AccountId: 011433970860
ContactId: 7bb070c8-5bff-423f-872f-0321ec699ab4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 454519 ms
Total Talk Time (AGENT): 174716 ms
Total Talk Time (CUSTOMER): 251779 ms
Interruptions: 11
Overall Sentiment: AGENT=1.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/31/7bb070c8-5bff-423f-872f-0321ec699ab4_20250131T21:18_UTC.wav
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[AGENT][POSITIVE] Afternoon thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello [PII]. I'm [PII]. I'm calling from provider's office regarding our claim status.
[AGENT][POSITIVE] Claims, uh, [PII], it would be my pleasure to assist you with that claim status. What is a good callback number?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] I'm sorry. Uh, just give me a second. Uh, uh, the policy ID is 024503778.
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] And what is the callback number?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] With an extension of [PII].
[AGENT][NEUTRAL] Thank you, [PII]. And do you mind giving me that policy number one more time, please, sir?
[CUSTOMER][NEUTRAL] Uh, it's uh 024.
[CUSTOMER][NEUTRAL] 50378.
[CUSTOMER][NEUTRAL] Just one second and.
[AGENT][NEUTRAL] Thank you and the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Pa's first name is going to be uh [PII] and the last name is [PII].
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] Yeah [PII]. Thank you.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] And it would be my pleasure to assist you with claim status for [PII]. What is the data service?
[CUSTOMER][NEUTRAL] [PII], uh, with the amount of $732 even.
[CUSTOMER][NEUTRAL] I think.
[AGENT][NEUTRAL] All right thank you one moment and what is the facility name please?
[CUSTOMER][NEUTRAL] Yes, sir. Just give me a second. I will help you the facility name. Yeah, the facility name is going to be.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] National Health LLC.
[AGENT][POSITIVE] All right, thank you. It's my pleasure to assist you with that claim status, [PII]. We received the claim on [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And processed on [PII].
[AGENT][NEUTRAL] For the 99214, that was denied it's non-covered.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] The patient's plan does not provide a benefit for office visits. It is noncovered.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And for the CPTs of 93,000 and 36415, that was denied as.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The primary insurance provided full benefits, therefore benefits are not payable.
[CUSTOMER][NEUTRAL] Just.
[CUSTOMER][NEUTRAL] That.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, uh, can you repeat the sentence for the CPT 9?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 3000.
[AGENT][NEUTRAL] Yes, sir. The insurance primary insurance provided full benefits, therefore, benefits are not payable.
[CUSTOMER][NEUTRAL] OK, the insurance, the primary insurance provider though?
[AGENT][POSITIVE] Full benefits. That's correct.
[CUSTOMER][POSITIVE] Full benefits, right?
[CUSTOMER][NEUTRAL] Hi this is calling your provider's office on a status. I mean it's a few little full benefits.
[AGENT][NEUTRAL] That's right. So this policy, the APL policy only pays to the deductible copay and co-insurance of the primary that is applied after primary processes the claim.
[CUSTOMER][NEUTRAL] Yeah, just this is just.
[CUSTOMER][NEUTRAL] Um ID number 141456162.
[AGENT][NEUTRAL] And according to the EOB, they provided full benefits. Therefore, there was nothing payable on this policy.
[CUSTOMER][NEUTRAL] OK, you're sitting in the the.
[CUSTOMER][NEUTRAL] For CPJ 93,000, the primary paid TP max pay, uh, like primary maximum allowed amount.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Paid in full.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the name is OK. Got it. OK, for the last line, line of item.
[AGENT][NEUTRAL] For the 36415, it is the same. The primary provided full benefits, therefore, there's no benefits payable.
[CUSTOMER][NEUTRAL] The primary pay full benefits than the secondary.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So that in this case you are not going to pay the.
[CUSTOMER][NEUTRAL] Pay this for the super tonight.
[AGENT][NEUTRAL] There's no
[AGENT][NEUTRAL] That's right, because there's no benefits payable. We only pay toward the deductible, co-pay or co-insurance.
[CUSTOMER][NEUTRAL] we have received.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] And yeah.
[CUSTOMER][NEUTRAL] Total amount is $2610.
[CUSTOMER][NEUTRAL] OK, you're stating that, uh, the primary has been paid full benefits, so the secondary will be not payable for the benefits as it will go only deductable co-pay and coincidence of the primary, am I right? Like, upon checking, uh, but, uh, upon checking, I can see that it was processed towards copay, right, the $90 actually the BCBS was primary it was paid and left over $90 towards copay.
[AGENT][POSITIVE] That's correct. That is correct.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That it was billed to the American the APL.
[CUSTOMER][NEUTRAL] So that's the reason. Mhm.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] And that's for the 99214. The 99214 is not a covered benefit.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Office visits are not covered under the patient's plan.
[CUSTOMER][NEUTRAL] Sure, got it. OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, what does the number plan have?
[AGENT][NEUTRAL] It's a secondary gap policy.
[CUSTOMER][NEUTRAL] The gap policy. Mhm. Could you please help me the claim number?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 353.
[CUSTOMER][NEUTRAL] But actually.
[AGENT][NEUTRAL] 1791.
[CUSTOMER][NEUTRAL] Um, OK, uh, I'm sorry, 35317.
[CUSTOMER][NEUTRAL] The of the.
[AGENT][NEUTRAL] 91
[CUSTOMER][NEUTRAL] OK, I'll give it 353-1791. OK, so you move to another thing mhm.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Is it for the same member or different member?
[CUSTOMER][NEUTRAL] No, it's for different numbers. Mhm.
[AGENT][NEUTRAL] Alright, give me just one second.
[AGENT][NEUTRAL] [PII], I'm ready for that next policy number.
[CUSTOMER][NEUTRAL] So, the next policy number is going to be?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, sure, OK, got it. Uh, with no, like, can you spell your name? Like, upon checking, I don't have any uh links. Could you please help me the claim number of call reference.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Well, the call reference number would be my name and today's date, and I spell my name [PII] First initial of my last name is [PII].
[CUSTOMER][NEUTRAL] That's it.
[CUSTOMER][NEUTRAL] Actually we have received uh.
[AGENT][POSITIVE] And [PII], it was a pleasure to assist you with that claim status and thank you for calling APL. Hope you have a great weekend.
[CUSTOMER][NEUTRAL] I paid.
[CUSTOMER][NEUTRAL] You too. Bye for now. He is on my end. Yeah, hello, [PII]. I'm sorry. Uh.
[AGENT][NEUTRAL] Bye-bye.
[AGENT][NEUTRAL] Yes, sir. Yes.