AccountId: 011433970860
ContactId: 79658d39-cd76-469f-a758-9cc712d76890
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1204099 ms
Total Talk Time (AGENT): 287820 ms
Total Talk Time (CUSTOMER): 467648 ms
Interruptions: 5
Overall Sentiment: AGENT=0.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/06/79658d39-cd76-469f-a758-9cc712d76890_20250506T17:57_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, good afternoon. My name is [PII], and I'm calling you from the provider office, specialty care surgical assist, and I'm looking for claims information, please.
[AGENT][NEUTRAL] OK, so you're checking claim status?
[CUSTOMER][NEUTRAL] Uh-huh. Uh, yeah, I'm, yeah, most probably, I'm looking for the appeal statuss.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] So it's an appeal status, so you submitted an appeal on a deny claim?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK. What's the policy number?
[CUSTOMER][NEUTRAL] Policy ID I have here.
[CUSTOMER][NEUTRAL] It's 195.
[CUSTOMER][NEUTRAL] 479 6.
[AGENT][NEUTRAL] And what's a good phone number in case we're disconnected, [PII]?
[CUSTOMER][NEUTRAL] Sure. The phone number is area code [PII]. It's a direct line.
[AGENT][POSITIVE] OK, thank you. OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient name I have here, it's
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And date of birth of.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And can you repeat the policy number?
[CUSTOMER][NEUTRAL] Sure. I have 1954796.
[AGENT][NEUTRAL] OK, that's a different family.
[AGENT][NEUTRAL] Do you have a copy of the card?
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] The ID card?
[CUSTOMER][NEUTRAL] That's family.
[CUSTOMER][NEUTRAL] Um, no, I did not have that, but let me check one thing here.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEGATIVE] Rumble.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK, the policy ID looks the same for.
[CUSTOMER][NEUTRAL] [PII] May 1954795.
[AGENT][NEUTRAL] 0, 95 and not 96. 95. OK. All right. One moment.
[CUSTOMER][NEUTRAL] Yes, 95, yeah, right.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm sorry, I didn't get your name. What's your name, please?
[AGENT][NEUTRAL] It's [PII] First initial last name is [PII], and you'll use my name and today's status reference for today's call.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK, all right.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm OK.
[AGENT][NEUTRAL] OK, and you said that it's for [PII] or [PII]. Date of birth is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so that is the correct policy number and what's the date of service for your claim, [PII]?
[CUSTOMER][NEUTRAL] Sure, dates of service.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the bill charges of $745 even.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] 7:45.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you tell me the, is it procedure 47562?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Was there a modifier on that claim?
[CUSTOMER][NEUTRAL] AS modifier.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] When did you submit the appeal?
[CUSTOMER][NEUTRAL] This was submitted on.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So I do show that it was received and acknowledged. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm showing it received [PII] this processed on the [PII].
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what is the provider of service?
[AGENT][NEUTRAL] The name of the provider service?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Rendering doctor?
[AGENT][NEUTRAL] Mm, the practice name?
[CUSTOMER][NEUTRAL] The practice named specialty care surgical assist.
[AGENT][NEUTRAL] So I'm looking at a letter dated [PII] that was mailed to that entity at department [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And let's see.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So it says that we have reviewed your claim and the explanation of benefits you submitted and determined that it is that it was processed correctly and according to the policy contract so the uh initial claims decision was upheld and like I said, this has already been mailed. Are you at that location or is there a department that you could reach out to to confirm receipt?
[AGENT][NEGATIVE] And um I think it was also fat.
[CUSTOMER][NEUTRAL] Uh, we are, yeah.
[AGENT][NEUTRAL] To [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So he should have a copy of that.
[CUSTOMER][NEUTRAL] OK, so you have faxed it to [PII] as well on [PII].
[AGENT][NEUTRAL] Mel, melt and fast.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, one thing, I just.
[CUSTOMER][NEUTRAL] One in there here.
[CUSTOMER][NEUTRAL] That the initial claim.
[CUSTOMER][NEGATIVE] That was denied because the primary sur I mean the primary insurance, uh, denied the claim.
[CUSTOMER][NEUTRAL] And the primary uh insurance doesn't have indicating of patient responsibility on the initial claim. So later on, the claim was reprocessed by the primary surgeon, I mean, the, I mean, sorry, primary insurance and the whole allowed amount the bill charges was applied to patients deductible. So we billed that uh claim or
[CUSTOMER][NEUTRAL] Submit that primary you will be where the primary insurance uh applied this amount to the patient deductible. We sent it several times, the EOB and also the claim was sent back for reprocessing, yes.
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] Was it sent with the appeal?
[CUSTOMER][NEUTRAL] Sorry.
[AGENT][NEUTRAL] I said was the corrected EOB submitted with the appeal or prior to you sending the the appeal OK.
[CUSTOMER][NEUTRAL] Yes, right. Prior to, yeah, prior to appeals also we submitted the corrected UB and also the claim was sent back for reprocessing for that with the correct UOB, but still the claim was denied. So we finally filed the appeal with the correct UOB because
[AGENT][NEUTRAL] When what
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] When was the corrected EO be sent?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It was sent on.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Just just a moment. First one was sent on.
[CUSTOMER][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] I be there.
[CUSTOMER][NEUTRAL] Just, just a moment please.
[CUSTOMER][NEUTRAL] Yeah, it was sent on [PII].
[AGENT][NEUTRAL] OK, so the last claim process was [PII], and we denied it, um, and if you have a copy, do you have a copy of the primary explanation?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. Can you pull it up? Because there's a remark code on there. It looks like they're asking for information from the patient before they can proceed.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And that was the uh original denial.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm. Information not completed and a remarked code which the uh additional information has been requested from the patient.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] But that was denied.
[AGENT][NEUTRAL] We deny that in December.
[CUSTOMER][NEUTRAL] Back on July, right.
[AGENT][NEUTRAL] Mm. Well, we denied it [PII], saying that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You know if it's not paid by your the primary this plan doesn't cover it either and you're saying that you submitted uh it the corrected one with the appeal again.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK the 17 pages that was submitted, it's just medical records. There's no EOB attached.
[AGENT][NEUTRAL] There's no EOB attached to the document that you sent or that was sent on [PII].
[CUSTOMER][NEUTRAL] Uh, just a moment, I'm looking as well.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Page 17.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No, you'll be, I don't know.
[CUSTOMER][NEUTRAL] Hm, interesting.
[AGENT][NEUTRAL] Do you have any other questions?
[CUSTOMER][NEUTRAL] This was sent without the EOB.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] All right. No, that's all I need. And um,
[CUSTOMER][NEUTRAL] Do we still have time to submit that correct UP?
[AGENT][NEUTRAL] OK. So the EOB that was submitted, it shows the amount under deductible, but it also stated that that additional information is being requested from the patient. Are you sending that one again or is it a different one?
[CUSTOMER][NEUTRAL] No, uh, the descriptions that given has nothing to do with the deductible amount because on the remark codes of the patient's uh primary insurance UOB doesn't show any of that, uh, remark codes.
[AGENT][NEUTRAL] OK, you can go ahead and submit it for review, yeah, you can go ahead and submit it and we can review it. That's the best, you know, that we can do.
[CUSTOMER][NEUTRAL] Because on remark codes, there is nothing but.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, yeah, sure. I'll do that, um, resubmissions with the correct explanations code and uh that lines because on the claim after the reprocessing of the claim by the primary insurance, there is no remark codes or any denial codes, just the deductible. So I'll send that you'll be.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK OK.
[AGENT][NEUTRAL] OK, and what's the date of the you'll be the corrected will be?
[CUSTOMER][NEUTRAL] I mean they uh processed by the primary insurance?
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] That was made on.
[CUSTOMER][NEUTRAL] Uh, just a moment.
[CUSTOMER][NEUTRAL] The check date, let me pull up the correct check date here.
[CUSTOMER][NEUTRAL] So that uh.
[CUSTOMER][NEUTRAL] Actual.
[CUSTOMER][NEUTRAL] Just give me a moment.
[CUSTOMER][NEUTRAL] This might take uh.
[CUSTOMER][NEUTRAL] A little while.
[AGENT][NEUTRAL] Go ahead and send us what you have and we'll review it.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] And it's, um, I mean, there is no specific time frame, well, you mean?
[AGENT][NEUTRAL] Well, you've already submitted an appeal, so are you sending another appeal or are you just sending the ELB the corrected ELB?
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Yeah, because um the last representative suggest me to send an appeal with the correct UP where, where it says, uh, so the patient responsibility as they corrected claim, yeah, that corrected claim was, I mean the corrected, um, UB was already sent and also the claim was sent back free processing with that correct UB uh several times, 2 or 3 times.
[AGENT][NEUTRAL] It wasn't attached?
[CUSTOMER][NEUTRAL] So, um, but still, the claim was denied because of that, uh, remark code which is given on the below the, um, explanations that given below the UOB states that the, uh, information requested from the patient, the original of denial decisions was mentioned there. So that's the reason, uh mhm.
[AGENT][NEUTRAL] And that
[AGENT][NEUTRAL] And that's what I was asking.
[AGENT][NEUTRAL] The corrected one that you're saying you're going to send, does it have that verbiage, the same verbiage on there, or is it a total different one with that removed?
[CUSTOMER][NEUTRAL] Yeah, I will remove that one because that doesn't mention on that correct UOB.
[AGENT][NEUTRAL] OK, so you can just.
[CUSTOMER][NEUTRAL] That is the uh original decisions you'll be.
[AGENT][NEUTRAL] OK, uh, you're more than welcome to submit it, [PII], for review, but not guaranteeing a payment, of course.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] So, uh, as for now, you want me to just submit the primary UB, right?
[AGENT][NEUTRAL] You're saying it's a corrected EOB so if it's a corrected EOB it should reflect something different than what you've submitted before.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, I'll do that.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] So, um, no need to send as in uh reconsideration or appeal.
[AGENT][NEUTRAL] OK, so now you're saying something different, so are you appealing it again?
[CUSTOMER][NEUTRAL] No, I, I'm asking you if uh I need to send an appeal or just the UB the correct UB.
[AGENT][NEUTRAL] OK, we cannot advise, we cannot advise.
[AGENT][NEUTRAL] So it's up to, to you.
[AGENT][NEUTRAL] The appeal that was previously was submitted.
[CUSTOMER][NEUTRAL] OK, because the last representative was suggesting me to send an appeal. So I'm just um asking if you want me to send an appeal as an appeal with the correct the UB or?
[AGENT][NEUTRAL] Yeah, yeah, yeah, we.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] [PII], I cannot advise it.
[CUSTOMER][NEUTRAL] Is it OK if I send only the.
[AGENT][NEUTRAL] It's totally up to you whatever documentation you feel pertinent, um, I will not advise you as to what to send us.
[AGENT][NEUTRAL] Outside of the corrected ELB.
[AGENT][NEUTRAL] That you said you had.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] OK. Anything else?
[CUSTOMER][POSITIVE] Anyway, thank you so much for your time. And uh so you do not have any time frame as well?
[AGENT][POSITIVE] Absolutely.
[AGENT][NEGATIVE] If you're just sending the ELB there's no time frame to send the corrected ELB. If it's an appeal, it's different. It's 180 days from the original date of denial.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you for your time, that's all I need and you have a good day.
[AGENT][POSITIVE] Absolutely.
[AGENT][POSITIVE] You too, [PII], thanks for calling APL have a good day.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank thank you.
[AGENT][NEUTRAL] Uh-huh. Bye-bye.
[CUSTOMER][POSITIVE] Have a good day too. Bye now. Bye.