AccountId: 011433970860
ContactId: 4f86de74-e3df-4753-a83f-68ed6b0a6937
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1339739 ms
Total Talk Time (AGENT): 431027 ms
Total Talk Time (CUSTOMER): 453960 ms
Interruptions: 7
Overall Sentiment: AGENT=0.8, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/09/4f86de74-e3df-4753-a83f-68ed6b0a6937_20250609T13:12_UTC.wav
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[AGENT][POSITIVE] Thank you for contacting. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Good morning. Thank you for contacting ATO. My name is [PII]. How may I help?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling for the provider to check on an appeal status. Please be informed that this call is being recorded and monitored for quality and training purposes, and your voice is sounding too low, ma'am. Uh, could you please hold your mic closer to your
[CUSTOMER][NEUTRAL] Close to you.
[AGENT][NEUTRAL] I'm sorry, this is as bad as it get, [PII]. I'm very sorry. Um, I understand that you want to have a claim checked. Um, what is that policy number that we're looking at today, please?
[CUSTOMER][NEUTRAL] Uh, yeah, um, the member ID is 02536197 and I'm looking for an appeal status.
[AGENT][NEUTRAL] OK, I can certainly help with that. The patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] The patient's first name is [PII] and the last name is [PII]. The date of birth will be [PII].
[AGENT][NEUTRAL] Thank you. Is there a callback number I can have in the event that we're disconnected?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, it's [PII]. No extension it's a direct line.
[AGENT][NEUTRAL] OK, thank you. And what is that um.
[AGENT][NEUTRAL] What is the uh date of service please for [PII]?
[CUSTOMER][NEUTRAL] The date of service is [PII].
[AGENT][POSITIVE] Thank you, and the build amount, please?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] The bill amount will be $1870 even.
[AGENT][POSITIVE] $1870. That's thank you very much now.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So
[AGENT][NEGATIVE] Poor [PII], I don't show any claims at all.
[AGENT][NEUTRAL] Uh, this is a dental policy, uh, that went into effect on [PII]. He would have been active on that date of service. Uh, he was active until [PII]. But [PII], I don't have any claims for him at all, so, uh, no claims have been submitted.
[CUSTOMER][NEUTRAL] I'm looking for an
[CUSTOMER][NEUTRAL] I'm looking for an appeal status for this one.
[AGENT][NEUTRAL] updated status, OK, I.
[CUSTOMER][NEUTRAL] It just
[AGENT][NEUTRAL] Right, um, well, that the only thing.
[CUSTOMER][NEUTRAL] Just.
[AGENT][NEUTRAL] Oh, please go ahead, [PII]. I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Yeah, I'm double checking with the bill amount just a sec.
[CUSTOMER][NEUTRAL] OK, it's the same bill amount, $1870 even and the date of service is also [PII].
[AGENT][NEUTRAL] For [PII]
[CUSTOMER][NEUTRAL] Just a second, let me do that.
[AGENT][POSITIVE] Great.
[AGENT][NEUTRAL] Is that correct?
[CUSTOMER][NEUTRAL] Do you want the claim number?
[AGENT][POSITIVE] Uh, yes, please, if you can give me the claim number, that would be great.
[CUSTOMER][NEUTRAL] Mm, yeah. The claim number is
[CUSTOMER][NEUTRAL] 353-7217.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] This is a dental policy, so maybe we're looking at something else. Let me see if I can't.
[AGENT][NEUTRAL] 353-7217.
[CUSTOMER][NEUTRAL] Yeah, 353-721-7.
[AGENT][NEUTRAL] Oh, OK, so this is OK, so this is.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] We're looking at his medical policy.
[CUSTOMER][NEUTRAL] Do you want to pay?
[AGENT][NEUTRAL] Uh, no, no, what, no, no, that's fine. Um.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So the, the, he has several different policies with us. Um, the, the number you gave me is for is is the dental policy. Let's see if we can, I'm looking at his medical policy now. Excuse me just one moment please.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] For the day of service, [PII].
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And you're looking for an updated status.
[CUSTOMER][NEUTRAL] Uh, it's uh for an appeal status appeal.
[AGENT][NEUTRAL] An appeal status, yes, I, I understand.
[AGENT][NEUTRAL] I'm just checking yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. When did you submit your appeals, um,
[AGENT][NEUTRAL] 7
[CUSTOMER][NEUTRAL] Uh, we have submitted an appeal via mail. And I could help you with the mailing address where we have submitted and on the date which we have submitted.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, yes. And what is that, please?
[CUSTOMER][NEUTRAL] Oh yeah. The date when we have submitted an appeal is [PII] is the date which we have submitted an appeal. And we have submitted an appeal to the address is [PII].
[AGENT][NEUTRAL] OK, let's see what we got here. OK, give me just one moment, please. I'll be right back. Excuse me just one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, [PII], I do see where we received this and an appeal from you, um.
[AGENT][NEUTRAL] And uh
[AGENT][NEUTRAL] We did index it to appeals um.
[AGENT][NEUTRAL] It's
[AGENT][NEGATIVE] The only thing I can tell you is is that we did receive it um it looks like that uh they're not gonna be able to pay that.
[AGENT][NEUTRAL] Um, let's see what we have here.
[CUSTOMER][NEUTRAL] OK, so the appeal is being denied.
[AGENT][NEUTRAL] That looks like the appeal has been advised. Let me give you the claim number for that please.
[AGENT][NEUTRAL] And it looks like we did receive it on the [PII] and it was processed.
[CUSTOMER][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] So the uh denial date was 3, excuse me, the denial claim was 35.
[AGENT][NEUTRAL] 67
[AGENT][NEUTRAL] 546 again that was 35.
[AGENT][NEUTRAL] 647
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Let's see, I'm sorry, [PII], I'm sorry, there's, there's several claims here. Let's go over that again. The denial, the denial appeal claim is 65.
[AGENT][NEUTRAL] Uh, excuse me 356-754-6.
[AGENT][NEUTRAL] And it does look like we received that uh on the [PII], but it looks like the denial was was uh he was denied was denied.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh, on which date the appeal was denied?
[AGENT][NEUTRAL] Uh, looks like large. Let's see.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] It's just a lot of claims here. Let me see if I can't find it.
[AGENT][NEGATIVE] OK, it looks like we received it on the [PII] on the [PII]. It was denied on the [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And if you'd like, I can send you a.
[CUSTOMER][NEUTRAL] And when you received?
[AGENT][NEGATIVE] Uh, it looks like we received it on the [PII] and denied it on the.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Denied on the [PII]. Now what I can do is I can send you a copy of that EOB if you would like, um.
[CUSTOMER][NEUTRAL] Just a second.
[AGENT][NEUTRAL] Would you like me to fax that to you?
[CUSTOMER][NEUTRAL] And.
[CUSTOMER][NEUTRAL] 25.
[CUSTOMER][NEUTRAL] OK, and the claim number for this is 3567546.
[AGENT][POSITIVE] That's correct, yes, yes.
[CUSTOMER][NEUTRAL] OK, and what's the reason for the denial?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So just
[AGENT][NEUTRAL] OK and so the maximum benefit for this calendar year had been matched.
[AGENT][NEUTRAL] Uh, now from this type of service, let me see if I can't find it.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] This, this is a hospital indemnity policy and it this has limited, yeah, it has limited benefits and that's what has happened is that by the time we've received your claim, the maximum benefits had been met, um, and so there was nothing left to pay out.
[CUSTOMER][NEUTRAL] OK. Uh, so the max.
[CUSTOMER][NEUTRAL] OK. The service has been maxed out. Am I right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK OK. So could you please tell me what is the allowed services amount per time frame?
[AGENT][NEUTRAL] For this type of service.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I apologize my computer is a little bit slow here. We'll just try and get through it.
[AGENT][NEUTRAL] Uh, it was 150.
[CUSTOMER][NEUTRAL] Yeah, I'm talking about what is.
[AGENT][NEUTRAL] Yes, uh-huh, it's, I'm, I'm sorry, that's what I'm trying to get to, [PII], is I'm just trying to get to that. It's $150.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] And that had already been met for that calendar day.
[CUSTOMER][NEUTRAL] OK, $150.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, could you please help me when was the last service, uh, when was the last this type of services were built.
[AGENT][NEUTRAL] The last service that was still.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah, with this type of services.
[AGENT][NEUTRAL] Or do you mean
[CUSTOMER][NEUTRAL] Who are uh.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Is right.
[AGENT][NEUTRAL] Just checking
[AGENT][NEUTRAL] It would have been [PII], and then the policy lapsed in December.
[CUSTOMER][NEUTRAL] October.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Could you please help me what will be the timely filing limit to submit the corrected claim?
[AGENT][NEUTRAL] 180 days.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And what will be the time, uh, time period to build this service?
[AGENT][NEGATIVE] Well, there's no time, there's no timely filing, um, to, to actually file the claim. Uh, that $180 is really just for the, uh.
[AGENT][NEUTRAL] For the appeal, so you can file the claim at any time, any time you want.
[CUSTOMER][NEUTRAL] OK, and there is no timely filing limit for to submit the corrected claim as well, am I right?
[AGENT][POSITIVE] That is correct. That is right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And.
[CUSTOMER][NEUTRAL] Could you please help me with the mailing address to submit the corrected claim?
[AGENT][NEUTRAL] It's gonna be the same one that you used before [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] That is in [PII].
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And the zip code?
[CUSTOMER][NEUTRAL] Yeah, are you?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yes
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK. And what will be the timely filing limit to submit an appeal? It will be the same, no timely filing limit.
[AGENT][POSITIVE] It it's a, it's 100, yeah, it's 180 days. That is correct.
[CUSTOMER][NEUTRAL] It's 180 days or no time filing limit?
[AGENT][NEUTRAL] There there's no timely filing limit to file the claim, [PII], but if you're doing an appeal.
[AGENT][NEUTRAL] That's when the, that's when the 180 days comes in. So if you're filing the claim for the first time or you're wanting to refile it or whatever, that's, that's different. You can file it at any time, but if we're looking at an appeal, if you're wanting to send in an appeal.
[AGENT][NEUTRAL] That's that's when that that time frame.
[CUSTOMER][NEUTRAL] OK. What will be the time if I need to submit an appeal? It will be 180 days from the from the denial date?
[AGENT][POSITIVE] 180 days. That's correct.
[AGENT][POSITIVE] Uh yes, sir, that is correct.
[CUSTOMER][NEUTRAL] There is there any specific form for a nappy?
[AGENT][NEUTRAL] No, there is not.
[AGENT][NEUTRAL] Just any time.
[CUSTOMER][NEUTRAL] OK. Do we have any, uh, second level of your rights?
[AGENT][NEUTRAL] You can, you can file you can file a second appeal, certainly, absolut[PII] you can just be sure and input that it that it's, uh, that you're labeling it as an appeal.
[AGENT][NEUTRAL] Please label it is an appeal.
[CUSTOMER][NEUTRAL] OK, and the second level timely filing limit will be the same 180 days from the denial date.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, just a second.
[CUSTOMER][NEUTRAL] And denied UV is required while submitting the claim or an appeal.
[AGENT][NEUTRAL] Uh yes, please.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][POSITIVE] Yeah that's good.
[CUSTOMER][NEUTRAL] So denied UB is required, am I right? While submitting an appeal, we need to submit a copy of UB as well.
[AGENT][NEUTRAL] Please. Yes, please.
[AGENT][NEUTRAL] Yes, please.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the uh what will be the appeal document control number?
[AGENT][NEUTRAL] Well, I don't have one. I'm sorry. I, uh, there's no document control number for me.
[CUSTOMER][NEUTRAL] Sorry?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yeah I don't have a control document, uh, number, um, [PII], I'm sorry, I can give you a claim number um from the claim that was filed, but we don't have a control document number on me.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a second.
[CUSTOMER][NEUTRAL] And the claim number is 3567.
[CUSTOMER][NEUTRAL] 546.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. It's the updated claim number, am I right?
[AGENT][POSITIVE] That is right.
[CUSTOMER][NEUTRAL] OK. And what will be the call reference number?
[AGENT][NEUTRAL] My name is [PII]. The first letter of my last name is [PII]. We'll use that in today's date is a reference.
[CUSTOMER][NEUTRAL] OK, [PII]. How many claims can you assist me today? I do have more 4 claims on the file.
[AGENT][NEUTRAL] I can, I can do, OK, I can do one more. What is that policy number, please, [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, just a second, it's loading.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah. Uh, it's 02509920 M as in Mike, L as in Lima, and the number 8.
[AGENT][NEUTRAL] OK, I'm sorry, you said it's 0250992.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] 0 M as in Mike, L as in Lima, and the number 8.
[AGENT][POSITIVE] OK, great.
[AGENT][NEUTRAL] Thank you. And what is the uh insured's name and date of birth, please?
[CUSTOMER][NEUTRAL] that
[CUSTOMER][NEUTRAL] Uh yeah. The insured name.
[CUSTOMER][NEUTRAL] It's [PII]. First name is [PII] and the last name is [PII]. The date of birth is [PII].
[AGENT][NEUTRAL] Thank you. And what date of service are you looking for for [PII]?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] And the bill amount will be.
[CUSTOMER][NEUTRAL] $160 even.
[AGENT][NEUTRAL] OK, thank you. Your claim number is 35.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] 92.
[AGENT][NEUTRAL] 399.
[AGENT][NEUTRAL] And it looks like we received your claim.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] Let me just check.
[AGENT][NEUTRAL] It looks like we received your claim on the [PII].
[AGENT][NEGATIVE] We processed it on the [PII]. Now, this policy does not have a benefit for the office visit co-pay.
[CUSTOMER][NEUTRAL] insurance
[AGENT][NEUTRAL] So claim number 3592399 is denied.
[AGENT][NEUTRAL] Because it does not have that office visit copay.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEGATIVE] It does, it does not cover that at all.
[CUSTOMER][NEUTRAL] that's
[CUSTOMER][NEUTRAL] OK. And the member's plan, am I right?
[AGENT][NEGATIVE] By the member's policy, it does not cover that at all.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a second, just a second.
[AGENT][NEUTRAL] And we'll use today's date and my name as the reference.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, and the claim number is 3592399.
[AGENT][POSITIVE] Uh, that is correct, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] There is only one procedure code, 99213, and that is not covered under the member's plan. Am I right?
[AGENT][POSITIVE] That is right.
[CUSTOMER][NEUTRAL] And the further details will remain same as for the previous claim, the timely filing limit, and everything else.
[AGENT][POSITIVE] That's exactly the same. That's right.
[CUSTOMER][POSITIVE] OK, [PII]. Thanks for your assistance. I hope you have a wonderful day. Thanks for assisting me.
[AGENT][POSITIVE] OK, OK, thank you for contacting APO. You have a good day.