AccountId: 011433970860
ContactId: 8cbe2908-1a7b-49b9-815c-9f1046ad76bc
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1627579 ms
Total Talk Time (AGENT): 318074 ms
Total Talk Time (CUSTOMER): 366565 ms
Interruptions: 1
Overall Sentiment: AGENT=0.9, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/28/8cbe2908-1a7b-49b9-815c-9f1046ad76bc_20250128T13:52_UTC.wav
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[AGENT][NEUTRAL] And thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, hi, [PII]. This is [PII], and I need the claim information.
[AGENT][NEUTRAL] OK, [PII], you have a claim that you're needing status on, is that correct?
[CUSTOMER][POSITIVE] Yeah, yes, correct.
[AGENT][POSITIVE] Yes, I can help you with that. And what is your callback number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and how many claims, [PII], do you have to check status on?
[CUSTOMER][NEUTRAL] I have uh let me count.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] I have a number of 7 claims.
[AGENT][NEUTRAL] Are they for the same patient or different patients?
[CUSTOMER][NEUTRAL] Different patient
[AGENT][POSITIVE] OK [PII], so I can help you now a couple of things in advance you will use my name that I gave you for all of your call reference numbers along with today's date.
[AGENT][NEUTRAL] Also, any information that is provided on any of the claims will be a verification of benefits and not a guarantee of payment and if you need a copy of any of the explanation of benefits, you can go to our portal at [PII] to print those once I provide you the claim number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is the first member's policy number?
[CUSTOMER][NEUTRAL] OK, so the first one I have uh.
[CUSTOMER][NEUTRAL] 02173251
[AGENT][NEUTRAL] One moment.
[CUSTOMER][POSITIVE] OK, sure. Take your time.
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] And the date of birth is uh
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Just one moment, [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Give me just one second, [PII].
[CUSTOMER][POSITIVE] sure take your time.
[AGENT][NEUTRAL] OK, and what is the data service and total bill amount for her, please?
[CUSTOMER][NEUTRAL] OK. Date of service I have uh.
[CUSTOMER][NEUTRAL] Um, [PII] and the amount is uh.
[CUSTOMER][NEUTRAL] 839 even.
[AGENT][NEUTRAL] How much?
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] What is the amount?
[CUSTOMER][NEUTRAL] It is for 883839 $839.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] And uh it was uh denied for a DX inconsistent uh with uh uh DX it's not covered under the patient's plan. And uh we already sent the reconsideration on this claim on [PII]. So please check, have you received the reconsideration which you sent?
[AGENT][NEUTRAL] You sent an appeal.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And you said you sent that back last year?
[CUSTOMER][NEUTRAL] Uh-huh, yes, on June.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] I'm still trying to look locate some information. Do you already have claim numbers, [PII] on all the claims and you have questions on today?
[CUSTOMER][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] Uh, let me check.
[CUSTOMER][NEUTRAL] Yes, I have a claim number 334-534-3.
[AGENT][NEUTRAL] OK, so the denial, we did receive the claim, the denial was upheld.
[AGENT][NEUTRAL] Upon review of the claim, it was found that the claim was processed according to the policy contract and benefits are not payable for these services.
[CUSTOMER][NEUTRAL] No, no, no. So have you received the reconsideration?
[AGENT][NEUTRAL] This was a reconsideration.
[CUSTOMER][NEUTRAL] So when did you see?
[AGENT][NEUTRAL] The denial was upheld.
[CUSTOMER][NEUTRAL] OK, the night was a pass.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So it means it was, it was not corrected, right?
[AGENT][NEUTRAL] That was received on [PII] and processed on [PII].
[CUSTOMER][NEUTRAL] Processed on [PII]. And it was denied correctly.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] One moment. Just, just a moment.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK, just a second.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK, just a second.
[CUSTOMER][NEUTRAL] OK, so I have the next one. OK for the next one.
[AGENT][NEUTRAL] Are you and is that all of the information that you need on this number?
[CUSTOMER][NEUTRAL] Uh, yes, yes.
[AGENT][NEUTRAL] OK, so give me a moment to get finish what I need to do on this part.
[AGENT][NEUTRAL] OK, and what is the next member's policy number?
[CUSTOMER][NEUTRAL] OK, next, uh,
[AGENT][NEUTRAL] And you said you have 7.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm. Yes, yes, so 40.
[CUSTOMER][NEUTRAL] 0188409.
[AGENT][NEUTRAL] I'm sorry, your voice cut out [PII]. What was that again?
[CUSTOMER][NEUTRAL] I have a tax ID 0188.
[CUSTOMER][NEUTRAL] 4094.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] OK, so next, uh, member I name is [PII].
[AGENT][NEUTRAL] I'm sorry, what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh [PII] U M M E R, [PII] Styles, [PII].
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] Date of birth, [PII].
[AGENT][NEUTRAL] And what is the person's name again?
[CUSTOMER][NEUTRAL] [PII]. Last name [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, now I do not have.
[AGENT][NEUTRAL] Anyone by that name on this policy.
[CUSTOMER][NEUTRAL] Let me give you the member ID again.
[AGENT][NEUTRAL] I have the ID correct ID number, but there's no one by the name of Summer.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] So, uh, Stiles is a, I guess first name. [PII] is the last name. Do you have his name?
[AGENT][NEUTRAL] On this policy.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] No, I do not.
[CUSTOMER][NEUTRAL] OK, uh,
[CUSTOMER][NEUTRAL] Let me check again. So I have uh uh one more name, uh [PII]. Do you have this name?
[AGENT][NEUTRAL] He is the subscriber is the claim for him.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, you were giving me, OK.
[AGENT][NEUTRAL] What is [PII]'s date of birth?
[CUSTOMER][NEUTRAL] OK, just a second.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEGATIVE] No sir, that is incorrect information that does not match our records.
[CUSTOMER][NEUTRAL] Mm let me check again. OK, so I, uh, I have [PII], so I don't have exact, uh, let me check one more time.
[CUSTOMER][NEUTRAL] So I found that [PII]. I have only this one.
[AGENT][NEUTRAL] OK, so, um, again there's no one by that, there's no one by that name on this policy.
[CUSTOMER][NEUTRAL] [PII] of.
[CUSTOMER][NEUTRAL] OK, it means we need to check the patient ID card, right?
[AGENT][NEUTRAL] You need to check the patient's information because the information you're providing me with name and date of birth.
[AGENT][NEUTRAL] Do not match any of our records on this policy.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] So let me open the next one.
[AGENT][NEUTRAL] OK, so just one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, and the next time your policy number?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So, I have an extra ID number.
[CUSTOMER][NEUTRAL] 02435035
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] OK. Patient's name, I have [PII]
[CUSTOMER][NEUTRAL] And the date of birth is uh.
[CUSTOMER][NEUTRAL] Mm, uh, [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][POSITIVE] It does service and total build amount.
[CUSTOMER][NEUTRAL] OK. Get a service in Virginia.
[CUSTOMER][NEUTRAL] And uh OK, just service. uh [PII] amount is uh 3586 even.
[AGENT][NEUTRAL] 358 6
[AGENT][NEUTRAL] $3,586 is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, 35,860.
[AGENT][NEUTRAL] And you did say 53 of 2024, correct?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And you do not have a claim number on this one, is that also correct?
[CUSTOMER][NEUTRAL] Uh, let me check just a moment please.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] No, no payments I I have.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we submitted this claim on [PII]. So please check have you received.
[AGENT][NEUTRAL] I'm looking
[CUSTOMER][POSITIVE] took your time.
[AGENT][NEGATIVE] And we have not received that we did not receive that.
[AGENT][NEUTRAL] There's no claim on file for that data service and total bill amount?
[AGENT][NEUTRAL] And this one is one that you will also need to send us the primary insurance company's explanation of benefits along with the claim for review.
[CUSTOMER][NEUTRAL] OK, sir. So, uh, patient defective date do you have?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] 2
[AGENT][NEUTRAL] Active.
[CUSTOMER][NEUTRAL] Current, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Thank you. Let me open the next one.
[AGENT][NEUTRAL] OK, and I'll finish my portion on this one while you're doing that.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the next one.
[CUSTOMER][NEUTRAL] OK. 02435030.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Date of birth, [PII].
[AGENT][NEUTRAL] And the name?
[CUSTOMER][NEUTRAL] Uh [PII]
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh date of birth [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Data service and total bill amount?
[CUSTOMER][NEUTRAL] Uh-huh. Sure, the service.
[CUSTOMER][NEUTRAL] Uh, [PII] range amount of 1906 even.
[AGENT][NEUTRAL] OK, let's do the, OK.
[AGENT][NEUTRAL] What is the date range again?
[CUSTOMER][NEUTRAL] Uh, [PII] of last year.
[AGENT][NEUTRAL] And the total bill amount.
[CUSTOMER][NEUTRAL] Mhm. $1,906 even.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and we do not have a claim on file for this member for that data service and that total bill amount.
[CUSTOMER][NEUTRAL] OK. So we need to submit it again with family, right?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, and uh effective rate for this number?
[AGENT][NEUTRAL] The claim and the primary EP.
[CUSTOMER][NEUTRAL] Effective date.
[AGENT][NEUTRAL] [PII] and it is active.
[CUSTOMER][POSITIVE] Thank you so much. So, I have a
[CUSTOMER][NEUTRAL] Uh, 2 more.
[CUSTOMER][NEUTRAL] Uh, I have, uh, just 2 more. Uh, let me check. On the one more, not more than.
[AGENT][POSITIVE] Mm. Yes, I can.
[AGENT][NEUTRAL] One more.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, and the next number's policy number?
[CUSTOMER][NEUTRAL] Uh-huh. Next number is 02357788.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And your patient's name and date of birth?
[CUSTOMER][NEUTRAL] OK. Patient name is [PII]. Date of birth is uh
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][POSITIVE] Sure, take your time.
[AGENT][NEUTRAL] And what is the data service and total bill amount, please?
[CUSTOMER][NEUTRAL] OK, date of service is [PII].
[CUSTOMER][NEUTRAL] Amount is 5975 even.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] At the time.
[CUSTOMER][NEUTRAL] And for this one, we already submitted the claim on uh
[CUSTOMER][NEUTRAL] [PII], so please check your receipt.
[AGENT][NEUTRAL] I'm so sorry, [PII], but I can't I can't hear you.
[CUSTOMER][NEUTRAL] OK, I said we submitted this claim on [PII], so please check have you received.
[AGENT][NEUTRAL] OK, and again, you said the data services [PII], is that correct?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, so we did not receive that claim.
[CUSTOMER][NEUTRAL] OK. So, saying we have this.
[AGENT][NEUTRAL] There is no claim on file.
[CUSTOMER][NEUTRAL] Thank you. So, can I get the effective date for this number?
[AGENT][NEUTRAL] Yes, the effective date on the policy is.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And it has a term date?
[CUSTOMER][NEUTRAL] I'm sorry. Please repeat. What did you say?
[AGENT][NEUTRAL] Oh, it doesn't have a
[CUSTOMER][NEUTRAL] It's a repeat, what did you say?
[AGENT][NEUTRAL] [PII] [PII].
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] To current, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK. Thank you so much for like our claims information.
[AGENT][POSITIVE] Oh, you're very welcome. And is there, and that was the last one that you had?
[CUSTOMER][POSITIVE] And uh have a nice day. Goodbye.
[AGENT][NEUTRAL] Is that [PII]? You didn't have any more?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][POSITIVE] No, no. Thank you so much, bye.
[AGENT][POSITIVE] OK, well then, thank you again for calling APL and I hope you have a very nice day.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Mm, you, bye-bye.