AccountId: 011433970860
ContactId: 87b68c95-e038-4301-83a0-5144abe14f31
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 375750 ms
Total Talk Time (AGENT): 126441 ms
Total Talk Time (CUSTOMER): 155370 ms
Interruptions: 0
Overall Sentiment: AGENT=0, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/03/87b68c95-e038-4301-83a0-5144abe14f31_20250203T19:07_UTC.wav
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[AGENT][NEUTRAL] Calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is I'm calling on behalf of provider's office. I'm here for a clarification of claims, so can you please help me out with that?
[AGENT][NEUTRAL] I can help you, [PII]. What's the policy number and the claim number?
[CUSTOMER][NEUTRAL] Uh, allow me a moment. Yeah. The, uh, policy ID is 02450260.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And the claim claim number?
[CUSTOMER][NEUTRAL] Uh, I don't have claim number. Sorry for that. I was trying to pull the claim details but couldn't get any details. So, yeah.
[AGENT][NEUTRAL] Did you say you need clarification on a claim?
[CUSTOMER][NEUTRAL] Yes, uh, the, the American Public Life Insurance is a secondary and the BCBS is primary and the BCBS was denied and that's why we transferred the claim to the secondary insurance. So just need uh
[AGENT][NEUTRAL] What was it denied for, do you know?
[CUSTOMER][NEUTRAL] Uh, just a second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Bear with me.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The claim was denied by the patient, uh, I mean, so BCBS is that the newborn eligibility enrollment doesn't exist.
[CUSTOMER][NEUTRAL] For this patient.
[AGENT][NEUTRAL] What's the patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you and what's the date of service?
[CUSTOMER][NEUTRAL] [PII], with charge amount 8 $850 even.
[AGENT][NEUTRAL] 850. OK, one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Alright, so claim received date is [PII].
[AGENT][NEUTRAL] Process date is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, the reason for the, uh, APL denial sites that.
[AGENT][NEUTRAL] Uh, the policy provides.
[AGENT][NEUTRAL] No benefits for treatment?
[AGENT][NEUTRAL] Of conditions other than an accident or an injury um as deemed by the policy. So was that for a wellness visit?
[AGENT][NEGATIVE] Well, this is not covered under this plan.
[CUSTOMER][NEGATIVE] So, uh, you mean to say that the service center uh for this patient, which is a newly born baby, uh, the service is not covered.
[AGENT][NEUTRAL] Wellness, if it's wellness, it's not covered under the policy.
[CUSTOMER][NEUTRAL] Let me just check, just bear with me.
[AGENT][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] The procedure code is 54,150, right?
[AGENT][NEUTRAL] OK, that's a surgical code. Give me a second.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] It's a circumcision, uh, surgery and which can be performed on patient of any age.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm one moment.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] I've got to check it against this policy.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And did you say that the primary denied the charge?
[CUSTOMER][NEGATIVE] Uh, primary was denied for a different reason. Uh, they denied stating that patient, uh, is a newborn and eligibility does not exist.
[CUSTOMER][NEUTRAL] For the patient.
[CUSTOMER][NEUTRAL] Patient was not eligible in short.
[AGENT][NEUTRAL] OK, so we, so this policy is secondary to the major medical plan and we only received the itemized bill, so we would need a copy of the primary ELB in order to consider the benefit.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK. No, no worries. Uh, may I know the fax number so we can send the
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm. It's um 8.
[CUSTOMER][NEUTRAL] Primary insurance.
[AGENT][NEUTRAL] Mhm. It's 877.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 365.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 942 3.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And make it to the attention of claims.
[AGENT][NEUTRAL] And they could review attention claims and they can review to verify if a benefit is payable under that claim.
[CUSTOMER][NEUTRAL] Attention to claims.
[CUSTOMER][POSITIVE] OK. No worries. We.
[AGENT][NEGATIVE] But if it if it was denied as non-covered by the primary, it's not gonna be covered under this one either.
[AGENT][NEUTRAL] I do know that.
[CUSTOMER][NEUTRAL] OK. Uh, OK. Thank you for that additional information. Uh yeah, uh, and what is the timely, uh, filing to send the EOB?
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] No timely filing.
[CUSTOMER][NEUTRAL] OK. By the way, can you just spell your name?
[AGENT][NEUTRAL] Uh, you'll use my I can, you'll use my name and today's date as reference for today's call, [PII]. And did you have any other questions, then I can help out with today?
[CUSTOMER][NEUTRAL] Uh, no, that's it from my end. Yeah, we'll definitely do the, uh, one thing, we'll definitely send the primary UB and thank you for the additional information also. And yeah, do you have any claim number?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That claim number is 3541164.
[CUSTOMER][NEUTRAL] I repeat, 3541164. Is that right?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] All right. Thank you so much, [PII]. Yeah, that's it from my end. And the reference number will be your name and today's date, right?
[AGENT][POSITIVE] Thank you got it. That's correct.
[CUSTOMER][POSITIVE] All right. Thank you so much, [PII]. Yeah, that's it, ma'am.
[AGENT][POSITIVE] You're welcome, thanks for calling APO. Have a good day.
[CUSTOMER][POSITIVE] Bye, take care.
[AGENT][NEUTRAL] Mhm.