AccountId: 011433970860
ContactId: 5cf602f3-7f79-4bfd-8468-cfdb3bed1c0e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 354869 ms
Total Talk Time (AGENT): 114730 ms
Total Talk Time (CUSTOMER): 127368 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/12/5cf602f3-7f79-4bfd-8468-cfdb3bed1c0e_20250212T21:07_UTC.wav
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[AGENT][NEUTRAL] APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey, my name is [PII]. I have a claim which has been denied. So I just want to know the reason. Could you please help me with that?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I can help you, um, spell your first name for me, please.
[CUSTOMER][NEUTRAL] Yeah, it's [PII],
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. And what's the claim, the policy number and the claim number?
[CUSTOMER][NEUTRAL] OK claim number is uh
[CUSTOMER][NEUTRAL] 6492867.
[AGENT][NEUTRAL] That's the claim number?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Do you have the explanation of benefits in your hand?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Just let me check.
[AGENT][NEUTRAL] Mhm. And if you have the policy number, give me the policy number.
[CUSTOMER][NEUTRAL] No, I did not have.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Member ID I can share with you.
[AGENT][NEUTRAL] You can or cannot
[CUSTOMER][NEUTRAL] I can share with you the member ID. Please write down. It's 025.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 42049 M as in
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, mango, L as in Linda, 8.
[AGENT][POSITIVE] OK, thank you. What's a good phone number [PII] in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah. It's uh [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient name is [PII], and date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And what is the date of service?
[CUSTOMER][NEUTRAL] D of service is [PII].
[AGENT][NEUTRAL] And the total charge?
[CUSTOMER][NEUTRAL] To the charge amount is
[CUSTOMER][NEUTRAL] $225.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you were wanting to know the reason for the denial?
[CUSTOMER][NEUTRAL] Uh, yes. Uh, here is the reason is mentioned that.
[CUSTOMER][NEUTRAL] CO242 service not provided by a network or primary care provider.
[AGENT][NEUTRAL] Uh, that's not the explanation of uh the explanation on our explanation of benefits. It says that benefits are payable only if your major medical insurance provider provides benefits and so it appears that this claim was denied.
[AGENT][NEUTRAL] By the major medical uh carrier.
[AGENT][NEGATIVE] And so if it's denied by the major medical carrier, this policy does not cover it.
[CUSTOMER][POSITIVE] Uh, I'm so sorry. Could you please let me know what you are saying that?
[AGENT][NEUTRAL] OK, do you have a copy of the primary explanation of benefits?
[CUSTOMER][NEUTRAL] Let me check. Just give me one minute.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yes, I have.
[AGENT][NEUTRAL] And what is the explanation on their claim?
[CUSTOMER][NEUTRAL] OK, let me check.
[CUSTOMER][NEUTRAL] Benefits are payable only if your major medical insurance provider provides benefits. If the claim is later paid, mhm.
[AGENT][NEUTRAL] OK, that's
[AGENT][NEUTRAL] Mhm. Go ahead.
[CUSTOMER][NEUTRAL] by your major medical insurance, please send the explanation of benefits showing benefits were paid.
[AGENT][NEUTRAL] OK, that's our explanation benefits. That's what our denial code says.
[CUSTOMER][NEUTRAL] OK. So we have to send the explanation of benefit to the secondary insurance, I mean, to you. Is it?
[AGENT][NEUTRAL] We, we've already received it, so I was asking you, do you have a copy of the major medical explanation of benefits? The one that you just read, that's, that's our EOB.
[AGENT][NEUTRAL] That's why we denied the claim.
[CUSTOMER][NEUTRAL] So, now, uh, what we have to do, could you please explain?
[AGENT][NEUTRAL] I mean I can't give instructions uh as to what you need to do on your end. I can only speak to the claim uh you know the APL claim and give you the reason that it wasn't paid.
[AGENT][NEGATIVE] And it wasn't paid because the primary insurance denied the claim.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And when the primary insurance denies the claim, APL will deny the claim as well.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] OK, uh, let me know the reference number of this call.
[AGENT][NEUTRAL] My name in today's date, [PII]
[AGENT][NEUTRAL] First initial of my last name is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Anything else I can assist with today, [PII]?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, thank you.
[AGENT][POSITIVE] Alright, thanks for calling ATL have a good day.
[CUSTOMER][NEUTRAL] You too.