AccountId: 011433970860
ContactId: 8879728d-154c-4c56-8bf4-fd9b1ea1ffbe
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1256449 ms
Total Talk Time (AGENT): 398863 ms
Total Talk Time (CUSTOMER): 282085 ms
Interruptions: 3
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/27/8879728d-154c-4c56-8bf4-fd9b1ea1ffbe_20250527T12:56_UTC.wav
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[AGENT][POSITIVE] Good. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], I just received a confirmation for an explanation of benefits, and it mentioned that uh one of mine was not covered by the policy, and I wanted to get some more information on that.
[AGENT][NEUTRAL] OK, so you have a question regarding a denial on a claim, is that correct?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] Yes, sir, I can help you with that and who am I speaking with please?
[CUSTOMER][NEUTRAL] Uh, my name is [PII].
[AGENT][POSITIVE] Thank you and [PII], what is a good call back number for you please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And your policy number, please?
[CUSTOMER][NEUTRAL] Uh, give me a second. I'm looking for it, uh, 024967887.
[AGENT][NEUTRAL] OK, thank you. One moment while I get your information pulled up.
[AGENT][NEUTRAL] And [PII], I will need to verify several things with you first for security and also any information that is provided today will be a verification of benefits and not a guarantee of payment. So first off, if you could please verify your date of birth.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And then also your home mailing address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. The phone number we have for you is the same as the one you gave me, so that is your best contact number that we should have. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you. And lastly, your email address.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And the claim is for you. Is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is the data service for your claim and the bill amount?
[CUSTOMER][NEUTRAL] Um, well, it says 49 here, but I don't think that that's what the actual data of service was. I was looking, uh, I think the actual date of service was probably give me a second here.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] It's
[AGENT][NEUTRAL] [PII]. Is that correct?
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Or [PII].
[CUSTOMER][NEUTRAL] No, no, [PII] I believe is probably.
[AGENT][NEUTRAL] OK. And do you have the claim number as well, [PII]?
[CUSTOMER][NEUTRAL] Uh, I, I, I.
[CUSTOMER][NEUTRAL] I don't, um, I was trying to get a hold of my statement from.
[CUSTOMER][NEUTRAL] The provider but um I can't.
[CUSTOMER][NEUTRAL] Seem to get a hold of it.
[CUSTOMER][NEUTRAL] But it said that this was an office visit and I think that it may have just been put down incorrectly because uh based on the amount I'm pretty sure this was for an outpatient procedure.
[AGENT][NEUTRAL] OK, so I can tell you that for date of service to [PII], we do not have any claims denied for you.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah, it says 49 I think it's just that's when they got around to sending it.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Was [PII].
[CUSTOMER][NEUTRAL] From Gastro Health LLC.
[AGENT][NEUTRAL] Well, let me look at that data service because if they would have had to submit when you were actually seen and not just when they submitted it. The data service would have been your your appointment date or your treatment date. So let me look at that data service since we don't have anything denied for the other.
[AGENT][NEUTRAL] OK, so I do see that there is a claim that is for data service of [PII].
[AGENT][NEUTRAL] And that does show that you were seen by them. That is the information on the claim, and that is for Gastro Health and that claim number for APL is 3602537.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And this claim shows the billed amount was $348. And yes, sir, that claim was denied because office visits are not covered under your supplemental policy.
[CUSTOMER][NEUTRAL] Um I
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] One.
[CUSTOMER][NEUTRAL] Right, what I'm saying is I think that it was incorrectly I like identified either on their end or y'all because I'm pretty sure that this bill was for a procedure that I had those outpatient services.
[CUSTOMER][NEUTRAL] Not a standard visit.
[AGENT][NEUTRAL] OK, so I can look at the claims information.
[AGENT][NEUTRAL] Just see what we've received.
[CUSTOMER][NEGATIVE] Either that or perhaps they sent it to the wrong place and they should have sent it to my to my primary insurance.
[AGENT][NEUTRAL] OK just a moment while the other information is pulling up.
[AGENT][NEUTRAL] OK, so yes sir the claim that we received was for that data service and it was for showing us an office visit charge.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Or the 348.
[AGENT][NEUTRAL] And they did submit that as well to your primary insurance because they have to file with your primary first before filing with APL.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm, but so what did.
[AGENT][NEUTRAL] Any claims on yourself.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, so what is, um, I'm sorry, what, so you have down [PII]?
[AGENT][NEUTRAL] Yes, sir. Mhm.
[CUSTOMER][NEUTRAL] OK, because I think that they just submitted.
[AGENT][NEUTRAL] 49 2025.
[CUSTOMER][NEUTRAL] Yeah, I'm I'm saying I think that they just submitted the wrong or they submitted it late and it was for an out what what does.
[CUSTOMER][NEUTRAL] Is there a code or something that you have from them?
[AGENT][NEUTRAL] Yes, sir, it shows, yes, the code the bill was 99214, which is a visit.
[CUSTOMER][NEUTRAL] By chance
[CUSTOMER][NEUTRAL] 99214 and that's what Gastro Health.
[AGENT][POSITIVE] That's correct, yes, sir. Uh-huh.
[AGENT][NEUTRAL] And that is the only claim of all.
[CUSTOMER][NEUTRAL] Give me a second.
[AGENT][NEUTRAL] For that data service.
[CUSTOMER][NEUTRAL] 99214.
[AGENT][NEUTRAL] Yes sir.
[CUSTOMER][NEUTRAL] What other claims do you have from Gastro Health?
[AGENT][NEUTRAL] OK, for what dates of service? I would need to check the dates of service. I can't search by.
[AGENT][NEGATIVE] The provider billing because of how I, I, I can't do that.
[CUSTOMER][NEUTRAL] You, you have my full list of claim in front of you.
[AGENT][POSITIVE] I'm so sorry. Can you ask me that again, [PII]?
[CUSTOMER][NEUTRAL] Do you have my whole list of claims in front of you?
[AGENT][NEUTRAL] Yes, I mean dating all the way back to [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is there a way to search within that to see if there are others in gastro health?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, sir. Uh, that's what I was saying. I can't do that. I would just need for you to tell me when you have an appointment with them and I'll be happy to check that.
[CUSTOMER][NEUTRAL] Do you have anything from [PII].
[AGENT][NEUTRAL] And what date in February?
[CUSTOMER][NEUTRAL] I told you the [PII] is when I had the thing. I'm, I don't know when they submitted it.
[AGENT][NEUTRAL] Yes, sir. And I, yes, sir, for [PII].
[AGENT][NEUTRAL] For 224 of 2025, we received two claims that were both paid.
[AGENT][NEUTRAL] To the provider.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, one of them, and you can see this also in your portal. I can provide you the claim number for Gastrohealth. We did receive one for that data service 224-2025. There was a benefit paid to them in the amount of $59.48.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that is on claim number 3585705.
[CUSTOMER][NEUTRAL] Yes, I see that.
[AGENT][NEUTRAL] That's one of them, um, just one moment.
[CUSTOMER][NEUTRAL] Because what I think happened here is that they sent you the wrong number.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] And then also for data service, 224-2025, there was one received from Baptist Hospital.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And there was a benefit paid to them in the amount of $160.60.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Yes, let's do that.
[AGENT][NEUTRAL] Mhm. And that's claim number 3,583,490?
[CUSTOMER][NEUTRAL] So if I get in touch with Gastro Health and ask them what this you said that they said 99214 was the number that they gave you?
[AGENT][NEUTRAL] Yes, that's showing for the uh visit in April.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Trying to get this other one.
[AGENT][NEUTRAL] And that claim number in your portal for the one for the [PII].
[CUSTOMER][NEUTRAL] What was claim 33057?
[AGENT][NEUTRAL] was 3602537.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right, so what was 359-1012? What was who was that from and what was?
[CUSTOMER][NEGATIVE] The issue there.
[AGENT][NEUTRAL] That's also an office visit for gastrohealth for 3 nights, I'm sorry, data service is 3:13.
[AGENT][NEUTRAL] Of 2025.
[CUSTOMER][NEUTRAL] What is that?
[AGENT][NEGATIVE] And that was also for a billed amount of 348, which was denied.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] As office visits are not covered.
[CUSTOMER][NEUTRAL] Both of them.
[AGENT][NEUTRAL] Yes, sir. Uh-huh.
[CUSTOMER][NEUTRAL] No, they gave the same 99214.
[CUSTOMER][NEUTRAL] On the code?
[AGENT][NEUTRAL] I'll have to pull the client's information, just a moment.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] It was the same?
[AGENT][NEUTRAL] Uh-huh, it was.
[CUSTOMER][NEUTRAL] OK, I think that they just tried to resubmit.
[AGENT][NEUTRAL] For data service 3:13.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, I will get in touch with them then.
[CUSTOMER][NEUTRAL] Are there any other denials?
[AGENT][NEUTRAL] Mm, no, sir, not that I can see readily. The other things look like that they have been.
[CUSTOMER][NEUTRAL] Have you
[CUSTOMER][NEUTRAL] OK, did you ever receive anything from a radiology associate with South Florida?
[AGENT][NEUTRAL] And again, what data of service did you have X-rays or?
[AGENT][NEUTRAL] Imaging done?
[CUSTOMER][NEUTRAL] 128 25.
[CUSTOMER][NEUTRAL] The amount would have been $196.
[AGENT][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] If OK, so um.
[AGENT][NEUTRAL] I believe that's one of the ones.
[AGENT][NEUTRAL] Let me pull this information. Just a moment.
[CUSTOMER][NEUTRAL] And.
[CUSTOMER][NEUTRAL] For me
[AGENT][NEUTRAL] No, sir.
[AGENT][NEUTRAL] For data service [PII], the claims on file, one of them is 357-415-5 and that was for
[AGENT][NEUTRAL] Gastrohealth.
[AGENT][NEUTRAL] And there was a benefit paid in the amount of $430.57.
[CUSTOMER][NEUTRAL] I see that.
[AGENT][NEUTRAL] And that was on claim number 357-4155.
[CUSTOMER][NEUTRAL] Oh, I see it.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I'm trying to look at claim 3605059.
[CUSTOMER][NEGATIVE] But it's not coming up on my end.
[CUSTOMER][NEUTRAL] Can you please tell me what that one is for?
[AGENT][NEUTRAL] 3, what was the claim number again?
[CUSTOMER][NEUTRAL] 3605059
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] OK. Is that for your son?
[CUSTOMER][NEUTRAL] I, I'm not sure. I can't look at it. I'm trying to pull it up on my phone, but I can't. It's not.
[AGENT][NEUTRAL] OK, so that's not, yeah, OK, so that claim number is not under your profile. Give me just a moment.
[AGENT][NEUTRAL] Yes, sir. So that's for your son.
[AGENT][NEUTRAL] All right, one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And if you'll verify your son's date of birth, name and date of birth for me, please?
[CUSTOMER][NEUTRAL] [PII] [PII] that's the background right now.
[AGENT][NEGATIVE] Cause I
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] So I'm here.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] And that was for [PII]ta service [PII]?
[CUSTOMER][NEUTRAL] Wait
[CUSTOMER][NEUTRAL] The 3605059 was from [PII] and it's under my son's name.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, OK, that's, I see now. All right, yep, I see now that does make sense, OK.
[CUSTOMER][NEUTRAL] Why was this one not covered?
[CUSTOMER][NEUTRAL] Office visit?
[CUSTOMER][NEUTRAL] Are you there?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Are you there?
[CUSTOMER][NEUTRAL] Ma'am? Daddy.
[CUSTOMER][NEGATIVE] You are on hold.