AccountId: 011433970860
ContactId: 513e5b0a-2cf7-40d9-a9d0-1af6e2f0bc46
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 653520 ms
Total Talk Time (AGENT): 248046 ms
Total Talk Time (CUSTOMER): 200353 ms
Interruptions: 3
Overall Sentiment: AGENT=0.4, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/20/513e5b0a-2cf7-40d9-a9d0-1af6e2f0bc46_20250520T20:33_UTC.wav
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[AGENT][NEUTRAL] Afternoon, thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah, I'm [PII] and my last name is [PII] and [PII]. I'm calling from provider's office. I'm here to verify the claim status, so could you please find me from your end?
[AGENT][NEUTRAL] OK, [PII], did you say that you have one claim that you're needing status on, is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, I have 2 more claims. I mean, uh.
[CUSTOMER][NEUTRAL] I have one more claim apart from this, so could you please uh verify and tell me from your end.
[AGENT][NEUTRAL] So you have 2 claims that you're needing status on, is that correct?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yes, I can help you with that. And [PII], what is your callback number?
[CUSTOMER][NEUTRAL] Before the
[CUSTOMER][NEUTRAL] Yeah. Callback number is [PII].
[AGENT][NEUTRAL] Thank you and [PII], you will use my name that I gave you which is [PII] along with today's date as each of your call reference numbers. Also, any information that I provide for you on the claims will be a verification of benefits and not a guarantee of payment. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] And last
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the last thing is that if we do have the claims on file and you need a copy of the explanation of benefits once I give you the claim number, you can print those yourself by going to our portal located at [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what is your first patient's policy number, [PII]?
[CUSTOMER][NEUTRAL] Yeah, um, just give me a minute.
[CUSTOMER][NEUTRAL] Yeah. The member ID is 01841596 M as in Mike, L as in Lima 7.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And any information as I stated before that I provide today will be a verification of benefits and not a guarantee of payment. What is your patient's name, please, and date of birth?
[CUSTOMER][NEUTRAL] Patient first name is [PII] and last name is [PII] and you know who is uh
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the date of service and total bill amount please.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah, data services 8-19-2024. The bill amount is $75 total bill amount is $336. Uh, we got payment from primary and.
[AGENT][NEUTRAL] 336.
[CUSTOMER][NEUTRAL] Yeah. And also we got payment from secondary.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But uh
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] For $75 it got denied. I don't know for what reason it has been denied, or else it will be considered as an adjustment. I don't know. Uh, I just need to confirm. Uh, so could you please recheck and tell me from your end?
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And what is the tax ID for the provider that you're calling on behalf of?
[CUSTOMER][NEUTRAL] Yeah, the tax ID is uh
[CUSTOMER][NEUTRAL] Uh, yeah.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] So this claim, you do not already have the the claim number on the supplemental policy, is that correct, [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um,
[AGENT][NEUTRAL] OK, I'll provide it to you. So,
[CUSTOMER][NEUTRAL] I don't, yeah, I have claim number.
[AGENT][NEUTRAL] Is it 3503596?
[CUSTOMER][NEUTRAL] The claim number is 3.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. Uh, yes, sir, so that is the correct claim number. This claim was denied and the reason for the denial by this.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] By APL states benefits payable under this certificate are limits to those outlined on the schedule of benefits. This is not a covered loss under the plan. Therefore, no amount is payable for this expense. That is for the 99214.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So there will be
[CUSTOMER][NEUTRAL] So it will be considered uh rate of rate adjustment, isn't it?
[AGENT][NEUTRAL] APL does not determine patient responsibility, that would be up to the provider.
[CUSTOMER][NEUTRAL] So for this uh remaining amount we have to bill the patient or uh we have to uh adjust that, I mean, provide a discount.
[AGENT][NEUTRAL] Again, APL, yes, ma'am. AP there is no network with APL. We're not a major medical insurance company and we do not determine patient responsibility. That would be up to the provider.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] So we couldn't build the patient, right?
[AGENT][NEUTRAL] Again, we do not determine patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] OK. I understood.
[CUSTOMER][NEUTRAL] It will be not uh
[CUSTOMER][NEUTRAL] Sentra. OK, ma'am. Could you please tell me for what reason it has been denied only that information, could you please tell me that?
[AGENT][NEUTRAL] Yes, I've read you the I've read you the specific remark.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] This is not a covered loss under the plan. Therefore, no amount is payable for this expense. The members supplemental policy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Does not cover this.
[CUSTOMER][NEUTRAL] So the service is not covered by?
[AGENT][NEUTRAL] Under the member's plan.
[CUSTOMER][NEUTRAL] But we can't payment for the CD code.
[AGENT][NEUTRAL] [PII], you did not receive payment from APL.
[AGENT][NEUTRAL] The supplemental insurance, which is with APL, which is who I work for, has denied this claim.
[AGENT][NEUTRAL] It is not covered under this supplemental policy. APL, A as in Alpha, P as in Peter, L as in Lima.
[CUSTOMER][NEUTRAL] KPM, right?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The supplemental, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can I get the call?
[CUSTOMER][NEUTRAL] Caller reference number, please?
[AGENT][NEUTRAL] My, my name and today's date.
[CUSTOMER][NEUTRAL] His name is [PII], right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK. And now, can I get the call uh today's date, right? um.
[CUSTOMER][NEUTRAL] OK. I have one more claim. Uh, could you please tell me about that?
[AGENT][NEUTRAL] Yes, I can, one moment.
[AGENT][NEUTRAL] OK, and the next member's policy number, please, [PII]?
[CUSTOMER][NEUTRAL] Yeah, just give me a minute.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Another member ID.
[CUSTOMER][NEGATIVE] Uh, even this claim also paid and, uh, stolen. Yeah, even this claim also paid.
[CUSTOMER][NEUTRAL] Anyway, just a moment.
[AGENT][NEUTRAL] OK. Uh, now, the other claim that we just went over, yes, the claim that we just went over, APL did not pay on that claim. So what is the policy number for this claim that you would like for me to check?
[CUSTOMER][NEUTRAL] The member ID? Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 0234456.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And your patient's name and date of birth.
[CUSTOMER][NEUTRAL] Yeah, the patient first name is [PII] and the last name is uh [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] Yeah, date of birth is uh [PII].
[AGENT][NEUTRAL] I'm sorry, what was the year?
[AGENT][NEUTRAL] What is the year of the date of birth? Date of birth again, please?
[CUSTOMER][NEUTRAL] Date of, uh, yeah, yeah, yeah.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the date of service and total bill amount?
[CUSTOMER][NEUTRAL] Yeah, data service is 821-2024. The total bill amount is $221. Initially, you would have been paid.
[CUSTOMER][NEUTRAL] After that, uh, that amount has been crossed over to secondary.
[CUSTOMER][NEUTRAL] The secondary didn't pay any amount, so could you please recheck and tell me what happened to this claim?
[AGENT][NEUTRAL] Just one moment, [PII], and let me see if the secondary has received the claim.
[AGENT][NEUTRAL] OK, so we do not have a claim on file here at APL for date of service [PII] in the amount of $221.
[CUSTOMER][NEUTRAL] So we need to uh resubmit the claim, right?
[AGENT][NEUTRAL] Yeah, there is no claim on file for that data service and build them out and when you do submit the claim to APL you must also include a copy of her primary insurance company's explanation of benefits as well.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can I get the TFL? What is the TFL?
[AGENT][NEUTRAL] What is the what?
[CUSTOMER][NEUTRAL] PFL
[AGENT][NEGATIVE] There is no timely filing limit?
[CUSTOMER][NEUTRAL] Family filing limit.
[AGENT][NEGATIVE] No timely filing limit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much for providing information. Have a nice day bye.
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] Yes sir, can I help you with anything else?