AccountId: 011433970860
ContactId: 59d2440d-e99a-43ab-a5f6-bffef1c8fb0e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1201619 ms
Total Talk Time (AGENT): 398837 ms
Total Talk Time (CUSTOMER): 247792 ms
Interruptions: 6
Overall Sentiment: AGENT=0.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/14/59d2440d-e99a-43ab-a5f6-bffef1c8fb0e_20250114T19:23_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], [PII] or, or what, ma'am?
[AGENT][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Can you hear me, ma'am?
[AGENT][NEUTRAL] Hello.
[AGENT][NEUTRAL] I can hear you now.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] I can hear you now.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK. My name is [PII], ma'am, and I'm calling from the provider office to check on the claim status.
[AGENT][NEUTRAL] OK, you're needing claim status. Is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Yes, I can help you. Can you spell your first name for me, please?
[CUSTOMER][NEUTRAL] Uh [PII]
[AGENT][POSITIVE] I literally like
[AGENT][POSITIVE] Thank you and your callback number?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Thank you and how many claims today, [PII], do you have to check status on?
[CUSTOMER][NEUTRAL] One.
[AGENT][NEUTRAL] OK, yes ma'am, I can help you. And what is your patient's policy number?
[CUSTOMER][NEUTRAL] 1 2nd.
[CUSTOMER][NEUTRAL] Uh, member ID you're asking, ma'am?
[AGENT][NEUTRAL] It would start with a number.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Do you have that number?
[CUSTOMER][NEUTRAL] Oh yeah ma'am um.
[CUSTOMER][NEUTRAL] 02543700.
[AGENT][POSITIVE] Thank you. One moment.
[AGENT][NEUTRAL] And any information that I provide for you today, [PII] will be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] One second, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The patient's name is, ma'am, [PII]. Date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. One moment.
[AGENT][NEUTRAL] And this is for a dental policy that you're calling for claim status, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And what is the date of service and total bill amount please?
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Can you repeat your name for me?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Yeah, thank you so much. State of service is [PII].
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Total bills amount.
[CUSTOMER][NEUTRAL] Total bill was $9,999.10.
[AGENT][NEUTRAL] 9000, say the amount again, [PII].
[CUSTOMER][NEUTRAL] $9,999.10.
[AGENT][NEUTRAL] And this is a dental claim, is that correct?
[CUSTOMER][NEUTRAL] is that correct?
[CUSTOMER][NEUTRAL] Please, ma'am.
[AGENT][NEUTRAL] I'm sorry, yes.
[CUSTOMER][NEUTRAL] Uh, so medical claim, like it's not a dental claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, ma'am. I had initially asked you if it was dental and you said yes. The policy number you have provided for me is a dental policy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And there is no claim on file for him for that date of service.
[CUSTOMER][NEUTRAL] 2
[CUSTOMER][NEUTRAL] I do have the claim number, ma'am.
[AGENT][NEUTRAL] What is the claim number, [PII]?
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] It is mentioned here, the most recent claim number is 3532265.
[AGENT][NEUTRAL] And what is the policy number that's referenced on that explanation of benefits?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It was also paid for the $150 even.
[AGENT][NEUTRAL] Not on this policy, it wasn't. What's the correct policy number, [PII]?
[CUSTOMER][NEUTRAL] 01 2nd,
[CUSTOMER][NEUTRAL] The only policy I see here is the one which I provided you, ma'am.
[AGENT][NEUTRAL] OK, so that's not correct. So give me just a moment to see if I can locate the correct policy number.
[AGENT][NEUTRAL] This, this should be on.
[CUSTOMER][NEUTRAL] I do have one more policy number which is mentioned over here.
[CUSTOMER][NEUTRAL] 02543696.
[AGENT][NEUTRAL] That's for the limited benefit plan.
[AGENT][NEUTRAL] And what is, yes, that is, so the first policy number you gave me is not that again, you need to remove that one for the member.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let me get the correct policy information pulled up.
[AGENT][NEUTRAL] OK, and on this, how can I help you?
[CUSTOMER][NEUTRAL] I would like to check the claim status.
[AGENT][NEUTRAL] Denied
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The reason for the denial for that bill amount is the benefit maximum for the state of service has been met.
[CUSTOMER][NEUTRAL] When the claim was received?
[AGENT][NEUTRAL] This claim was received on [PII], processed and denied on [PII].
[CUSTOMER][NEUTRAL] process.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] Yes, ma'am. Uh-huh.
[CUSTOMER][NEUTRAL] Can you provide me the claim number?
[AGENT][NEUTRAL] That you gave me the claim number.
[CUSTOMER][NEUTRAL] 352, sorry, 322.
[CUSTOMER][NEUTRAL] 65, right?
[AGENT][NEUTRAL] Say that again.
[CUSTOMER][NEUTRAL] So, ma'am, and you're saying that this
[CUSTOMER][NEUTRAL] 353-2265, right?
[AGENT][POSITIVE] Mhm, that is correct.
[CUSTOMER][NEUTRAL] And ma'am, uh, you will take this bag, uh, will you take this bag?
[CUSTOMER][NEUTRAL] Are you 1 2nd.
[AGENT][NEGATIVE] This claim was received multiple times.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The original claim number that this was processed under was 3526454. There was a $50 benefit paid.
[CUSTOMER][NEUTRAL] With 35
[CUSTOMER][NEUTRAL] So the most recent is the one which you provided, right?
[AGENT][NEGATIVE] The most recent one that we received and it was denied was the was the claim number that you gave to me.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The original claim that we received for this number for this data service was on 114.
[AGENT][NEUTRAL] And it was processed on [PII].
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Under claim number 3526454.
[AGENT][NEUTRAL] And there was a $50 benefit paid.
[CUSTOMER][NEUTRAL] So, what, uh, like, uh, will you take this claim back for the reprocess, ma'am?
[AGENT][NEUTRAL] I, I don't understand your question.
[AGENT][NEUTRAL] This is not a major medical, this is not a major medical insurance plan.
[CUSTOMER][NEUTRAL] You'll take this claim back for the.
[AGENT][NEUTRAL] This is a hospital indemnity limited benefit plan.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, can you suggest me what further action I need to take on this?
[AGENT][POSITIVE] And the the check that we issued as payment on this claim has cleared.
[CUSTOMER][NEUTRAL] we
[CUSTOMER][NEUTRAL] But our expected allowed amount is uh not met, ma'am.
[AGENT][NEUTRAL] Again, we, this is not a major medical plan. You have 180 days from the date that the claim was processed to file an appeal.
[CUSTOMER][NEUTRAL] And your medical plan.
[AGENT][NEUTRAL] It must be submitted in writing.
[AGENT][NEUTRAL] And mailed to attention appeals department.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Are you still there, [PII]?
[CUSTOMER][NEUTRAL] Uh yes, ma'am. One sec.
[CUSTOMER][NEUTRAL] Just give me a moment, ma'am.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, do I need to submit a new claim?
[AGENT][NEUTRAL] Again, if you're, no, ma'am, it's gonna continue to be, uh, if you, if you don't agree with the decision on this claim, you would need to submit an appeal. It will need to be sent to attention appeals department.
[CUSTOMER][NEUTRAL] Bye
[CUSTOMER][NEUTRAL] It's gonna
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] No
[AGENT][NEUTRAL] And you must file that within 180 days from the date that this claim was processed.
[CUSTOMER][NEUTRAL] 1 2nd.
[CUSTOMER][NEUTRAL] Can I get the payer ID, ma'am?
[AGENT][NEUTRAL] 60801 but again if you are going to file an appeal, it must be submitted in writing to attention appeals department. The last time that we received this claim, it was denied as being a duplicate of previously submitted expenses.
[CUSTOMER][NEUTRAL] 6
[CUSTOMER][NEUTRAL] Bye
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] And.
[AGENT][NEUTRAL] This claim has been received 3 times as of now.
[CUSTOMER][NEUTRAL] 3 times.
[CUSTOMER][NEUTRAL] 3 times.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It was initially processed under the claim number in which I explained that the benefit was paid.
[CUSTOMER][NEUTRAL] It was initially
[AGENT][NEGATIVE] And then it was denied.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] For the reason on the claim number you gave me, and the 3rd time it was received was denied as a duplicate.
[CUSTOMER][NEUTRAL] It's gonna be
[AGENT][NEUTRAL] And if you need a copy of any of these explanation of benefits, [PII], you may get those by going to our portal at
[CUSTOMER][NEUTRAL] benefit
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Can you provide me the mailing address?
[AGENT][NEUTRAL] Secured arm.
[CUSTOMER][NEUTRAL] Ma'am?
[AGENT][NEUTRAL] Yes, ma'am. Did you hear me? I gave you our website. If you need to go, if you need a copy of any of the explanation of benefits, you may print them by going to [PII].
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] So you don't have the mailing address?
[AGENT][NEUTRAL] Yes, ma'am. You did not, uh, if you ask me for the appeals address, I did not hear you. Our claims address for appeals would be sent to [PII].
[CUSTOMER][NEUTRAL] I, I.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Can you spell, only the letter, can you just spell?
[AGENT][NEUTRAL] The zip code
[AGENT][NEUTRAL] I'm sorry, what do you need for me to spell, [PII]?
[CUSTOMER][NEUTRAL] And the name because I didn't get it. So, can you spell?
[AGENT][NEUTRAL] It's two words. The first word is spelled [PII] [PII] [PII] [PII]
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] Second word is [PII]
[AGENT][NEUTRAL] The state is also [PII].
[CUSTOMER][NEUTRAL] That it.
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I'll repeat the first name after the [PII]
[AGENT][NEGATIVE] No. No, ma'am. No, no, no. No.
[CUSTOMER][NEUTRAL] Huh.
[AGENT][NEUTRAL] The first letter is [PII], the second letter is [PII], the third letter is [PII]
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Fourth letter is [PII] 5th letter is [PII]
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Sixth letter is [PII], 7th letter is A, [PII].
[CUSTOMER][POSITIVE] Got it, ma'am. Thank you.
[AGENT][NEUTRAL] So it's [PII].
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII] and it must be put to attention appeals department.
[CUSTOMER][NEUTRAL] 5.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And uh it's 180 days, right?
[AGENT][NEUTRAL] Yes, ma'am. It's 180 days from the date of the decision.
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] And the original claim was processed and paid on [PII].
[CUSTOMER][NEUTRAL] Process
[CUSTOMER][NEUTRAL] What's the call reference number?
[AGENT][NEUTRAL] My name that I gave you along with today's date.
[CUSTOMER][NEUTRAL] T R S C Y 114.
[AGENT][NEUTRAL] And actually my name ends in an [PII]
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And is there anything else that I can help you with today?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] One second, OK?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Mm, um, I don't have any other claims, ma'am, for the day. Thank you so much for assisting me.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Well, you
[AGENT][POSITIVE] Yes, ma'am. You're very welcome, [PII], and thank you again for calling APL. I hope you have a nice rest of your day today.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Bye-bye.