AccountId: 011433970860
ContactId: 6ede3d81-499d-4ebb-8add-f0c38d241712
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1057930 ms
Total Talk Time (AGENT): 293779 ms
Total Talk Time (CUSTOMER): 454346 ms
Interruptions: 11
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/25/6ede3d81-499d-4ebb-8add-f0c38d241712_20250625T13:40_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, good morning. My name is [PII]. Yeah, I'm checking claim status.
[AGENT][NEUTRAL] OK, sure, I can assist you with claim status, Mr. [PII] And may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yeah, callback number [PII]. And I'm so sure I didn't get your name. May I have your name once again, please?
[AGENT][NEUTRAL] Sure. My name is [PII].
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You're welcome. And Miss, um, may I have the name of the facility you're calling from?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, first name is Nicholas Children's Hospital.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Yes, ID is 02117579 M as in Mary, L as in Larry, number 7.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Patient name is [PII]. Date of birth [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] May I have the date of service and the amount of the claim.
[CUSTOMER][NEUTRAL] Uh, service date [PII].
[CUSTOMER][NEUTRAL] And the bill amount $1700.17.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK. So that's [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] All right, and for the future, you can check claim status online through our website at [PII] and that's just optional.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And let me see if I can find this claim.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] I don't have that date of service on file.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you're saying there's no claim found for this date of service, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So, uh, if, um, could you please verify if the policy was active during the date of service?
[AGENT][NEUTRAL] Yes, uh, the effective date on this one is, one moment.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] [PII] and it is active at the moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the effective date was [PII] and currently active, right.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Thank you. And if you don't mind, could I also verify with the payer ID.
[AGENT][NEUTRAL] OK, this claim needs to be either faxed or mail because this is a secondary policy and it needs to have that primary it'll be attached to it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] So you can either fax it or mail it. You need the fax number or the mailing address?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Uh, yes, may I have
[CUSTOMER][NEUTRAL] They an interest first.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Um, may I have the mailing address, please?
[AGENT][NEUTRAL] Mailing address, OK. Mailing address is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] You said the address was [PII].
[CUSTOMER][NEUTRAL] [PII]. Is that right?
[AGENT][POSITIVE] No, that's correct, yes.
[CUSTOMER][NEUTRAL] And what is the, uh,
[CUSTOMER][NEUTRAL] Family filing for the claim submission.
[AGENT][NEGATIVE] We don't have timely filing limits.
[CUSTOMER][NEUTRAL] So there's no timely filing to submit it, uh, to submit claim, right?
[AGENT][NEUTRAL] Correct, there's no family filing limits.
[CUSTOMER][NEUTRAL] All right, thank you, uh, Ms. So, I appreciate that. All right, so then, uh, we are done for this claim, but I do have one more claim to check, but, uh, it's for different patients, so if you don't mind, please help me out.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] So you don't need any other information on this one?
[CUSTOMER][POSITIVE] Yeah, for this claim, yeah, we are done for this and thank you so much. I appreciate that.
[AGENT][NEUTRAL] OK, you're welcome. One moment, let me go ahead and make a note on this one so I can finalize the call on this one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, what's the next policy number?
[CUSTOMER][NEUTRAL] Uh, the next policy number is.
[CUSTOMER][NEUTRAL] 02465765 M for Mary, L for Lima, number 7.
[CUSTOMER][NEUTRAL] And the same
[AGENT][NEUTRAL] Thank you. What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Patient name is [PII].
[CUSTOMER][NEUTRAL] Clean down
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Paid of service, [PII].
[CUSTOMER][NEUTRAL] In the bill amount $1,134.36.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah I'm waiting on the EOP.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] What is the name of the provider of service for this one? sorry.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, the best name is Nicholas Children's Hospital.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] I don't see one for make his children, um.
[AGENT][NEUTRAL] Looks like there is a claim, but it's not for [PII]'s children.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Can you verify that information just to make sure it is coming from [PII].
[CUSTOMER][NEUTRAL] OK, you said there is a claim on file, but that is not for Nicholas Children's Hospital, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Just a moment, let me quickly double check.
[CUSTOMER][NEUTRAL] The facility name um bill on the screen.
[CUSTOMER][NEUTRAL] Oh, was this claim under the Miami, uh, Miami Lake Outpatient center.
[AGENT][POSITIVE] OK, yeah, that's, that's the one. Thank you.
[CUSTOMER][NEUTRAL] Yeah, actually, you know, he has a different name.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Uh, for this Nicholas Children's Hospital, yeah, that's a reason it has the same exciting, yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] OK, alright, so it looks like this one was processed on [PII] and it was denied. The reason for this denial is that.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] So we only pay if major medical pay. Um, so um based on the information we received from the major medical, there was nothing applied towards the deductible co-payment or co-insurance.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You said uh these benefits are payable only if major medical insurance provider benefit has been paid. That's what you're saying?
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] So in that case, like you are saying that uh
[CUSTOMER][NEUTRAL] From the primary, like none of the major medical has been paid and like uh the whole allow amount was applied towards to the to the to the paper, that's what it said, right?
[AGENT][NEUTRAL] Correct. Um, there is nothing applied towards the deductible, co-payment and co-insurance, and there's no payment from the major medical. We are the secondary, so we follow major medical. If they don't pay, we do not pay.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, so actually, on this, you know, what happened was that um by the primary, the claim was processed by the Aetna, commercial as a primary.
[CUSTOMER][NEUTRAL] And yeah, the paid amount was 0. However, like the whole allowed amount was applied towards the patient to the table.
[CUSTOMER][NEUTRAL] So like if we submit the primary it will be uh in the case like the can the claim be reprocessed and pay like for.
[AGENT][NEUTRAL] Um,
[AGENT][NEGATIVE] You're breaking, you're breaking up, Miss.
[CUSTOMER][NEUTRAL] Oh, sorry about that. Is it better now or still the same?
[AGENT][NEUTRAL] Uh, it's better now. Can you repeat what you were saying because I didn't get half of what you said.
[CUSTOMER][POSITIVE] OK thank you.
[CUSTOMER][NEUTRAL] Oh sure, uh, yeah, I was saying that.
[CUSTOMER][NEUTRAL] Yeah, we billed to American public life as a secondary and claim was initially processed by Aetna Commercial as a primary, but it was paid $0. However, the whole allowed amount was applied to the patient deductible.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] So in that case, if we submit the primary EOB, can the claim rep process of reviewing the EOB?
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Yes, if you can send an updated ELB with that information showing that there was something applied towards the deductible co-payment and co-insurance, then we can reprocess the claim, but right now we just don't have that information to reprocess.
[CUSTOMER][NEUTRAL] And if you can like I see the next day showing the.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. So, also like uh there is no EOP information that um
[CUSTOMER][NEUTRAL] The secondary insurance has, right?
[AGENT][NEGATIVE] We have an EOB but that EOB shows 00 deductibles, zero co-insurance, 0 co-payment, 0 payment. It's just, everything is in zeros.
[CUSTOMER][NEUTRAL] they have an EOB EOB.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] OK, so everything is showing 0, like there is no patient responsibility or like there's no payment made by the primary. That's what it shows the EOP which you have, OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, the only thing we have is the reported amount and the non-cover amount of everything else is 0.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, uh, just to make sure, uh, the claim was for the charge amount of $1,134.36. Is it the same bill amount.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And for say a service date of September, no, no, [PII], right.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And if you don't mind, I just want to verify uh that because like the EOP which I have and like which you have like, uh, you know, I mean like the claim which we have billed it's the same. I just want to verify also I just want to verify the CPD code bill on that claim was 963-72J 069699214 is that.
[CUSTOMER][NEUTRAL] The same thing you have.
[AGENT][NEUTRAL] What are you, what are you reading? I'm sorry, can you tell me why, what number are you reading?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] And that's the uh the procedure code bill on the claim.
[AGENT][NEUTRAL] Oh yeah, yeah, the procedure code is the same yeah is the correct one. All the information is the correct. The only thing that I see here again is the EOB not having the information needed to process.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK. And in that case, like the insurance doesn't have the right EOP.
[CUSTOMER][NEUTRAL] That is the reason like the claim got denied. Alright, yeah, so then in that case, yeah, we'll be, uh, resubmitting the EOB which have the, uh, patient res which shows the patient responsibility like the deductible amount, so it will be something that EOB and like to submit that EOP, is there any fax number or like the mailing address where we can submit the EOB please?
[AGENT][NEUTRAL] It looks like it.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, and it's gonna be the same as the one prior. um it's gonna be [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] The fax number is [PII].
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK. So, uh, in that case, like, we can resubmit a paper claim and we can attach the primary UB to that claim. We can do that, right?
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Mm
[CUSTOMER][POSITIVE] All righty. uh, Mr. So yeah, thank you for the information for helping me. Um, that will be all for now. Thank you so much. I appreciate that.
[CUSTOMER][NEUTRAL] And do you have any call reference number for today's call, please?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] We don't have a reference number, Mr. [PII] You can use my name and they see.
[CUSTOMER][POSITIVE] Your name into this. Thank you so much. All right, thank you. I appreciate that.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] You're welcome and thank you for calling APL. Have a good day.
[CUSTOMER][POSITIVE] Thank you. You have a good one. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye bye.