AccountId: 011433970860
ContactId: 5989ea80-58f7-4bcc-95be-1af5a3f6b907
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 527320 ms
Total Talk Time (AGENT): 177500 ms
Total Talk Time (CUSTOMER): 126752 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/24/5989ea80-58f7-4bcc-95be-1af5a3f6b907_20250124T21:32_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]. My name is [PII], and I'm calling for Kids Medical Service to check on our client status and we inform me that this call is being recorded and monitored for the quality and training purpose.
[AGENT][POSITIVE] OK, well I'll be more than happy to help you with the claim status, and [PII], how many claims do you have in total today?
[CUSTOMER][NEUTRAL] A one time?
[AGENT][NEUTRAL] OK, may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, sure, and please inform me that this call is being recorded and monitored for the quality and training purpose. The callback number is [PII], and it's a direct line.
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Sure. It's 1, I'm sorry. It's 01822572. M as in Mike, L as in Larry.
[CUSTOMER][NEUTRAL] Number 8.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, sure. The member name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Thank you, 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 and the total bills?
[CUSTOMER][NEUTRAL] Sure. The date of service is on [PII] and charge amount is $570.01.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] 57001.
[AGENT][NEUTRAL] And what is the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] It's get medical service.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] So we have quite a few claims that day. I'm just going through them. Hold on one moment so I can see your total bills.
[CUSTOMER][NEUTRAL] Uh, for this one, did you receive any appeal?
[AGENT][NEUTRAL] I'm locating the claim. Give me just one moment.
[CUSTOMER][NEUTRAL] Yes, sure.
[AGENT][NEUTRAL] You said $570.01?
[CUSTOMER][NEUTRAL] $570 I'm sorry, 570.01.
[AGENT][NEUTRAL] OK, so we don't have a claim on file with that total bill for [PII].
[CUSTOMER][NEUTRAL] OK, give me a minute. Let me check in a client form.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm sorry, the charge amount is
[CUSTOMER][NEUTRAL] $7,201 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] $7,201. OK.
[AGENT][NEUTRAL] OK, so you originally received the claim on [PII]?
[AGENT][NEUTRAL] That claim number is 351.
[AGENT][NEUTRAL] 1465.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Requesting a detailed explanation of benefits that shows the amounts applied to the co-pay, deductible or co-insurance.
[AGENT][NEUTRAL] Then it looks like we received the claim again on [PII].
[AGENT][NEUTRAL] Claim number 3554646.
[AGENT][NEUTRAL] And the claim was denied because the inpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] Uh, it exceeded the maximum allowed of service.
[AGENT][NEUTRAL] The inpatient benefit for the calendar year has been met.
[AGENT][NEUTRAL] So the calendar year max for this policy, go ahead.
[CUSTOMER][NEUTRAL] OK. Did you receive any
[CUSTOMER][NEUTRAL] I'm sorry, did you receive any update on [PII]?
[AGENT][NEUTRAL] October.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] No, we only received the first claim and then the 2nd 1 in January.
[CUSTOMER][NEUTRAL] And may I know for this number you want the 2nd pay, right?
[AGENT][NEUTRAL] Are we? Yes, we're the secondary insurance.
[CUSTOMER][NEUTRAL] OK. May I know the mailing address?
[AGENT][NEUTRAL] Sure, so it's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] Attention to appeals.
[AGENT][NEUTRAL] To APL appeals department.
[CUSTOMER][NEUTRAL] And the timely filing limit?
[AGENT][NEUTRAL] For an appeal is 180 days from the denial.
[CUSTOMER][NEUTRAL] May I know the dinner date also?
[AGENT][NEUTRAL] Um, for the original claim or the second claim?
[CUSTOMER][NEUTRAL] Uh, is it the 180 days from the original dinner date or the last process, last dinner date?
[AGENT][NEUTRAL] Can you say that one more time slowly, please?
[CUSTOMER][NEUTRAL] The timely filing limit for appeal is 180 days from the original denial date or the last process date.
[AGENT][NEUTRAL] It's just from the denial date. So, are you filing the appeal for the second claim or the 1st claim?
[CUSTOMER][NEUTRAL] First class.
[AGENT][NEUTRAL] OK, so the first claim then was, hold on one second.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] That was back in September. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is there any specific form we need to attach along with an appeal?
[AGENT][NEUTRAL] Um, I'm not really sure on this one. there's no form that you need to fill out for the appeal, no.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And the initial claim was denied for primary UB, right? And the claim number ended with 465?
[AGENT][NEGATIVE] No, it was denied because the, the benefit for the calendar year has been used.
[AGENT][NEUTRAL] So by the time your claim came in, they used all of their benefits, which is why we can't pay out.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Can you please repeat the denial reason again? I'm sorry. Impatient.
[AGENT][NEUTRAL] Benefit
[AGENT][NEUTRAL] For this calendar year has been met.
[CUSTOMER][NEUTRAL] Give me a min[PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, may I have the call reference number?
[AGENT][NEUTRAL] Sure, 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] Thank you. Thank you so much for the assisting [PII]. Have a wonderful day.
[AGENT][POSITIVE] You're welcome and thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Bye.