AccountId: 011433970860
ContactId: 7e0358c9-ea64-40ca-b0ae-15c75b8edc76
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 326029 ms
Total Talk Time (AGENT): 156554 ms
Total Talk Time (CUSTOMER): 101224 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/23/7e0358c9-ea64-40ca-b0ae-15c75b8edc76_20250523T19:29_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, yes, I was calling to see if the claim was on file for a patient.
[AGENT][NEUTRAL] OK, I can verify claim status for you and your name is?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, and Ms. [PII], what is that policy number, please?
[CUSTOMER][NEUTRAL] It is 02584454.
[AGENT][POSITIVE] Thank you, one moment.
[AGENT][NEUTRAL] And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] OK, thank you. And verify the patient's name, date of birth.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And this is for [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you and excuse me, what was the data service and amount of the charge?
[CUSTOMER][NEUTRAL] Uh, she has two days that I want to check on the first one is 4 1625, and that's for $1,942.55.
[AGENT][NEUTRAL] OK, and the next date and amount?
[CUSTOMER][NEUTRAL] Is 4 925 and that's for $944.32.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] OK, thank you, give me one moment, Ms. [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said 416 or 25?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] I don't show we received that claim. And you're calling from?
[CUSTOMER][NEUTRAL] Jenny Stewart Medical Center.
[AGENT][NEUTRAL] OK, I show we received the one for the 49 and that claim processed as.
[AGENT][NEUTRAL] Uh, medical test for this data service is not covered under the diagnostic benefit. Therefore, benefits are not payable.
[CUSTOMER][NEUTRAL] So they owe the whole uh 944 32?
[AGENT][NEUTRAL] Um, we can give patient responsibility, um.
[AGENT][NEUTRAL] But under the patient's policy.
[AGENT][NEUTRAL] Uh, that diagnostic test is not covered.
[AGENT][NEUTRAL] Excuse me.
[CUSTOMER][NEUTRAL] OK, um, um, can you re appeal or is it just she has no diagnostic coverage?
[AGENT][NEUTRAL] She has diagnostic coverage, but it's, um, only certain procedures are covered. Um, to submit an appeal, you have up to 180 days from the time the claim was processed, which was [PII] of this year, and you must submit a letter stating the reason for appeal.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah, and um is it showing that [PII] is in network? Is there a discount there and adjustment amount?
[AGENT][NEUTRAL] Well, we don't have a network. She can go to a multi-plan provider, um, but I guess to verify if it was repriced, you would have to contact um IMA and I can give you their phone number.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. The phone number is [PII], option one.
[CUSTOMER][NEUTRAL] So you guys are just the pricing company?
[AGENT][NEUTRAL] No, she just has a limited policy with our company and also she has a policy with IMA and from what I understand, they can process some claims or reprice, but we don't.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So it's just a limited plan like HMO Limited or PPO?
[AGENT][NEUTRAL] I guess, well, I'm not sure if HMO or PPO. We don't have a network. Uh she can go to a multi-plan provider, but it's not required it wouldn't affect her benefits she has with us.
[AGENT][NEUTRAL] So I'm not sure you consider HMO or.
[CUSTOMER][NEUTRAL] Mm, OK.
[CUSTOMER][MIXED] OK, but the other one's not on file and um.
[CUSTOMER][NEUTRAL] But we are to send the claims to you first before they go to IMA.
[AGENT][NEUTRAL] Well, if you send a claim through the mail to that address in [PII] or send it a payer ID, it will go to both companies and typically um claim. Well, when it's sent to that address or payer it comes to both companies, but I don't know how they process their claims.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] But I
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Good
[CUSTOMER][NEUTRAL] And what's your initial timeline?
[AGENT][NEGATIVE] I'm oh there's no time with filing.
[CUSTOMER][NEGATIVE] OK, no timely filing, but it's just 180 days from the denial to submit for a written appeal.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] OK, well thank you very much.
[AGENT][POSITIVE] Yes, ma'am. Thank you for calling APL. You have a great day and weekend, Ms. [PII].
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye.