AccountId: 011433970860
ContactId: 663da565-c8e3-42c3-bd68-a81bb0c4e830
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 832000 ms
Total Talk Time (AGENT): 298170 ms
Total Talk Time (CUSTOMER): 213366 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/10/663da565-c8e3-42c3-bd68-a81bb0c4e830_20250210T21:33_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, this is [PII] calling from provider's office and looking on a claim status.
[AGENT][NEUTRAL] OK, well, I'll be more than happy to help you with the claim status, [PII]. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] 3
[AGENT][NEUTRAL] And may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the first member's policy number?
[CUSTOMER][NEUTRAL] It's 1154265 ML 5.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] It's [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 for the claim you'd like me to check on?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] It's [PII] for $511 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And I'm not showing a claim on file for [PII] for [PII]. Um, let me see this actually, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So the policy number that you gave me termed on [PII], there is an active policy. That number is 148.
[AGENT][NEUTRAL] 0528.
[CUSTOMER][NEUTRAL] It's 1480528.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] So I'm gonna look on there to see if the client, yes, hold on one moment.
[CUSTOMER][NEUTRAL] OK. Can you check? OK.
[AGENT][NEUTRAL] So I'm showing the claim was received on [PII].
[AGENT][NEUTRAL] I'm sorry, [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] It's integrated dermatology of South Miami.
[AGENT][NEUTRAL] Alright, the claim number is 355.
[AGENT][NEUTRAL] 7675.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Um, there's a few reasons claim, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Procedure code 99214 was denied because office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The other two claims, 11104 and 11105, were denied because the service is not is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEGATIVE] Service not covered.
[CUSTOMER][NEUTRAL] OK. Under the patient's plan.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK. And may I have the patient's plan name?
[AGENT][NEUTRAL] Sure, hold on one moment.
[AGENT][NEUTRAL] This is the Metlink supplemental gap insurance?
[CUSTOMER][NEUTRAL] Oh, OK. And uh can you fax me the EOB?
[AGENT][NEUTRAL] Yes, so you need the ELB for all the uh all the three claims that we go over?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And what's a good fax number for you?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] And that's attention [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And that was [PII]?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] OK, so I'll go ahead and fax that over to you and the next member, is it the same member, just different dates or different members?
[CUSTOMER][NEUTRAL] No, it's a different member.
[AGENT][NEUTRAL] OK, and the next policy number?
[CUSTOMER][NEUTRAL] Yeah, the next policy number is 1659386.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service for the claim you like me to check on?
[CUSTOMER][NEUTRAL] Date of service is?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] For the bill amount of
[CUSTOMER][NEUTRAL] Uh, no, one moment. Actually, for [PII]
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The date of service is [PII] for $150 even.
[AGENT][NEUTRAL] And again, just for the call, the information provided is a verification of benefits, not a guarantee of payment. Hold on one moment while I locate the claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm sure I received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 349.
[AGENT][NEUTRAL] 5460.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because benefits are only payable if the major medical insurance provides benefits. So if there is an explanation of
[CUSTOMER][NEUTRAL] No, actually, after that, yeah, after that, we have submitted it.
[CUSTOMER][NEUTRAL] And I have actually uh another claim number on the uh previous call on [PII].
[AGENT][NEUTRAL] OK, so you just want the 2nd 1, you don't want the original. Hold on one second, I'll look that up. OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] So on [PII], we received the um corrected claim, claim number 3530346. On [PII], we made a payment of $50.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Actually, the um primary uh leftover is $60 co-pay.
[AGENT][NEUTRAL] Right, so hold on, let me see what the benefit is.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] I'm just waiting for it to come up.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what benefit was you?
[AGENT][NEUTRAL] OK, so the
[AGENT][NEUTRAL] The benefit that was used as a specialist office visit, that benefit pays up to $50 per visit with a max of 4 visits per calendar year. So although it was a $60 co-pay, the max that it would pay is up to $50. So that is why the $50 was applied to this claim.
[CUSTOMER][NEUTRAL] OK. So for a visit, only $50 can be paid.
[AGENT][NEUTRAL] Right, the max is up to $50 per visit.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK. And may I know the clear date of this check?
[AGENT][NEUTRAL] Of the check, hold on one moment.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK. Can you fax me this EOB as well?
[AGENT][NEUTRAL] Mhm. I'll be faxing you all of them, and you just want the the second one.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yes. The second one which was paid for $50.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. And the next member's policy number?
[CUSTOMER][NEUTRAL] Yeah, the next member's policy number is 02507926ML8.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] No, that's.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] Or
[CUSTOMER][NEUTRAL] [PII], date of birth, [PII], [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 for the claim?
[CUSTOMER][NEUTRAL] Yeah, the date of service is [PII] for $410 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] Hold on one moment. I'm just waiting for everything to come up for 10.
[AGENT][NEUTRAL] Alright, so I'm showing that the claim was received on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That claim number is 355.
[AGENT][NEUTRAL] 562 5.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] As the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] OK. Same as the very first one.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK. Of visit is also not covered and the procedure code 17,110 is also not covered under the patient's plan.
[AGENT][NEUTRAL] Correct, when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] And may I have the patient's plan name?
[AGENT][NEUTRAL] This is their supplemental um gap insurance. It's Medlink.
[CUSTOMER][NEUTRAL] OK. So, uh,
[CUSTOMER][NEUTRAL] Please subtract this UVX bill.
[AGENT][POSITIVE] Yes, I'll be sending you you'll be for all three of the claims we went over today.
[CUSTOMER][NEUTRAL] And then we will receive the fax?
[AGENT][POSITIVE] Um, usually with faxes, you give it about an hour um to be received. If you have not received it by end of day today, you can definitely give us a call and we'll be more than happy to resend it for you.
[CUSTOMER][NEUTRAL] OK. Can you spell your name for me?
[AGENT][NEUTRAL] Sure, my name is [PII] uh.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And the call reference number for this call?
[AGENT][NEUTRAL] For the entire call will be my name and today's date.
[CUSTOMER][POSITIVE] OK, [PII]. Thank you so much for the information you provided me on this call.
[AGENT][NEUTRAL] You're welcome, [PII]. Was there anything else I can assist you with today?
[CUSTOMER][POSITIVE] No, that's all for today. Thank you for asking.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. I hope you have a great day.
[CUSTOMER][POSITIVE] You too as well. Thank you. Bye.
[AGENT][POSITIVE] Thank you. Bye bye.