AccountId: 011433970860
ContactId: 9994c7ee-210b-4a55-99fd-dd671793db5b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1283579 ms
Total Talk Time (AGENT): 289247 ms
Total Talk Time (CUSTOMER): 372930 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/16/9994c7ee-210b-4a55-99fd-dd671793db5b_20250116T18:44_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] Hi, good morning. My name is [PII] and I'm calling you from the provider office. I just want to know the claim status. Can you please help me?
[AGENT][NEUTRAL] Yeah, I can check on a claim for you [PII]. Uh, can I get a good call back number from me first in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, sure, one moment please, I'm telling you.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] The callback number is [PII].
[CUSTOMER][NEUTRAL] And the extension number is [PII].
[AGENT][NEUTRAL] OK, thank you. And then do you have the policy number?
[CUSTOMER][NEUTRAL] Yeah, one moment. I'm telling you everything.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, the page is still loading.
[CUSTOMER][POSITIVE] OK, so thank you for your patience. So the policy number is.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, one moment, yeah. 023 2.
[CUSTOMER][NEUTRAL] 252 1.
[AGENT][NEUTRAL] OK, thank you and what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] The insured name is
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Calling this and the date of birth is.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that [PII]. um I do have a different last name for [PII].
[CUSTOMER][NEUTRAL] Uh, let me check again. One moment please.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, so I'm checking over here, yeah, uh.
[CUSTOMER][NEUTRAL] What you are saying, can you repeat one more time of your words?
[AGENT][NEUTRAL] Oh, the last name for [PII], we have a different last name.
[CUSTOMER][NEUTRAL] OK. So the first name is [PII] and the second and last name is [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, I've got a different last name. Um, let's see.
[CUSTOMER][NEUTRAL] OK, so if you want to take any, if you want to take any other information so I can provide you.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, do you happen to have a mailing address or address for her? OK, let's see.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, I, I have the patient address which is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, yes, that's correct. I have her last name as [PII], yeah, OK, alright, well I appreciate you verifying that information. What was the date of service for this claim, [PII]?
[CUSTOMER][NEUTRAL] Uh, OK. Uh-huh.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] The date of service is [PII], with the amount $2,733.10.
[AGENT][NEUTRAL] And 10 cents?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, thank you. One moment please.
[CUSTOMER][POSITIVE] Take your time.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] What's the provider, is it a Roper Hospital?
[CUSTOMER][POSITIVE] Yeah, that is correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Bear with me just a moment.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] OK, so we did receive this claim, [PII], we were unable to pay a benefit as it's not covered under the policy. It only allows payment for outpatient surgery in an outpatient hospital or a physician's office.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So as you said, uh, the service is not covered, right? This claim was denied, right? Uh, so is.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] Not covered.
[CUSTOMER][NEUTRAL] Under the patient plan, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. And what is the process date?
[AGENT][NEUTRAL] This claim was processed [PII].
[CUSTOMER][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] May I have your name? Can you spell out your name, please?
[AGENT][NEUTRAL] Yeah, it's uh [PII]
[CUSTOMER][NEUTRAL] [PII], and what is your last initian name?
[AGENT][NEUTRAL] A
[CUSTOMER][POSITIVE] OK, thank you so much. One moment please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And what is the received date?
[AGENT][NEUTRAL] Uh, the claim was received [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Ice on [PII].
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, so as you said, uh why the service is not covered, can you repeat one more time, please?
[AGENT][NEUTRAL] Yes, give me just a moment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So the policy only allows payment for outpatient surgery in an outpatient hospital or in a physician's office.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You can so as you said, the policy is only allow.
[CUSTOMER][NEUTRAL] For outpatient.
[AGENT][NEUTRAL] Surgery in an outpatient hospital or physician office.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] Or outpatient.
[CUSTOMER][NEUTRAL] Hospital.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so what we have to do for the.
[CUSTOMER][NEUTRAL] Uh, so can we send an appeal on it?
[AGENT][NEUTRAL] Um, I'm afraid the appeal time is going to be, it's gonna be out of the window for that. Uh, it would have to be within 180 days.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] So, uh, the remaining amount, uh, will be billed to the patient, right?
[AGENT][NEUTRAL] We don't say what is patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Ask to.
[CUSTOMER][NEUTRAL] OK, so actually I'm checking in my system we are seeing over here the balance is $739 147 cents. So what, uh, we have to do for this amount?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, as I said, we don't say what is patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] OK, it's totally up to the provider, right?
[AGENT][NEUTRAL] It's up to the provider, yes.
[CUSTOMER][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And uh [PII], what is the call reference number for this one?
[AGENT][NEUTRAL] Reference number would just be my first name, last initial, and today's date.
[CUSTOMER][NEUTRAL] Uh, see, yeah, I'm giving you the next member ID number, but I need to finish my note. Then I will give you the next information, next question information.
[AGENT][NEUTRAL] Was there anything else I could help you with, [PII]?
[AGENT][NEUTRAL] OK, this is for a different policy?
[CUSTOMER][NEUTRAL] Uh, let me check, ma'am. Uh, please stay on the call. First of all, I need to finish my note, then I will give you the next member ID so I can pull up the account. Yeah, just one moment please. Thank you.
[AGENT][NEUTRAL] OK, yes.
[AGENT][NEUTRAL] OK. Sure.
[CUSTOMER][POSITIVE] OK, thank you so much for your patience. So I'm giving you the next ID number.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Which is, let me check.
[CUSTOMER][NEUTRAL] 47.
[CUSTOMER][NEUTRAL] 77
[CUSTOMER][NEUTRAL] OK, so the next member ID is 044 02446499.
[AGENT][NEUTRAL] OK. And the uh name and date of birth for the patient?
[CUSTOMER][NEUTRAL] [PII], and the date of birth is.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. What was the date of service for this claim?
[CUSTOMER][NEUTRAL] The date of service is let me check.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII] with charge amount $2,432 even.
[AGENT][NEUTRAL] OK, that was 2,452.
[CUSTOMER][NEUTRAL] 243 2.
[AGENT][NEUTRAL] 2432 OK.
[AGENT][NEUTRAL] All right, one moment, please.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Yes, take your time.
[AGENT][NEUTRAL] OK, and then just to confirm that was [PII], correct?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Is this the same provider, uh, Roper radiologist?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][POSITIVE] Yes, that is correct.
[AGENT][NEUTRAL] It is OK, OK, so I do have a claim here for that date of service from them, um, that amount was $12.04. Was that the remaining amount after major medical paid?
[CUSTOMER][POSITIVE] Uh, let me check, ma'am. Actually my system again still loading. I think that uh I'm facing the some technical issue over here, so sorry for the inconvenience.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Oh, you're fine. No, I understand that happens.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, so do you have the claim?
[AGENT][NEUTRAL] I think I'm not quite sure this is the same claim, [PII], um.
[AGENT][NEUTRAL] As this one we the amount we received to be billed was $12.04.
[AGENT][NEUTRAL] And I pulled up um the claim information it says the total bill charges were $611 so I don't think that we received the claim that you're referring to.
[CUSTOMER][NEUTRAL] You can, so
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, so we can see that with this amount of no claim on file on the date of service, right?
[AGENT][NEUTRAL] Yeah this was for [PII] correct? [PII], OK, yeah, yeah, this is the only claim I have on file for him, so yes, does not look like we received it.
[CUSTOMER][NEUTRAL] OK. Mhm.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] OK. So, uh, can I actually, uh, sorry for that. Actually, I was, uh, forget the claim number of the previous claim. So I need the claim number. Sorry for that. Uh-huh. And you also forget.
[AGENT][NEUTRAL] Oh,
[AGENT][POSITIVE] No, no, that's perfectly fine. Let's see. I did. I know we were going, let's see. Oh goodness.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, bear with me just a moment.
[CUSTOMER][POSITIVE] Take your time, no problem.
[AGENT][NEUTRAL] There it is, OK, let me know when you're ready.
[CUSTOMER][NEUTRAL] Yeah, go ahead.
[AGENT][NEUTRAL] OK, it is 343-2703.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, it, I'm, uh, repeating, and I, I just told, I, I just want to confirm and verify the number is 343-2703. Is that right, [PII]?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][POSITIVE] No problem, thank you so much for giving me the information. So I'm coming back to my
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh, another account.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] One moment, please.
[CUSTOMER][NEUTRAL] OK, so as you said, the no claim on file on the date of service and what is the timely filing limit to.
[CUSTOMER][NEUTRAL] Rebuild the claim.
[AGENT][NEGATIVE] There is no timely filing limit.
[CUSTOMER][NEUTRAL] OK, not a full timely finding one moment.
[AGENT][NEUTRAL] Mhm I can give you I've got a mailing address, fax number, and a pair ID.
[CUSTOMER][NEUTRAL] Uh, one moment. I have to check if I have, so there is no need to take the call information.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so what is the effective date of this member? The member was active or inactive on the date of service?
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Yes, so this policy's effective date was [PII] and it is currently active.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what is the PR ID number, Kara?
[AGENT][NEUTRAL] Payer ID is 60801.
[CUSTOMER][NEUTRAL] 60801, got it.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] And what is the timely for OK, as you said, no, no timely finding limit. What is the mailing address unfortunately, mhm.
[AGENT][NEUTRAL] Right, mailing address is, yes, it is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that is in [PII] City?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] Uh-huh. Got it.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] Did you need the fax number as well?
[CUSTOMER][NEUTRAL] Uh, yeah. What is the fax number?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, fax number is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Fixed number.
[CUSTOMER][POSITIVE] OK, [PII]. Thank you so much for giving me the information.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] It has been done from my end and thank you so much for your time. Have a wonderful day and nice.
[AGENT][NEUTRAL] Yeah, was there anything else I can help you with?
[CUSTOMER][POSITIVE] Nothing else. Nice to talk to you.
[AGENT][POSITIVE] OK, yes, you too, [PII]. I hope you have a great rest of your day.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Thank you, bye bye.
[CUSTOMER][NEUTRAL] Mhm bye.