AccountId: 011433970860
ContactId: 62ca1aee-97ab-4fe2-b032-099bf24cccb8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1326530 ms
Total Talk Time (AGENT): 397864 ms
Total Talk Time (CUSTOMER): 388894 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/03/62ca1aee-97ab-4fe2-b032-099bf24cccb8_20250403T18:21_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] Hey, hi, [PII]. This is [PII]. I'm calling for the provider, Francisco Rubio. Please note this call will be monitored and recorded for quality and training purposes. I'm calling to obtain claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status. [PII]. May I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, callback number is [PII]. It's a direct line, no extension.
[AGENT][NEUTRAL] Thank you for that. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] I do have 4 claims.
[AGENT][NEUTRAL] And may I have the first member's policy number?
[CUSTOMER][NEUTRAL] Yes, policy number, it is.
[CUSTOMER][NEUTRAL] 107
[CUSTOMER][NEUTRAL] 0130.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes, my name is.
[CUSTOMER][NEUTRAL] [PII] sorry, [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] Yes, the date of service is.
[CUSTOMER][NEUTRAL] [PII]. And the charge amount it is
[CUSTOMER][NEUTRAL] $468.60.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And that's [PII] for $468.60.
[CUSTOMER][POSITIVE] Uh yes, correct.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] So we only received one claim for that data service, but it's a different total bill. Um, what's the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yes, provider of his name is the Hand Institute PL.
[AGENT][NEUTRAL] Is there any other total bill that it can be, or is it just the 468?
[CUSTOMER][NEUTRAL] 468. For the secondary, it is $121.07.
[AGENT][NEUTRAL] OK, well, this is not that amount either. Um, so we don't have a claim on file with your total bill. We do have a claim from the Han Institute, but it's a different total bill.
[CUSTOMER][POSITIVE] OK. Thank you so much. So, may I know uh
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Is the patient was active on the date of service?
[AGENT][NEUTRAL] Um, let me see. Data service 1227.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] Um, so yes, the policy has been active since [PII].
[AGENT][NEUTRAL] So I was active on the data service, we just don't have a claim with that total bills.
[CUSTOMER][NEUTRAL] OK. So active from, effective from [PII] to till now.
[AGENT][NEUTRAL] Yes, so not, it's still active.
[CUSTOMER][POSITIVE] OK. Thank you so much. And uh
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yes. May I know, uh, are you primary or secondary?
[AGENT][NEUTRAL] We are secondary.
[CUSTOMER][POSITIVE] Thank you so much. And do you have that information when the last CO be updated?
[AGENT][NEUTRAL] There is no coordination of benefits. This policy is second only to, hold on one moment.
[AGENT][NEGATIVE] It's second only to AMed. It's through their employer. Any other policies, this policy won't be effective.
[CUSTOMER][NEUTRAL] OK. So no CO be updated, correct?
[AGENT][POSITIVE] But correct.
[CUSTOMER][NEUTRAL] Yeah. May I know the claim submission timely filing, please?
[AGENT][NEGATIVE] There's no timely filing as long as the policy was active on the data service.
[CUSTOMER][NEUTRAL] No, thank you. And may I know the claim submission mailing address, please?
[AGENT][NEUTRAL] Sure, it's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] And uh do you have the electronic payer ID?
[AGENT][NEUTRAL] 60.
[AGENT][NEUTRAL] 801.
[CUSTOMER][POSITIVE] Thank you so much. And uh yes, when you are ready, we'll move with next claim, next member.
[AGENT][NEUTRAL] Um, hold on one moment, let me note this policy.
[AGENT][NEUTRAL] OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] Yes, it is 016.
[CUSTOMER][NEUTRAL] 11442
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And that was 10611442?
[CUSTOMER][NEUTRAL] It is 01611442.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes, my name is [PII].
[CUSTOMER][NEUTRAL] Through the 4. Date of birth, [PII].
[AGENT][NEUTRAL] Thank you for that. And again, all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] [PII]. And uh the charge amount, it is $720 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 503 hold on one moment 301.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, is there any other total other than, well, first, what's the name of the provider on file, the office?
[CUSTOMER][NEUTRAL] Yes, provider name is Florida Homan Care LLC.
[AGENT][NEUTRAL] OK, so this is correct, but there's no, um, we received 3 claims, but there's no total bill with $720. Could there be another amount?
[CUSTOMER][NEUTRAL] I do have a 300, uh, I do have, uh, we have received the EOB and as for UB the total charge amount, it is $382 even.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And I'm looking for the appeal for this. We have recently submitted appeal.
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] OK, so we've received it 3 times. Are you needing the 2nd or the 3rd?
[CUSTOMER][NEUTRAL] Uh, actually, we have submitted a bill just once on a [PII], 24.
[AGENT][NEUTRAL] OK, hold on, let me see what's closest to that one.
[AGENT][NEUTRAL] Alright, so we received it on [PII].
[AGENT][NEUTRAL] The claim number is 353.
[AGENT][NEUTRAL] 852-3.
[AGENT][NEUTRAL] And on [PII], the claim was denied?
[AGENT][NEUTRAL] Because the service is not covered when.
[CUSTOMER][NEUTRAL] Uh, sorry for the interrupting.
[CUSTOMER][NEUTRAL] Uh, sorry for interrupting, but actually for this, we have recently submitted appeal on [PII]. So, did you receive any appeal or reconsideration after [PII]?
[AGENT][NEUTRAL] OK, so that's the 3rd 1. So we received it on, hold on one moment, let me get that 3rd claim.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] That was uh reconsideration.
[CUSTOMER][NEUTRAL] Mhm. Sorry.
[AGENT][NEUTRAL] I understand what you're saying. What I'm explaining is we received it 3 times, the original and then twice after. So the second one we we received in December, the 3rd we received in January. So I'm going to give you that claim status now.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So we received it on [PII].
[AGENT][NEUTRAL] The claim number is 355.
[AGENT][NEUTRAL] 75.
[AGENT][NEUTRAL] 03
[AGENT][NEUTRAL] And on [PII], the claim was denied as a duplicate to the second claim.
[AGENT][NEGATIVE] which was denied because the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] OK, but we have submitted an appeal. Did you receive any appeal after [PII]? We did not submit any claim after, uh-huh.
[AGENT][NEUTRAL] Yes, that's
[AGENT][NEUTRAL] The claim that we received after the December date that you gave is [PII]. That's the last claim received for your date of service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So you have received the bill on [PII] 25 and denied on 12925 for the denied as a duplicate. Correct?
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Thank you so much. And do you have any document control number for this appeal?
[AGENT][NEUTRAL] This was not processed as an appeal, it's just as a, as a duplicate. There's no doc number for this. I have a patient account number from you all.
[CUSTOMER][NEUTRAL] And uh provider have a right to submit the second developing.
[AGENT][NEUTRAL] When you submit the appeals, make sure you put attention appeals department. It's the same address as the claims mailing address, but if you do not specify appeal, it will be processed as a regular claim. So if you're wanting to submit this as an appeal, put attention APL appeals department.
[CUSTOMER][NEUTRAL] Attention APL.
[CUSTOMER][NEUTRAL] Bill department. So provided our right and uh like uh there is a second level uh like uh mailing address is should be the same and attention to APL appeal department, correct?
[AGENT][NEUTRAL] Correct, you can appeal as many times as you like, but it's, it most likely will be denied unless the place of service changes.
[CUSTOMER][NEUTRAL] OK. May I know the time you're filing to submit the appeal? I can.
[AGENT][NEUTRAL] Um, you have 180 days from the denial date.
[CUSTOMER][NEUTRAL] And uh there is any specific app form?
[AGENT][NEUTRAL] No, there's not. There's no specific appeal.
[CUSTOMER][NEUTRAL] Do we need to attach the dinner?
[AGENT][NEUTRAL] Um, it's not required.
[CUSTOMER][POSITIVE] Mm thank you so much and uh
[CUSTOMER][NEUTRAL] And uh may I know the correct claim timely filing?
[AGENT][NEUTRAL] There's no timely filing limit as long as the policy is active on the data service.
[CUSTOMER][NEUTRAL] And uh may I know the mailing address for the corrected claim? Is it the same?
[AGENT][NEUTRAL] Yes, it's the same.
[CUSTOMER][POSITIVE] Thank you so much, really appreciate and uh yes, when you are you are ready, we'll know with next claim, next number.
[AGENT][NEUTRAL] OK, and the next mover's policy number?
[CUSTOMER][NEUTRAL] Yes, policy number, it is.
[CUSTOMER][NEUTRAL] 02511352
[CUSTOMER][NEUTRAL] Sorry.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes, my first name [PII], last name [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Thank you for that. And again for the call, all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] Yes, the date of service is [PII].
[CUSTOMER][NEUTRAL] And the charge amount is?
[CUSTOMER][NEUTRAL] $3,565.50.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, so there's no claims on file for [PII].
[CUSTOMER][POSITIVE] Thank you so much, really appreciate. And uh just a moment. May I know um
[CUSTOMER][NEUTRAL] May I know the uh policy effective and term date?
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] So the policy is still active, it's been effective since [PII].
[CUSTOMER][NEUTRAL] The [PII].
[CUSTOMER][NEUTRAL] And our date of service, [PII]. OK, thank you so much. And uh may I know, are you primary or secondary for this?
[AGENT][NEUTRAL] We are secondary.
[CUSTOMER][NEUTRAL] And uh may I know, uh, do you have that information when was the last C will be updated or no information?
[AGENT][NEUTRAL] There's no um coordination of benefits. We're second only to their primary, which for this policy is Community Care HMO.
[CUSTOMER][NEUTRAL] Mhm. And timely filing?
[CUSTOMER][NEGATIVE] No timely filing and payer ID and uh um mailing address, it should be the same, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Thank you so much. Yes, whenever you are ready, we'll move it next claim.
[AGENT][POSITIVE] I'm ready.
[CUSTOMER][NEUTRAL] Last name?
[CUSTOMER][NEUTRAL] Mhm. It is.
[CUSTOMER][NEUTRAL] T Tango,
[CUSTOMER][NEUTRAL] 49
[CUSTOMER][NEUTRAL] 111203.
[AGENT][NEUTRAL] OK, so that one's not an APL policy number. Do you have a uh APL policy number for this one?
[CUSTOMER][NEUTRAL] Let me check again, just a moment.
[CUSTOMER][NEUTRAL] Actually I do have the same.
[CUSTOMER][NEUTRAL] Member ID. Could you please check with the member name?
[AGENT][NEUTRAL] Sure, what's the member's first and last name?
[CUSTOMER][NEUTRAL] Check. Just allow me a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh yes, I do have a patient ID. It is 000.
[CUSTOMER][NEUTRAL] C as in Charlie.
[CUSTOMER][NEUTRAL] 100.
[CUSTOMER][NEUTRAL] 47616.
[AGENT][NEUTRAL] Yeah, so the APL policy numbers usually start with a 01 or 02, have an ML 7 or 8 at the end like the others. Um, I can check with the first and last name or the full social if you have it.
[CUSTOMER][NEUTRAL] Yes, uh yes, I do have a full social security number. Just a moment. Let me open that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just allow me a moment.
[CUSTOMER][POSITIVE] Just a moment, it's loading. Really appreciate your patience.
[CUSTOMER][NEUTRAL] Yes. It is [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And what is the member's first and last name?
[CUSTOMER][NEUTRAL] Yes, ma'am first name [PII], last name [PII].
[AGENT][NEUTRAL] OK, I'll start with the first and last name because nothing came up with the social.
[AGENT][NEUTRAL] Um, does he have a, well.
[AGENT][NEUTRAL] There's quite a few [PII], but none of them have the same social, um,
[AGENT][NEUTRAL] And the two policy numbers are not APL policy numbers. So this number we don't have on file.
[AGENT][NEUTRAL] Do you have an EOB with a claim number or anything on it?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Uh, yes, I do have a claim number. It is.
[AGENT][NEUTRAL] OK, what's the claim number?
[CUSTOMER][NEUTRAL] 122
[CUSTOMER][NEUTRAL] 624
[CUSTOMER][NEUTRAL] 799,020.
[AGENT][NEUTRAL] OK, that's not an APL claim number either. Um, so it sounds like it may have been filed through primary only. Uh, I don't see a policy for the insured here with APL.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm may I know the call reference number then?
[AGENT][NEUTRAL] Sure, so the call reference number for the entire call will be my name and today's date. And again, that's [PII], first initial to my last name is [PII].
[CUSTOMER][POSITIVE] Yeah, I really appreciate you and ah.
[CUSTOMER][POSITIVE] I really appreciate your assistance, [PII]. Thank you so much. Have a great day. Bye for now.
[AGENT][POSITIVE] Thank you, [PII]. You also, was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] No, thank you so much. I really appreciate it.
[AGENT][POSITIVE] All right, thanks for calling APL. Have a great day. Bye bye.