AccountId: 011433970860
ContactId: 8fda4bb5-7f80-4d00-a106-567f74539856
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 374309 ms
Total Talk Time (AGENT): 146902 ms
Total Talk Time (CUSTOMER): 104043 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/31/8fda4bb5-7f80-4d00-a106-567f74539856_20250131T19:15_UTC.wav
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[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. I'm calling regarding claim status. Could you help me with that?
[AGENT][POSITIVE] Sure, I'll be more than happy to help you with the claim status, [PII], and how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Only one.
[AGENT][NEUTRAL] OK, may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah it's uh [PII] with the extension of [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] It's 225-0022.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] Yeah, sure. It's [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim you like me to check on?
[CUSTOMER][NEUTRAL] Yeah, it's [PII] with the bill amount of $1330 even.
[AGENT][NEUTRAL] 1,313 or 30?
[CUSTOMER][NEUTRAL] 30, it's 30.
[AGENT][NEUTRAL] And what was the sense?
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] $1330 was it even or was it changed?
[CUSTOMER][NEUTRAL] Even it's even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][POSITIVE] Yes, sure, please take your time.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, here it is.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So clinic.
[AGENT][NEGATIVE] I'm sorry, the phone's breaking up.
[CUSTOMER][NEUTRAL] Uh, Samsung clinic.
[AGENT][NEUTRAL] Thank you for that. So I'm showing that we received the claim on [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] The claim number is 3493393.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Because the the services are not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Let me think.
[CUSTOMER][NEGATIVE] But already the pri the primer was paid the payment. Then however it's not covered?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So primary insurance has their own benefits and their secondary insurance. Um, we have our own benefits, so it could be covered for primary, but
[AGENT][NEGATIVE] Not covered for us because of the place of service.
[CUSTOMER][NEUTRAL] You're stating the place of service was incorrect, right?
[AGENT][NEUTRAL] I'm stating that it's not covered, the services are not covered when performed in a doctor's office or clinic. So yes, primary may have applied to it, but because secondary has its own benefits, if it's in a doctor's office or clinic, the service is not covered for the patient's policy.
[CUSTOMER][NEUTRAL] be
[CUSTOMER][POSITIVE] OK. OK, thanks for that information, uh.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Is there any chance can we appeal for this, the medical records?
[AGENT][NEUTRAL] Um, you can, uh, unless the place of service changes, there, there would be no reason to appeal it. It's because of where it was done, not what was done.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, thanks for that. Uh, can I, may I know the time and which?
[AGENT][NEUTRAL] Sure, it's 180 days from the denial date.
[CUSTOMER][NEUTRAL] Days from denial date also, could you help me with the current claim timely filing limit.
[AGENT][NEGATIVE] Uh, there's no timely filing for a corrected claim.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] May I know the uh mailing address and fax number to submit the correct claim on time if I apply send for appeal.
[AGENT][NEUTRAL] Yes, the fax number is [PII]. For an appeal, it would be attention APL appeals department.
[AGENT][NEUTRAL] And our mailing address is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] OK, thanks for the information. Can I get the call reference number?
[AGENT][NEUTRAL] Sure, sir, there's no call reference number, but you can use my name and today's date. Again, it's [PII], first initial to my last name is [PII], and then today's date.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're very welcome. Was there anything else I can assist you with today, darling?
[CUSTOMER][POSITIVE] Thank you very much.
[AGENT][POSITIVE] Alright, thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] No, it's [PII], not dumb.
[CUSTOMER][NEUTRAL] Yep
[CUSTOMER][POSITIVE] Happy weekend.
[AGENT][POSITIVE] OK. Have a good day. Bye-bye.