AccountId: 011433970860
ContactId: 9cee7696-123b-45aa-a438-de0f986986e4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 315559 ms
Total Talk Time (AGENT): 76838 ms
Total Talk Time (CUSTOMER): 167648 ms
Interruptions: 2
Overall Sentiment: AGENT=0, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/05/9cee7696-123b-45aa-a438-de0f986986e4_20250605T21:17_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from provider office to check on the claim status.
[AGENT][NEUTRAL] Hey [PII], I can help you with claim status. Do you have a good callback number?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Sure. [PII].
[AGENT][NEUTRAL] OK, and the policy number for the patient?
[CUSTOMER][NEUTRAL] 02509837. And the member name is [PII] After that, [PII] The last name is [PII] Date of birth is [PII].
[AGENT][NEUTRAL] And date of service and bill charges?
[CUSTOMER][NEUTRAL] The service is [PII] with the charge amount $940 even.
[CUSTOMER][NEUTRAL] Do you need the claim number?
[AGENT][NEUTRAL] Uh, you have the claim number?
[CUSTOMER][NEUTRAL] Yeah. Uh, the number is 359-953-2.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, and the date of service was.
[AGENT][NEUTRAL] [PII], correct?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII], is that right?
[CUSTOMER][NEUTRAL] Mhm. [PII].
[AGENT][NEUTRAL] OK, um, so are you calling to check the denial reason? You said you have the claim number. What was your question?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, the reason, denial reason is CO16 claim lack information which is needed for adjudication. So what exact reason of, sorry, information you need to process the claim?
[AGENT][NEUTRAL] We need an explanation of benefits that shows how the major medical applied this to deductible or co-insurance or co-pay.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, no, not like this. Uh, what information it does need required to process the claim. You just mentioned a CO 16, even there's no, uh, allow the allowed amount and paid amount.
[AGENT][NEUTRAL] Oh, the primary explanation of benefits that we received didn't show.
[AGENT][NEUTRAL] Let me pull it up. Hold on one moment.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEGATIVE] It does not show any deductable or the allowed amount.
[AGENT][NEUTRAL] Correct, so we, we need something that shows how to primary process the claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You guys are acting as primary mhm for this patient, you guys are primary.
[AGENT][NEUTRAL] You know when that was sent.
[AGENT][NEUTRAL] No, we're not primary.
[AGENT][NEUTRAL] No, we are secondary.
[CUSTOMER][NEUTRAL] OK. So,
[CUSTOMER][NEUTRAL] Ohh.
[CUSTOMER][NEUTRAL] Only 12.
[CUSTOMER][NEUTRAL] So, who is acting as primary here?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Uh, let me look, one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, so what needs to be done now?
[AGENT][NEUTRAL] We need an explanation of benefits from AvMed that shows how it applied to deductible, co-pay, or co-insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I made.
[CUSTOMER][NEUTRAL] 324.
[CUSTOMER][NEUTRAL] OK. So you just need the primary UB?
[AGENT][NEGATIVE] Right, we received the primary EOB. We received it and it shows that the amount was not covered, so we won't pay if the primary does not cover the services.
[CUSTOMER][NEUTRAL] We do have [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So if if they did cover the services we need something that shows that in order to consider the claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, sure. Well, that's it. And may I have your name, uh, your name is [PII], right? OK. Last name [PII]?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Thank you so much. May I know the reference number?
[AGENT][NEUTRAL] My name and today's date.
[CUSTOMER][POSITIVE] OK. [PII] 65 2025. Got it. Thank you so much for your assistance. Have a good day. Bye for now.
[AGENT][POSITIVE] Thanks for calling APL. You too. Bye bye.
[CUSTOMER][NEUTRAL] OK.