AccountId: 011433970860
ContactId: 7da77998-3ed1-4db4-9e1b-a3f594f0e542
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1503640 ms
Total Talk Time (AGENT): 375693 ms
Total Talk Time (CUSTOMER): 630146 ms
Interruptions: 3
Overall Sentiment: AGENT=0.3, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/03/7da77998-3ed1-4db4-9e1b-a3f594f0e542_20250303T19:43_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yeah, hi, my name is [PII] calling from office, and I want to claim status.
[AGENT][NEUTRAL] OK, sure. I can assist you with claim status, and I'm sorry, I didn't quite catch your name. Can you repeat your name?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII].
[AGENT][NEUTRAL] OK, thank you. And may I have a callback number just in case we get disconnected, Mr. [PII]?
[CUSTOMER][NEUTRAL] Yeah, my call back number is [PII].
[AGENT][NEUTRAL] OK, and may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Yeah, the patient policy number is 755562.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII]. Last name [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK perfect thank you and what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, data service is [PII] build amount $681.
[CUSTOMER][NEUTRAL] like like yeah.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] And for future you can check claim status online through our website at [PII] and that's just optional.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Yeah, uh, I have already checked the claim status. I have not the claims denied, the maximum benefits, but I want to clarify that what are the reasons behind the claim denied.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, we pay the maximum benefit of $75. That is the maximum.
[CUSTOMER][NEUTRAL] So the, the allowed amount is 606.00 cents.
[AGENT][NEUTRAL] OK. We are not a major medical, um, because we're not a major medical, we pay an indemnity amount which is a flat amount. $75 is the maximum benefit for wellness testing.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] that
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And that's what we paid. The maximum benefit was paid with that $75 check that we sent out.
[CUSTOMER][NEUTRAL] So you said the maximum amount you pay $75. Otherwise you uh the remaining balance is the patient responsibility.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] It's up to the provider's discretion. We don't know if they have any other policies out there. This is not a major medical. This is a limited policy.
[CUSTOMER][NEUTRAL] I was
[CUSTOMER][NEUTRAL] OK. Is there any other policy active on the service?
[AGENT][NEGATIVE] Not with us.
[CUSTOMER][NEUTRAL] No, with others. So like can you please uh
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I, uh, I see my system. The person has to take the Cologuard testing one time in 3 years, so it, it was, uh, eligible to take the service.
[AGENT][NEUTRAL] OK, it's not due to the service, it's due to the maximum benefit of the policy, how much the policy will pay. This policy will only pay $75 which is the maximum benefit. So we already sent that check for the $75 any remaining balance is up to the provider's discretion. We don't have any contractual involvement on the remaining of the claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, no worry. So I have a like question what was the member activating term date?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let me get that for you one moment.
[CUSTOMER][NEUTRAL] Yeah, please.
[AGENT][NEUTRAL] OK, effective date was [PII] and it is active at the moment.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII] and it's active at the moment.
[CUSTOMER][NEUTRAL] OK. What was the plan type?
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] Does it say limited hospital indemnity plan?
[CUSTOMER][NEUTRAL] Ininity plan.
[AGENT][NEUTRAL] Limited plan.
[CUSTOMER][NEUTRAL] Yeah, OK, so what was the call with this one because I have an next number ID.
[AGENT][NEUTRAL] And we don't have a reference numbers you can use my name in today's date if you will.
[AGENT][NEUTRAL] And I need to make a note. My name is [PII].
[CUSTOMER][NEUTRAL] Your, your name?
[AGENT][NEUTRAL] Last initial is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so I have a next member.
[AGENT][NEUTRAL] Bear with me, I need to make a note. Can move forward without the note, OK? One moment.
[CUSTOMER][POSITIVE] OK, no issue.
[CUSTOMER][POSITIVE] OK, no worries. Take your time. Yeah.
[AGENT][POSITIVE] Well, thank you.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I'm.
[CUSTOMER][NEUTRAL] That I want to know about like.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, what's the next policy number?
[CUSTOMER][NEUTRAL] Yeah, the number is 1545909 M for Mike L for Lima 8.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah, name is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Mhm. And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, the the service is [PII]. Bill amount $681.
[AGENT][NEUTRAL] [PII] for 681.
[CUSTOMER][NEUTRAL] Yeah, right.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment. Let me pull the you'll be on this one.
[CUSTOMER][NEUTRAL] Yeah, please.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK. So this one was processed November 1[PII] and the claim was denied. The reason for this denial is that uh we cover outpatient services and they're in a hospital, outpatient surgery center, or diagnostic center. So we do not cover the independent lab.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Like you said the, the preventive service are not cover the patient plan.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] Preventive services are not covered.
[CUSTOMER][NEUTRAL] And uh.
[CUSTOMER][NEUTRAL] His plan.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, what was the number activated term date?
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] Effective [PII], it is active at the moment.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] [PII] till plan type?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] Secondary supplemental plan.
[CUSTOMER][NEUTRAL] Secondary supplement plan.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the member responsible for the payment.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] I'm sorry, can you repeat?
[CUSTOMER][NEUTRAL] Yeah, any other insurance active on data service?
[CUSTOMER][NEUTRAL] So I
[AGENT][NEUTRAL] None with us. Um, they do have a primary insurance.
[CUSTOMER][NEUTRAL] OK that's OK.
[CUSTOMER][NEGATIVE] Not good.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, so I have the next number.
[AGENT][NEUTRAL] Bear with me. I need to make a note.
[CUSTOMER][POSITIVE] Yeah, please. No worries.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] No I don't.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, what's the next policy?
[CUSTOMER][NEUTRAL] I see that
[CUSTOMER][NEUTRAL] Yeah, the next number ID is 02335013.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah right.
[AGENT][NEUTRAL] Hey.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Yeah, I got too many numbers.
[AGENT][NEUTRAL] Let me have that number one more time, digit by digit, please.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. The number is 02335013.
[AGENT][NEUTRAL] OK. May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah, name is [PII]. Date of birth, [PII].
[AGENT][NEUTRAL] OK. And may I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, your service is [PII] bill amount $681.
[AGENT][NEUTRAL] So that's [PII]?
[CUSTOMER][NEUTRAL] Yeah, right.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I was
[AGENT][NEUTRAL] Yeah, I'm waiting on the ALP. Bear with me.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] 208164.
[AGENT][NEUTRAL] All right, and it, it's like we process the claim [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the claim was denied, indicating that our records indicate that the premium for the date of service was not received, therefore benefits are not payable.
[CUSTOMER][NEUTRAL] Like you said, the premium not pay, the preventive service are not covered.
[AGENT][POSITIVE] Correct.
[AGENT][NEGATIVE] No, this one indicates that the premium for the date of service was not received.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So they had a lapse in coverage.
[CUSTOMER][NEUTRAL] OK. So what was the effective date and date?
[AGENT][NEUTRAL] OK, I got it. Effective is [PII]. It is still active, but they had a lapse in coverage during this period.
[CUSTOMER][NEUTRAL] Like the coverages started [PII]. I like 12%.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] Yeah, OK, we are not paid. So what the responsible for the, for this?
[AGENT][NEUTRAL] It's up to the provider's discretion.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] OK, so the the call reference your name. OK, [PII].
[AGENT][NEUTRAL] My name in today's name.
[CUSTOMER][NEUTRAL] Yeah, OK, no worries. Uh, so I have the next, the last.
[AGENT][NEUTRAL] Give me just a minute.
[CUSTOMER][NEUTRAL] Yeah, any, uh, like I have a question, any other insurance electron data service.
[AGENT][NEUTRAL] None that I know of. The only one they have with us is this one.
[CUSTOMER][NEGATIVE] OK, yeah. I have lost.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] What?
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] What is the next policy number?
[CUSTOMER][NEUTRAL] Yeah, next policy number is started with 02150691.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] thank you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And may I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah, the patient name is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] And what is the day of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, the service is [PII] bill amount of $81 even.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] It.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me pull this EV.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Like.
[CUSTOMER][NEUTRAL] So you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, we processed this one on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And this one is indicated that independent lab are not covering this policy.
[CUSTOMER][NEUTRAL] Like the services, the preventive services are not covered.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, services are not covered under the patient plan.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] plan.
[CUSTOMER][NEUTRAL] So what was the number if I if I could term date?
[AGENT][NEUTRAL] OK, let me get that one moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] the policy number because you're.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] And 903.
[AGENT][NEUTRAL] OK. So this one was effective on [PII] and it is active at the moment. This is one of our secondary supplemental plans for the major medical.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] So any other insurance data service?
[AGENT][NEUTRAL] They have a primary insurance, we are just a secondary.
[CUSTOMER][NEUTRAL] Who who the family insurance?
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So this is the.
[AGENT][NEUTRAL] United Healthcare.
[CUSTOMER][NEUTRAL] OK, you want to help with the primary insurance.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah they don't.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, so I have, I have a next member ID.
[AGENT][NEUTRAL] You have another one? OK, very.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] This was the last one. Bear with me just a second, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm gonna put you on a brief hold.
[CUSTOMER][POSITIVE] OK, no worries.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, thank you for holding. OK, what's the next policy?
[CUSTOMER][NEUTRAL] Yeah, the next policy is 01477436.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] And my name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] That's the date of service and the amount of the claim.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Yeah, your service is [PII] build amount $681.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] it's.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, we process the claim [PII], and we need the primary explanation of benefits to continue the processing of this claim.
[CUSTOMER][NEUTRAL] You need the primary EOP.
[AGENT][NEUTRAL] Yes, mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] And who's the primary insurance?
[AGENT][NEUTRAL] Looks like it's, it's Adam.
[CUSTOMER][NEUTRAL] Item.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] Can you please provide the member ID?
[AGENT][NEUTRAL] We don't have that information.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] We can only see the name. We don't have any information about the primary insurance. The only thing we have is the name of the company.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] But we don't have any anthem insurance, primary insurance.
[AGENT][NEUTRAL] Let me spell it out for you because um Anthem is an insurance company, but it's not us. One moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Yeah, please.
[CUSTOMER][NEUTRAL] Yeah, please.
[CUSTOMER][NEUTRAL] And so I'm gonna pull up and see you.
[AGENT][NEUTRAL] That is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Like anthem.
[AGENT][NEUTRAL] Mhm, yes.
[CUSTOMER][NEUTRAL] But this is not the only like proper insurance. I need the full name and then the member ID so I, so I get the primary OB.
[AGENT][NEUTRAL] Well, you, you need to contact Anthem.
[CUSTOMER][NEUTRAL] Hi.
[AGENT][NEUTRAL] To get that information. We don't have that information for Anthem.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Again, we can only see the name of the major medical. We don't have the details or information about each individual policy.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Is there anything else I may help you with today?
[CUSTOMER][NEUTRAL] No, no. And your good name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome. Thank you for calling APO. Have a good afternoon.
[CUSTOMER][NEUTRAL] I