AccountId: 011433970860
ContactId: 64dbb6d7-9125-42a4-a47a-8eac5619a50b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 676479 ms
Total Talk Time (AGENT): 267269 ms
Total Talk Time (CUSTOMER): 202753 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/16/64dbb6d7-9125-42a4-a47a-8eac5619a50b_20250516T13:25_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, [PII], my name is [PII]. I'm calling from the provider office looking for the general claim status.
[AGENT][POSITIVE] OK, I'll be more than happy to help you with the claim status, and did you say your name was [PII]?
[CUSTOMER][NEUTRAL] [PII]. It's a spell like [PII]
[AGENT][NEUTRAL] All right, and [PII], may I have a good contact number in case we're disconnected and the member's policy number?
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[CUSTOMER][NEUTRAL] And the policy ID I have 01221549 M as in Mike, L as in Lima, number 8.
[AGENT][NEUTRAL] Thank you for that. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] So, I have a total 2 claims with the different patients.
[AGENT][POSITIVE] OK, and I'll be more than happy to help with the claim status. May I have the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure, it's uh [PII].
[CUSTOMER][NEUTRAL] Market, and the date of birth, [PII].
[AGENT][NEUTRAL] Thank you for that. May I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] Yeah, it's in [PII].
[CUSTOMER][NEUTRAL] And the total charges I have $1,339 even. 1339.
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. Hold on one moment while I take a look for the claim.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yeah, it's a Holy Cross Medical Group.
[AGENT][NEUTRAL] Alright, so I'm showing the claim was received on [PII].
[AGENT][NEUTRAL] Claim number is 358.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 692 1.
[AGENT][NEUTRAL] And on [PII], the claim was denied because the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Services are not covered under the patient claim, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And may I know the patient plan, which plan it is?
[AGENT][NEUTRAL] Yes, this is a Medlink supplemental gap insurance policy.
[CUSTOMER][NEUTRAL] Meddling supplemental.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. Got it.
[CUSTOMER][NEUTRAL] So, office visits are not covered, right?
[AGENT][NEUTRAL] Right, it's not covered when performed in doctor's office or clinic, correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And will you able to send me the copy of U via fax?
[AGENT][NEUTRAL] Yes, so you need the EOB for both claims that we go over today?
[CUSTOMER][NEUTRAL] Yes. Um, I don't know the other claim. Uh, I need to know the, uh, status of that one as well.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Right, I'm just asking if you'll need a copy of the explanation of benefits so I can send it at the end of the call for you.
[AGENT][NEUTRAL] So you'll need
[CUSTOMER][NEUTRAL] Yeah, OK it's OK.
[AGENT][NEUTRAL] All right. May I have a good fax number for you?
[CUSTOMER][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And is that attention [PII]?
[CUSTOMER][NEUTRAL] Uh yes, my name.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] So I can definitely go ahead and send the explanation of benefits. I'll send them both at the end of the call. Um, did you need any other assistance with this number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] No, no.
[AGENT][NEUTRAL] OK, hold on one moment, let me note this policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So what about the call reference number for this patient?
[AGENT][NEUTRAL] For the entire call, it will be my name and today's date, and again that's [PII], first initial to my last name is [PII], and then today's date.
[CUSTOMER][POSITIVE] OK, got it. Thank you so much for that information.
[AGENT][NEUTRAL] You're welcome, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] The policy number I have here, it's 02.
[CUSTOMER][NEUTRAL] 102761 M as in Mike, L as in Lima, 8.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure. It's uh [PII] and the 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 bill for the claim?
[CUSTOMER][NEUTRAL] Sure. Uh, it's [PII].
[CUSTOMER][NEUTRAL] And the total charges $761 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, so it looks like, hold on one moment, and for this one, it would it be a different provider or it's the same?
[CUSTOMER][NEUTRAL] Yeah, same provider. Holy Cross Medical Group.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, we received this claim twice. Did you need both claim statuses or just the original?
[CUSTOMER][NEUTRAL] Yeah, so, after [PII].
[CUSTOMER][NEUTRAL] Looks like we have submitted on [PII].
[AGENT][NEUTRAL] OK, so the of the two we received, we received one on [PII] and the second was on [PII]. Are you wanting the [PII]?
[CUSTOMER][NEUTRAL] Yeah. So, what about the original claim status and uh you can go ahead with the both uh uh I can get it. Yeah, yeah.
[AGENT][NEUTRAL] Alright, so
[AGENT][NEUTRAL] Do you need both? OK.
[AGENT][NEUTRAL] The original claim was received on [PII].
[AGENT][NEUTRAL] The claim number is 35588872.
[AGENT][NEUTRAL] Code 99213 was denied because office visits are not covered on this policy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Code 20,550 and J 0702 were both denied requesting the explanation of benefits from primary insurance.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So once we receive that, we can continue processing?
[CUSTOMER][NEUTRAL] OK, so got it. Uh, will you able to help me with a good fax, fax number?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] 365.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 942 3.
[CUSTOMER][NEUTRAL] Yeah. Let me confirm when I had the account uh correct uh [PII].
[AGENT][NEUTRAL] Yes, that's the first claim. Now you sent in the 2nd claim to answer that. So did you want that second status?
[CUSTOMER][NEUTRAL] However, it was denied as it you will get, right?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Mhm. So what about this one?
[AGENT][NEUTRAL] It's a reprocessing of the first one.
[AGENT][NEUTRAL] You need, you want the 2nd 1?
[CUSTOMER][NEUTRAL] Mhm. So go ahead with the second one. Yes, yes.
[AGENT][NEUTRAL] Alright, so it was received on [PII].
[AGENT][NEUTRAL] Claim number is 3586719.
[AGENT][NEUTRAL] On [PII], the claim was denied, so the 99213 is the same, office visits aren't covered, but the other two we received the explanation of benefits for, but it shows that the primary insurance um provided full benefits. So if you have an explanation of benefits, um, well, let me say this, hold on, hold on, hold on. Let me correct what I just said.
[CUSTOMER][NEUTRAL] Yes, yes. For the 2nd 1 I have.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So, it was denied because we can only pay out if major medical insurance provides benefits. So if you have an explanation of benefits showing that major did apply to this claim, um, you can just send it in to us and then we can reprocess.
[CUSTOMER][NEUTRAL] So, however, you have the primary, uh, you will be right, uh, from primary process you will be.
[AGENT][NEUTRAL] Right, and it's showing that they did not apply anything to the claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So as a 2nd cannot apply to the claim if the 1st did not. So if you have something showing that they did, you can resubmit that and we can process it again.
[CUSTOMER][NEUTRAL] OK, got it. So you can send, you can send me the copy of your OB so I can go ahead and with the check and later I can, if possible, I can go ahead with the primary OB to send over to you.
[AGENT][POSITIVE] Yes, I'll be sending you all three explanation of benefits. Um, was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No. Uh, however, uh, could you please uh repeat the claim number once again? The 47 of 2025 received that one.
[AGENT][NEUTRAL] Um, 358.
[AGENT][NEUTRAL] 692 1.
[CUSTOMER][POSITIVE] OK. Thank you so much for that information.
[AGENT][NEUTRAL] You're welcome, [PII].
[CUSTOMER][NEUTRAL] And uh yeah.
[AGENT][POSITIVE] Well, thank you for calling APL. I hope you have a great weekend.
[CUSTOMER][POSITIVE] Have a great weekend to you. Bye-bye.
[AGENT][POSITIVE] Thank you, bye bye.