24.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] And did you have any other questions we can help with today?
[CUSTOMER][NEUTRAL] Uh one moment.
[CUSTOMER][NEUTRAL] Apart from this, uh, apart from this claim, this patient, I do have one more client today. Could you please, I mean two more clients today. Could you please just for the for too?
[AGENT][NEUTRAL] OK, so we'll give you the claim status and then I'll give you the claim number if you need the ELB you can download it from the site where you are. Give me one second, let me document this call for this member.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] I, I do, for the same patient, I do have one more client with me.
[AGENT][NEUTRAL] OK, and what's the date of service?
[CUSTOMER][NEUTRAL] Uh, date of service is on [PII], total charged on $141 even.
[AGENT][NEUTRAL] OK, so the claim number for this one is 345.
[AGENT][NEUTRAL] 19
[AGENT][NEUTRAL] I'm sorry, 1593. So that's 345.
[AGENT][NEUTRAL] 15.
[AGENT][NEUTRAL] 93
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, I, I do have the status here also this claim denied for the
[CUSTOMER][NEUTRAL] Office visit I'm in.
[CUSTOMER][NEUTRAL] Office visit has been adjusted. Uh, maximum benefits has been adjuster. Also, we do, uh, filed an appeal for this claim.
[AGENT][NEUTRAL] OK, I'm sorry, what was that?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] We, we filed an appeal for this claim. Could you please check the appeal claim status?
[AGENT][NEUTRAL] OK, give me just a second.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] 747.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Excuse me.
[AGENT][NEUTRAL] A few more seconds.
[AGENT][NEUTRAL] We
[CUSTOMER][POSITIVE] Yeah, sure. Take your time.
[CUSTOMER][NEUTRAL] Yeah,
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes, I need to wait for
[AGENT][NEUTRAL] OK, now what was your question regarding this uh claim, [PII]?
[AGENT][NEUTRAL] The one for, um, [PII].
[CUSTOMER][NEUTRAL] Uh, we submitted a
[CUSTOMER][NEUTRAL] We filed an appeal and we submitted the appeal via fax uh requesting to check what the appell claim status.
[AGENT][NEUTRAL] Was it made to the attention of appeals?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] Uh, it was not mild. It was patched.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And when was it faxed?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And what, what was it what's the appeal?
[CUSTOMER][NEUTRAL] We just uh fill the claim with medical records.
[AGENT][NEUTRAL] What was the reason for the appeal?
[CUSTOMER][NEUTRAL] We appealed the claim with medical records for the claim got denied for maximum benefit adjusted for office visit.
[CUSTOMER][NEUTRAL] And uh due to medical necessity.
[CUSTOMER][NEUTRAL] We do this client.
[AGENT][NEGATIVE] I do not show that received.
[AGENT][NEUTRAL] I re I show, yeah, I don't show that that claim is received.
[AGENT][NEUTRAL] Or the appeal.
[CUSTOMER][NEUTRAL] Data
[CUSTOMER][NEUTRAL] Do you have any other pills on this claim?
[AGENT][NEGATIVE] No, a pill has been received.
[CUSTOMER][POSITIVE] No bill has been received. OK.
[AGENT][NEUTRAL] For this date of service.
[CUSTOMER][NEUTRAL] For those data. OK, alright. Give me one second.
[CUSTOMER][NEUTRAL] May I know the actual mailing address?
[AGENT][NEUTRAL] It's [PII] in [PII].
[AGENT][NEUTRAL] State, [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And what is the apple time filing?
[AGENT][NEUTRAL] Just submit an appeal. It's 180 days from the date of denial.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] All right. And what is the denial date in this claim?
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] Uh, processed on [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do you have a fax number for a bill?
[AGENT][NEUTRAL] So may have exceeded the.
[AGENT][NEUTRAL] May have exceeded the timely filing limit for an appeal.
[CUSTOMER][NEUTRAL] Mhm, yeah.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And I'm sorry, what was your next question on that one?
[CUSTOMER][NEUTRAL] I just asked, do you have a fax option for offer?
[AGENT][NEUTRAL] For
[AGENT][NEUTRAL] Just a minute a pill.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, it's 877-365.
[AGENT][NEUTRAL] [PII] has to be made to the attention of appeals.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Were you able to
[CUSTOMER][NEUTRAL] And you still that the.
[CUSTOMER][NEUTRAL] Mhm go ahead.
[AGENT][NEUTRAL] Were you able to find that claim, uh, the EOB online?
[CUSTOMER][NEUTRAL] Yeah, I'm able to pull up the.
[AGENT][POSITIVE] OK, good.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Assisting me on that, how to get the web portal.
[AGENT][POSITIVE] Mhm you can share that with your teammates as well.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] Let me finish documenting this call and you said you had, so was this one of the two that you had? You have 1 more status?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] Yes, I do.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] And uh do you have a specific call reference for each patient or do you have a call references for your call?
[AGENT][NEUTRAL] For the entire call it's gonna be my name in today's date.
[CUSTOMER][POSITIVE] Your name's, uh, your name on today's date, that's great.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, one moment.
[AGENT][NEUTRAL] All right, I'm ready for that last policy number.
[CUSTOMER][NEUTRAL] Uh, it's 025.
[CUSTOMER][NEUTRAL] 63525
[AGENT][NEUTRAL] And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh, patient's name is [PII]. Date of birth, [PII].
[AGENT][NEUTRAL] OK, thanks for verifying that, [PII], and what's the date of service?
[CUSTOMER][NEUTRAL] Uh, data servers built here.
[CUSTOMER][NEUTRAL] One moment, my system's still loading here.
[CUSTOMER][NEUTRAL] Come on.
[CUSTOMER][NEUTRAL] Our date of service is on [PII] total charged on $298 even.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes, right.
[AGENT][NEUTRAL] Is an office visit and a, uh, an injection on that claim?
[CUSTOMER][NEUTRAL] Uh, yes, right.
[AGENT][NEUTRAL] So this claim was received.
[AGENT][NEUTRAL] Um, [PII] process [PII].
[AGENT][NEUTRAL] Uh, the payment issued is $75.
[AGENT][NEUTRAL] And that $75 is the maximum per per day and that was applied towards the 99213 procedure code.
[AGENT][NEUTRAL] And I have the claim number. Let me know when you're ready.
[CUSTOMER][NEUTRAL] 01 moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, I'm ready for the claim number.
[AGENT][NEUTRAL] It's 354.
[AGENT][NEUTRAL] 7559.
[CUSTOMER][NEUTRAL] 354-755-59, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Alright, I was able to pull up the the time you will be in your reporter.
[AGENT][NEUTRAL] You were?
[CUSTOMER][POSITIVE] Thank you for that.
[CUSTOMER][NEUTRAL] Yes, I am one moment.
[AGENT][NEUTRAL] So I have a, is it the same provider for each of these claims?
[AGENT][NEUTRAL] The same tax ID number? OK, OK, OK, so in the event that you have claims that could be perhaps for different providers with a different tax ID you would have to create an account for each tax identification number.
[CUSTOMER][NEUTRAL] Yes, it's the same same type yeah.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Just so you know.
[CUSTOMER][NEUTRAL] For each type identification number, we need to create a separate login.
[AGENT][NEUTRAL] Yes, because it's, it's, it's, it's pulling the tax ID number and the patient account number.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] Mhm. Oh, I got it.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Any other questions?
[CUSTOMER][NEUTRAL] So my question for this claim is for the maximum benefit uh for a day is $75 and it was applied to 9921.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Uh, 3, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] But we do have the injection code with 963-72 NJ 3301.
[AGENT][NEUTRAL] So if you're looking at the explanation of benefits, uh, read that remark code that's on there for those other two codes and it'll tell you why those were not payable.
[CUSTOMER][NEUTRAL] I was.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh more codes, uh, it shows that one.
[CUSTOMER][NEUTRAL] It shows that 11 was for the maximum benefit payable for the data service has been matched up.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Which is a $75.
[AGENT][NEUTRAL] The maximum is $75 per visit.
[CUSTOMER][NEUTRAL] Per, is it, right?
[AGENT][NEUTRAL] The maximum benefit is $75 per visit.
[CUSTOMER][NEUTRAL] Oh God.
[CUSTOMER][NEUTRAL] All right, OK.
[CUSTOMER][POSITIVE] I really appreciate your work, [PII]. You do have a great day. Bye-bye. Take care. Bye for now.
[AGENT][POSITIVE] You're welcome [PII] and if no other questions, thanks for calling APL have a good day.
[CUSTOMER][POSITIVE] You too have a great day bye bye take care bye for now.
[AGENT][NEUTRAL] Bye bye.