AccountId: 011433970860
ContactId: 93da5b04-9e5c-4a2b-94fc-d8fe505a68f8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1143180 ms
Total Talk Time (AGENT): 331811 ms
Total Talk Time (CUSTOMER): 332788 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/22/93da5b04-9e5c-4a2b-94fc-d8fe505a68f8_20250422T19:43_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APO. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh, hi, my name is [PII] calling from Optum Medical KPC, and can you please help me with the claim status of the number.
[AGENT][NEUTRAL] Yeah, of course.
[AGENT][NEUTRAL] You said your name was [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, my name is [PII] and last initially my name is [PII].
[AGENT][NEUTRAL] OK, perfect. Do you have the policy number?
[CUSTOMER][NEUTRAL] Yes, the policy number is 02538101.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. And what's a good callback number in case our call gets dropped?
[CUSTOMER][NEUTRAL] Yeah, the callback number is [PII]. There is no extension. It's a direct line.
[AGENT][NEUTRAL] OK, perfect. And then the patient's first and last name and date of birth, please?
[CUSTOMER][NEUTRAL] Patient's name is [PII], and the date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then do you have a data service and a charge amount?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes, the data service is [PII].
[CUSTOMER][NEUTRAL] And total bill is $324.
[AGENT][NEUTRAL] OK, for the data service, what was the day again? I have February.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the claim number for this is 358.
[AGENT][NEUTRAL] 6093.
[CUSTOMER][NEUTRAL] 3586093, right?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] And it looks like the received date is [PII].
[AGENT][NEUTRAL] The process date is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And it looks like this claim was denied.
[AGENT][NEUTRAL] And it says office visits are not covered by the above policy.
[CUSTOMER][NEUTRAL] Office visits will not covered by your policies?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] May I know the reason why it will not cover the office visits?
[AGENT][NEUTRAL] It's just per the policy.
[CUSTOMER][NEUTRAL] It's just
[CUSTOMER][NEUTRAL] Just checking that uh the primary payer was processed as a primary and the insurance is a secondary and it was denied as uh the visit will not cover, right?
[AGENT][NEUTRAL] Yes, office visits are not covered.
[CUSTOMER][NEUTRAL] This
[CUSTOMER][NEUTRAL] And what we have to do, should I bill to the patient?
[AGENT][NEUTRAL] Uh, we, so we do not determine patients responsibility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] Our company does not determine patients responsibility, so you would have to call them.
[CUSTOMER][NEUTRAL] OK. The, uh, as per your policy, you're saying that we, you will not cover office visit, right? The balance itself is the patient responsibility. So after billing the patient responsibility, the uh the denial has key. So can I bill the patient or not? No?
[AGENT][NEUTRAL] That is up to your company, but we do not determine the patient's responsibility.
[CUSTOMER][NEUTRAL] I do not
[CUSTOMER][NEUTRAL] OK, that's fine.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Is there anything else I could help you with today?
[CUSTOMER][NEUTRAL] Yeah, I do have another 2 claims. Can you please also help me with that?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] The next claim uh sorry, the next uh number is 123.
[CUSTOMER][NEUTRAL] 42
[CUSTOMER][NEUTRAL] 68
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. The patient's first and last name and date of birth, please?
[CUSTOMER][NEUTRAL] Yeah, the patient's uh first name is
[CUSTOMER][NEUTRAL] [PII] and the first name, last name is [PII] and the date of birth is
[CUSTOMER][NEUTRAL] [PII], uh.
[CUSTOMER][NEUTRAL] That's it.
[AGENT][POSITIVE] OK, perfect. Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and then do you have a data service and charge amount for this one?
[CUSTOMER][NEUTRAL] Yes, the data service is 2-18 of 2025 and total bill is $43.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so there is no claim on file for that data service?
[CUSTOMER][NEUTRAL] Actually, we built a claim for the data service on the [PII].
[CUSTOMER][NEUTRAL] To the to the mailing address [PII].
[AGENT][NEUTRAL] OK, so you are going to send claims to PO [PII].
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] 248.
[AGENT][NEUTRAL] 9.
[CUSTOMER][NEUTRAL] One moment, please, let me note it.
[AGENT][POSITIVE] You're OK.
[CUSTOMER][NEUTRAL] Yeah, that can you please continue?
[AGENT][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] [PII] City, [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Can you please spell out?
[AGENT][POSITIVE] Yes, [PII] is spelled OK.
[CUSTOMER][POSITIVE] Oh cool.
[CUSTOMER][NEUTRAL] It's
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, in the sense, OH will become, right?
[AGENT][NEUTRAL] Sorry, what was that?
[CUSTOMER][NEUTRAL] [PII] will come as a short form as OH, right?
[AGENT][NEUTRAL] Uh, you can send that claim, that EOB to this claims address that I just gave you.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] A
[CUSTOMER][NEUTRAL] [PII]. And the zip code, can you please repeat the zip code again?
[AGENT][NEUTRAL] Yes, ma'am. It's [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] For.
[CUSTOMER][NEUTRAL] OK. Can you also please uh tell me the the timely filing limit?
[AGENT][NEUTRAL] There is no filing limit.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And also the policy number that you gave me.
[AGENT][NEUTRAL] Um, it looks like it's no longer active.
[CUSTOMER][NEUTRAL] Oh, really? Then can you please tell me the effective date of the policy?
[AGENT][NEUTRAL] Yes, it looks like the effective date is [PII].
[CUSTOMER][NEUTRAL] It looks like the
[AGENT][NEUTRAL] And date paid to.
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] Hm.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK. Then the member was not effective for the data service, right?
[AGENT][NEUTRAL] Yes, and it looks like he has a new policy.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Uh, let me give you that policy number instead.
[CUSTOMER][NEUTRAL] that.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so that policy number is 16.
[CUSTOMER][NEUTRAL] That that.
[AGENT][NEUTRAL] 16.
[AGENT][NEUTRAL] 382.
[CUSTOMER][NEUTRAL] 1616382, right?
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Let me see if there's a claim on.
[CUSTOMER][NEUTRAL] OK. Can I will a claim?
[AGENT][NEUTRAL] Sorry.
[CUSTOMER][NEGATIVE] Sorry, come again.
[AGENT][NEUTRAL] Um, I'm going to see if there's a claim on file for this one.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on.
[AGENT][NEUTRAL] OK, so there is a claim on file for that date of service. It is the claim number is 35.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] 2614.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And it looks like this claim was denied.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Hold on, I will tell you why. Just a minute.
[AGENT][NEUTRAL] OK, so it looks like the received date is [PII].
[CUSTOMER][NEUTRAL] What
[AGENT][NEUTRAL] And the process date is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And the reason why this claim was denied.
[AGENT][NEUTRAL] OK. The service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEGATIVE] It pain
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hi. All right, I'm here.
[CUSTOMER][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] It means, can you please provide me the details about that? Why it was not covered by the service?
[AGENT][NEUTRAL] So it says service not covered in doctor's office when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] Then what do we have to do to get the payments for the safety for the service?
[AGENT][NEUTRAL] Uh, I mean, you can try to send another EOB over, but
[CUSTOMER][NEUTRAL] OK
[AGENT][NEGATIVE] I think it's just going to get denied again because
[CUSTOMER][NEUTRAL] I think
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] It was in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] It's just.
[AGENT][NEUTRAL] And for this policy.
[AGENT][NEGATIVE] It does not cover when it does not cover.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] That when it's in a doctor, doctor's office or clinic.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But the primary payer was uh processed uh towards a patient responsibility.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Somehow it will have to pay, right?
[AGENT][NEUTRAL] So we do not determine patients responsibility. You will have to contact them.
[CUSTOMER][NEUTRAL] OK, fine. Thank you. And can you please also help me with another claim?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, of course.
[AGENT][NEUTRAL] We also, we do have an OSC website that you can log on to and you can check claim status.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] Exactly
[CUSTOMER][NEUTRAL] OK. Actually, I have a claim for the same member only.
[CUSTOMER][NEUTRAL] And can you proceed with the data service directly?
[AGENT][NEUTRAL] Yes, is it a different data service?
[CUSTOMER][NEUTRAL] Yeah, the rate of service is the same, but the amount was a different.
[AGENT][NEUTRAL] OK. What is the amount for that one?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII] and total bill amount is $620.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK, just one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] OK, so it looks like I do not have that charge amount on file.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] There is a charge amount. Can you check carefully, it is uh $620 only.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. Can you see the charge amount is $457?
[AGENT][NEUTRAL] Yes, I see $457.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah, can you check with that.
[AGENT][NEUTRAL] Yes. So that claim number is 358.
[CUSTOMER][NEUTRAL] Yeah, so that number is.
[AGENT][NEUTRAL] 261 2.
[CUSTOMER][NEUTRAL] 6
[AGENT][NEUTRAL] And the received date is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm. OK.
[AGENT][NEUTRAL] Process date, [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and then this claim was denied, office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][POSITIVE] OK, thank you so much for giving me this information. Can you please help me with your name and the conference number?
[AGENT][NEUTRAL] Of course. My name is [PII]
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The call reference number please.
[AGENT][NEUTRAL] It would be my first name.
[AGENT][NEUTRAL] My last initial [PII] and then today's date.
[CUSTOMER][POSITIVE] Thank you, [PII], for giving me this information. Have a great day and bye for now.
[AGENT][POSITIVE] Of course, thanks for calling APL. Have a good day.
[CUSTOMER][POSITIVE] Thank