AccountId: 011433970860
ContactId: 6f35e6ac-3d9a-4e0b-b73c-6e8ed9483592
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 940400 ms
Total Talk Time (AGENT): 341019 ms
Total Talk Time (CUSTOMER): 427713 ms
Interruptions: 13
Overall Sentiment: AGENT=0.2, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/02/6f35e6ac-3d9a-4e0b-b73c-6e8ed9483592_20250402T20:25_UTC.wav
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[AGENT][NEUTRAL] Afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, [PII], my name is [PII]. I'm calling for provider to check on appeal status. Please be informed that this call is being recorded and monitored for quality and training purposes. May I know how can I help you with the patient's information or the provider's information?
[AGENT][NEUTRAL] OK, [PII], so you're needing claim status for one patient, is that correct?
[CUSTOMER][NEUTRAL] Yeah, it's uh appeal status.
[AGENT][NEUTRAL] You're needing to check an appeal status?
[CUSTOMER][NEUTRAL] Yeah, yeah.
[AGENT][NEUTRAL] OK. Yes, I can help you with that, [PII]. And what is your callback number, please?
[CUSTOMER][NEUTRAL] The callback number is [PII] and it's a direct line.
[AGENT][NEUTRAL] And the patient's policy number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh it's 016.
[CUSTOMER][NEUTRAL] 17605 the letter M as in Mike, L as in Lima and the number 8.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] It takes.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hello, how are you there? Crazy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, are you there?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, can you hear me?
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Can you hear me?
[AGENT][NEUTRAL] I can
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Here you are you able to hear me?
[CUSTOMER][NEUTRAL] Yeah, yes.
[AGENT][NEUTRAL] OK, any information that I provide.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] for you will be a verification of benefits and nonty of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] We
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Patient's first name is [PII] and the last name is
[CUSTOMER][NEUTRAL] I'll spell the last name is [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Thank you. Date of birth?
[CUSTOMER][NEUTRAL] The date of birth is [PII].
[AGENT][NEUTRAL] Thank you and the excuse me, the data service and total bill amount.
[CUSTOMER][NEUTRAL] The date of service is [PII] and the total charge amount is $1,352.55.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] You gave to me, [PII] would not have was not active for your data service, uh, the, the policy number you gave me was active from [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me locate
[CUSTOMER][NEGATIVE] Your voice is breaking up.
[AGENT][NEUTRAL] It's the correct policy number.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] I'm sorry. The policy number you.
[CUSTOMER][NEUTRAL] [PII], your, your wife.
[CUSTOMER][NEGATIVE] Your voice is breaking up.
[AGENT][NEGATIVE] Yes, I'm sorry, but there's nothing I can do, yeah, sorry, but there's nothing I can do about that. It's our connection. We have a poor connection.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You stated me the member ID is incorrect.
[AGENT][NEUTRAL] The policy number that you.
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] This po the policy number you gave me for the data service that you gave me, it was not active for that data service.
[CUSTOMER][NEUTRAL] OK. Oh.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] There is another policy let me that would be active for that data service.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that policy number would be 195.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 0910.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it is active with an effective date of [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And give me a moment to see if the claim is on this policy.
[CUSTOMER][NEUTRAL] Effective date is?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] We
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And give me a moment to see if I can locate the claim. What is the name of the facility?
[CUSTOMER][NEUTRAL] Yeah, just a moment.
[CUSTOMER][NEUTRAL] I'll provide you.
[CUSTOMER][NEUTRAL] The name of the facility, it shows like Palm Beach Orthopedic Institute.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so the most recent, OK, so this claim was received on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[AGENT][NEGATIVE] And it was processed and denied on [PII].
[CUSTOMER][NEUTRAL] That's
[AGENT][NEUTRAL] The claim number is 354.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 9250.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right
[AGENT][NEUTRAL] 0
[CUSTOMER][NEUTRAL] 50
[AGENT][NEUTRAL] And this claim was denied, yes, 354-925-0.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And [PII], this claim was denied. One of the remarks for denial states office visits are not covered by the above numbered policy. The member's plan does not cover office visits.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[AGENT][NEGATIVE] And the other remark for the other three line items states this service is not covered.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Well that's good.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] When performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] So, uh, [PII], do you have received an appeal which we have submitted on [PII]?
[AGENT][NEUTRAL] No, sir.
[AGENT][NEUTRAL] The this is the most recent claim that has been received for this number on this data service.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] So it, uh, you do have received the claim instead of the appeal.
[AGENT][NEUTRAL] That is correct. I don't show that we have received an appeal request.
[CUSTOMER][NEUTRAL] OK, just a moment, bear with me.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, [PII], could you just provide me the, the reason once again? The office visits are not covered as per member's plan, right?
[AGENT][NEUTRAL] Office
[AGENT][NEUTRAL] That is correct. And also this, the other codes are denied as this service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Rental, rental form or doctors.
[AGENT][NEUTRAL] The member's plan does not cover disservice when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Clinic, OK.
[CUSTOMER][NEUTRAL] And for this one, just a moment.
[AGENT][NEUTRAL] Mhm. And if
[CUSTOMER][NEUTRAL] Just a moment, bear with me.
[AGENT][NEUTRAL] Mhm. Sure.
[CUSTOMER][NEUTRAL] For this claim, uh, all the CPT codes, like all the CPT codes are denied, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Uh, line one.
[CUSTOMER][NEUTRAL] CPT code 99213.
[AGENT][NEGATIVE] That is the office visit. That is denied. Office visits are not covered.
[CUSTOMER][NEUTRAL] Uh, it's a security code.
[CUSTOMER][NEUTRAL] Uh 262-0605, right?
[AGENT][NEUTRAL] 20605 is, is not being covered when performed in a doctor's office or clinic, along with 20,600 and J 3301.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And if you need a copy of this explanation of benefits, [PII], you may print it from our portal now that you have the claim number.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, just a moment. Could you just provide me the timely filing?
[AGENT][NEUTRAL] By going to secured. [PII].
[CUSTOMER][NEUTRAL] Uh, could you just provide me the timely filing limit?
[AGENT][NEUTRAL] An appeal must be filed within 1.
[CUSTOMER][NEUTRAL] For corrected claim.
[AGENT][NEUTRAL] For an appeal
[CUSTOMER][NEGATIVE] For uncorrected claim.
[AGENT][NEGATIVE] There's no timely filing for that.
[AGENT][NEUTRAL] And an appeal must be filed within 180 days from the date of the decision, and it must be sent in writing to attention appeals department.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And uh there is uh like the there is no.
[CUSTOMER][NEUTRAL] Uh, timely filing limit for the corrected claim.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK, could you just provide me the timely filing limit for, uh, sorry, could you just provide me the mailing address to submit the corrected claim.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah, it's the same as the regular claims address. What do you show for our claims address?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Could you just provide me once again?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Could you just repeat it one second please? It was very fast. [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Do you have the claim's mailing address, [PII]?
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] No, ma'am.
[AGENT][NEUTRAL] OK, [PII].
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] It's in [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK, and it is for same as an appeal?
[AGENT][NEUTRAL] And you will need to put attention appeals department.
[CUSTOMER][NEUTRAL] The same address for an appeal, right?
[AGENT][NEUTRAL] Yes, but you do need to make sure to also include the words attention appeals department.
[CUSTOMER][NEUTRAL] Yeah. Is there any specific form for an appeal that needs to be used?
[AGENT][NEGATIVE] There is not.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. No, uh, no form. And do we need to attend a copy of denied UV?
[AGENT][NEUTRAL] You can and you can print that from our portal by going to secured.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] At [PII].
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] secure.
[AGENT][NEUTRAL] A
[AGENT][NEUTRAL] M
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][NEUTRAL] Yes sir.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. And like there is no necessary to attend the copy of denied UB or it is necessary.
[AGENT][NEUTRAL] It is not required, but you may include it with any additional documentation you would like considered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, yeah, could you just provide me once again the claim number, ma'am?
[AGENT][NEUTRAL] 354.
[AGENT][NEUTRAL] 9250.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] And may I know the call reference number for this account?
[AGENT][NEUTRAL] My name and today's date.
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][NEUTRAL] Uh, actually, it ends in an [PII] instead of a [PII]
[CUSTOMER][POSITIVE] OK. Thank you, [PII]. Thank you for your assistance. Have a great day.
[AGENT][POSITIVE] Well, you're welcome. Yes, sir. You're welcome, [PII]. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No.
[AGENT][POSITIVE] OK. Well, thank you again then if that's all I can help you with. Thank you for calling APL and I hope you have a nice rest of your day.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yeah bye bye take care.
[AGENT][POSITIVE] Uh-huh. You're welcome. You too. Bye-bye.
[CUSTOMER][NEUTRAL] OK.