AccountId: 011433970860
ContactId: a42a5369-98ed-497a-b798-9fcc48f54762
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1002659 ms
Total Talk Time (AGENT): 465927 ms
Total Talk Time (CUSTOMER): 276899 ms
Interruptions: 5
Overall Sentiment: AGENT=1.5, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/a42a5369-98ed-497a-b798-9fcc48f54762_20250117T20:16_UTC.wav
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[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, my name is [PII], calling from the provider's office regarding the claim status. How are you today?
[AGENT][POSITIVE] I'm doing wonderful, [PII], thanks for asking. How about yourself?
[CUSTOMER][POSITIVE] Thank you for asking. I'm good I'm doing great.
[AGENT][NEUTRAL] Good and [PII], you said you're calling for claim status, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Perfect. Do you mind if I get a good call back number from you real quick, sir?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Sure. [PII].
[AGENT][NEUTRAL] Thank you. And the policy number for the claim you want to look at today?
[CUSTOMER][NEUTRAL] Yeah. 2, sorry, 02454150 M as Mary, L as Lima 8.
[AGENT][POSITIVE] Perfect, give me just a moment to get that pulled up.
[AGENT][NEUTRAL] Thank you. And would you be able to verify for me, pretty please, your patient's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure. First name is [PII] and last name is [PII].
[AGENT][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] And the date of birth is?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Perfect, thank you. I see her here. And what is the date of service on the claim we want to look out for her today?
[CUSTOMER][NEUTRAL] [PII], total charge is $542 even.
[AGENT][NEUTRAL] Perfect. And can you verify for me, please, the name of the facility on this claim?
[CUSTOMER][NEUTRAL] This Gastro Health LLC NPI number is 1487767133.
[AGENT][NEUTRAL] All right. I do see it here for gastrohealth.
[AGENT][NEUTRAL] Alright, I have that your claim was received on, looks like [PII]. It looks like we processed your claim on [PII]. Your claim number is 352-8612.
[CUSTOMER][NEUTRAL] So, when it is processed? Sorry for the interruption.
[AGENT][NEUTRAL] No, you're OK. It was processed [PII].
[CUSTOMER][NEUTRAL] Uh, when it is processed?
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] And then do you need me to restate that claim number for you, sir?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK, claim number is 352-8612.
[AGENT][NEUTRAL] And then I do show the claim denied it states that um office visits are not covered by the above numbered policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Uh.
[CUSTOMER][NEUTRAL] Mhm. Is there any, uh, appealing the claim?
[AGENT][NEUTRAL] Um, I mean, you always have the right to appeal any claim. It's 180 days after it's been.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Um, been decided on, so you have 180 days from [PII], and then our appeals address you would just state your intent to appeal in that claim number and you would send it to the same address as our claims that [PII], but you would address it to APL appeals department.
[CUSTOMER][NEUTRAL] the
[CUSTOMER][NEUTRAL] I
[CUSTOMER][POSITIVE] OK. Thank you so much. Uh, can you please spell out your name for me?
[AGENT][NEUTRAL] Oh, you betcha. My name is [PII].
[CUSTOMER][NEUTRAL] OK, calls for this claim.
[AGENT][NEUTRAL] It's gonna be my name and today's date.
[CUSTOMER][POSITIVE] Thank you so much. I have 2 more claims to look. Can you please assist on those claims?
[AGENT][POSITIVE] Yeah, I can certainly help you with those today. Let me, um, quickly get my note put in for this one, [PII], and then
[AGENT][NEUTRAL] Um, are they going to be on different policies?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It is for the same provider, uh.
[AGENT][NEUTRAL] OK, and then what's
[CUSTOMER][NEUTRAL] I think it is for the different policy. I don't know what.
[AGENT][POSITIVE] That's OK. I'm ready for that next policy number then when you are, my friend.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 0143
[CUSTOMER][NEUTRAL] 5493.
[AGENT][NEUTRAL] You said 98 or 93 I'm sorry.
[CUSTOMER][NEUTRAL] 93.
[AGENT][NEUTRAL] 93. Thank you. One second.
[AGENT][NEUTRAL] All right. Thank you, [PII]. And can you provide me with their first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure. First name is [PII] and last name is [PII]. Uh, date of birth is [PII].
[AGENT][POSITIVE] Thank you. I do see [PII] here and
[CUSTOMER][NEUTRAL] If you receive the.
[AGENT][NEUTRAL] The date of service?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] [PII] total charge is $348 even.
[AGENT][POSITIVE] OK, perfect. Hang tight.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] me
[AGENT][NEUTRAL] OK, perfect. I see that one here for gastrohealth as well. It looks like we received your claim on 11-12-2024. It looks like we processed this claim on 11-14-2024, and it looks like your claim number is 3530095.
[CUSTOMER][NEUTRAL] Bye
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Um, this claim does have a denial code stating that these services were rendered after coverage was terminated. Let me see if I can find that termination date for you.
[AGENT][NEUTRAL] And it looks like the coverage terminated [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] Uh, the coverage
[CUSTOMER][NEUTRAL] OK. Can you please uh provide me the full effective and term date?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, the effective date was [PII], and then the term date was [PII].
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] My pleasure.
[CUSTOMER][NEUTRAL] Uh, I would like to request that you have for this claim.
[AGENT][NEUTRAL] I can help you with that. Hang tight.
[CUSTOMER][NEUTRAL] Can you please fax the claim, uh, sorry, EOB?
[AGENT][POSITIVE] Yes, I can. Give me one moment to get the EOB pulled up and then I can help you get it faxed out. No worries.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] Mhm. Thank you so much.
[AGENT][NEUTRAL] And [PII], are you gonna want that made attention to yourself or to the patient account number?
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] Attention to my name.
[AGENT][POSITIVE] OK, perfect, and I'm just waiting for that uh fax box to pop up one second.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] There it is, thank you.
[AGENT][NEUTRAL] And [PII], what is going to be the fax number I can send this to you today?
[CUSTOMER][NEUTRAL] Yeah. It's [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Perfect. Thank you so much. I'm hitting send on that right now for you, [PII]. You should get it in the next 5 to 10 minutes.
[CUSTOMER][NEUTRAL] Uh, please
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] All right. And then as far as this um this claim goes, is that all we're needing for this one?
[CUSTOMER][NEUTRAL] Nothing else for this claim. Uh.
[AGENT][NEUTRAL] All right, then I'm ready for that next policy number when you are, [PII].
[CUSTOMER][NEUTRAL] Yes, sir. Uh,
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] The other member ID is 1445533.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Number 8.
[AGENT][POSITIVE] Perfect, and give me just a moment on this one, my friend.
[CUSTOMER][POSITIVE] Just take your time.
[AGENT][NEUTRAL] All right. And could you um go ahead and verify for me your, the first and last name and date of birth again?
[CUSTOMER][NEUTRAL] OK. First name is [PII]. Last name is [PII], and the date of birth is [PII].
[AGENT][POSITIVE] Perfect. I do see [PII] here. Thank you. And what is the date of service for [PII] that we want to look at?
[CUSTOMER][NEUTRAL] [PII] total charge is $348 even.
[AGENT][NEUTRAL] You said [PII]. Is that correct?
[CUSTOMER][POSITIVE] Yes, perfect.
[AGENT][NEUTRAL] OK, hold on.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Let me take a look at something real quick, OK?
[CUSTOMER][POSITIVE] Yeah, please take your time.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Hang on one second, my friend.
[AGENT][NEUTRAL] It looks like your insured has an updated policy number. Is that something you're wanting to have today?
[CUSTOMER][NEUTRAL] OK, please provide me that.
[AGENT][NEUTRAL] Yeah, the updated policy number is 2451548.
[AGENT][NEUTRAL] But I do see your claim on file as well here, so let me know when you're ready for that and we can go over it.
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] Perfect. I have that your claim was received on [PII], and it was processed on [PII]. I do show your claim number listed is 354-577-0.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And I do show that the claim denied stating that office visits are not covered by the above numbered policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Can you please provide me the policy number for this patient?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Yes, the policy number was 2451548.
[CUSTOMER][NEUTRAL] I'm sorry, I'm asking about the policy effective date and term date.
[AGENT][NEUTRAL] Oh, I'm sorry, I misunderstood. Let me go back to that. Um, this policy has been effective since [PII] and it is active.
[CUSTOMER][POSITIVE] Mhm. Thank you so much.
[AGENT][NEUTRAL] No worries. And is this another EOB that you're gonna want sent to you?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK perfect and then same fax number correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Alright, perfect, give me one second, [PII] and I'll get that right out to you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] And I did just get confirmation that that first one came through, so you should have it at this point by now, I hope, fingers crossed.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] Mhm, OK.
[AGENT][NEUTRAL] All right. And [PII], I'm hitting send on this next EOB.
[CUSTOMER][NEUTRAL] Yes, please. Uh.
[AGENT][NEUTRAL] All right, so,
[AGENT][NEUTRAL] That next DOB I just hit send on.
[CUSTOMER][NEUTRAL] I have one last.
[CUSTOMER][POSITIVE] Sorry for the interruption. Yes, please continue.
[AGENT][NEUTRAL] Oh, I just hit send on it so it should be coming your way in a couple more minutes and then did you say you have another um claim you want us to look for?
[CUSTOMER][NEUTRAL] Yeah, this is
[CUSTOMER][NEUTRAL] Yeah, this is a, this one is the last one.
[AGENT][POSITIVE] Will be the last one? OK, perfect.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] Yes, member ID is.
[AGENT][POSITIVE] And I'm ready for that. Mhm.
[CUSTOMER][NEUTRAL] She
[CUSTOMER][NEUTRAL] 025098
[AGENT][NEUTRAL] 025098.
[CUSTOMER][NEUTRAL] 985 7.
[AGENT][POSITIVE] Awesome, thank you. Alright, let me get that one pulled up for you, my friend. Hang tight.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] [PII], would you be able to go ahead and uh verify for me the first, last name and date of birth?
[CUSTOMER][NEUTRAL] Sure. First name is [PII], last name is [PII], and the date of birth is [PII].
[AGENT][POSITIVE] Perfect. I do see [PII] right here and what is the data service we want to look at?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And date of service is on uh [PII]. Total charge is $2,467 even.
[AGENT][NEUTRAL] 2,467 or 76, I'm sorry.
[CUSTOMER][NEUTRAL] 67.
[AGENT][NEUTRAL] 67 and did you have a total charge after primary on that one?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No, uh, I.
[AGENT][POSITIVE] No, OK, no worries, hang tight.
[AGENT][POSITIVE] Alright, that's I'm pretty sure it's gonna be this one.
[AGENT][NEUTRAL] To
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Like what's on.
[AGENT][NEUTRAL] Yes, Gastro Health, this is it. All right, I do have that your claim with us was received.
[AGENT][NEUTRAL] On [PII]. It looks like we processed that on [PII]. And your claim number is 3544734.
[AGENT][NEGATIVE] And then I do show that claim denied. I have that denial reason stating um.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] It says that we have received the primary explanation of benefits that was submitted with your claim. However, the explanation of benefits received does not list the amounts that were applied to the deductible, co-pay, or co-insurance. Please submit a more detailed explanation of benefits that shows these amounts for further consideration on your claim. So it's just wanting a more detailed EOB from the major medical.
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][POSITIVE] Yeah, that's it from my end. Thank you for your assist.
[CUSTOMER][NEUTRAL] Uh, that's it.
[AGENT][POSITIVE] Yeah, absolutely. Is there anything else I can do for you?
[CUSTOMER][POSITIVE] Nothing else. Thank you so much for your patiently assisting me.
[AGENT][POSITIVE] Oh, absolutely, [PII]. Thank you so much. You too. Bye-bye. Thank you.
[CUSTOMER][POSITIVE] And have a great day. Thank you. Bye-bye.