AccountId: 011433970860
ContactId: 69a804b3-31e0-443a-bea1-f2d4c7a53eb3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 341929 ms
Total Talk Time (AGENT): 179217 ms
Total Talk Time (CUSTOMER): 77658 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/69a804b3-31e0-443a-bea1-f2d4c7a53eb3_20250117T13:55_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] Uh, hi, my name is [PII] calling from provider office. I want to discuss the denial on the claim.
[AGENT][NEUTRAL] OK, well, I'll be more than happy to assist you with the claim [PII]. And [PII], may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Yes, callback number is [PII] [PII] and policy number is 01813065 M as in Mary, L as in Lima 8.
[AGENT][POSITIVE] 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] Uh yes. My first name is [PII], last name is [PII]. Date of birth is [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] Yes, date of service is [PII].
[CUSTOMER][NEUTRAL] And bill amount is $513 even.
[AGENT][NEUTRAL] Alright, and thank you so much for verifying that information. All the information provided is a verification of benefits, not a guarantee of payment. And so the policy number that you gave me.
[AGENT][NEUTRAL] Termed on [PII], but there is a policy that was active. So let me look at the active policy and see if that claim was there. Um, did you need that policy number?
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] So it's 254.
[AGENT][NEUTRAL] 94
[AGENT][NEUTRAL] 97.
[CUSTOMER][NEUTRAL] It's 25494997.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK, so what should, what should we do for that?
[AGENT][NEUTRAL] And can you
[AGENT][NEUTRAL] Well, first, can you, what do you mean, what can we do for that?
[CUSTOMER][NEUTRAL] Uh, should I, should we, uh, update this policy number and resubmit the claim?
[AGENT][NEUTRAL] Well, let me check and see if there's a claim here first um for that data service. What's the name of the provider's office that would be on the claim?
[CUSTOMER][NEUTRAL] OK. Mhm. OK.
[CUSTOMER][NEUTRAL] It's Murray oncology and retina INC.
[AGENT][NEUTRAL] OK, so we do have the claim on file and um we received it [PII].
[AGENT][NEUTRAL] The claim number is 354.
[AGENT][NEUTRAL] 261 2.
[AGENT][NEGATIVE] And on [PII], it was denied. Hold on, let me get that reason.
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] OK, so it looks like the major insurance that was submitted with the claim was um
[AGENT][NEUTRAL] Either Tricare, Medicare or Medicaid. So no benefits are provided for these services. This is a secondary insurance, but it's only second to the members United Healthcare policy. So yes, this claim would need to be resubmitted with the United Healthcare information explanation of benefits.
[AGENT][NEUTRAL] If there is one.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so the basically the denial is, uh, this claim should be submitted with the primary care, uh, which is United Healthcare Information, right?
[AGENT][NEUTRAL] No, so basically it's saying that the pol, OK, so the policy that they have with us.
[AGENT][NEUTRAL] states that any other medical plan.
[AGENT][NEUTRAL] Managed care.
[AGENT][NEUTRAL] I'll just read the whole statement. So the policy states that the other medical plan means by any basic major medical, comprehensive medical, or managed care policy provided to the policyholder through which the person has coverage. The term of their medical plan does not include Tricare, Medicare or Medicaid. Therefore, no benefits will be provided for these services. So the member has one of those three.
[AGENT][NEUTRAL] And that was what was submitted, but the policy that they have with us is only second to United Healthcare, so we cannot provide services.
[CUSTOMER][NEUTRAL] OK, got it. Thank you. May I have the call reference number?
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name in today's date. Again, my first name is [PII] The first initial to my last name is [PII], and then today's date.
[CUSTOMER][POSITIVE] Uh, thank you so much, and uh have a great day for now.
[AGENT][POSITIVE] You also receive and thanks for calling APL. Bye-bye.