AccountId: 011433970860
ContactId: a570e0a4-8545-44bb-812a-0c3b96a2fe2b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 650320 ms
Total Talk Time (AGENT): 221791 ms
Total Talk Time (CUSTOMER): 163802 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/25/a570e0a4-8545-44bb-812a-0c3b96a2fe2b_20250225T16:12_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from the provider's office to check on a claim status. How are you doing today?
[AGENT][NEUTRAL] I'm doing fine. I'm sorry, could you give me your name again?
[CUSTOMER][NEUTRAL] Sure, my name is spelled as [PII].
[AGENT][NEUTRAL] OK, [PII]. Thank you. And your callback number?
[CUSTOMER][NEUTRAL] My callback number is [PII] with the extension number [PII].
[AGENT][NEUTRAL] That was [PII]. Is that correct?
[CUSTOMER][NEUTRAL] And could you also spell out your name for me?
[CUSTOMER][POSITIVE] That is correct.
[AGENT][NEUTRAL] OK, my name is [PII]
[AGENT][NEUTRAL] And you will use my name [PII] and today's date is your call reference number. So you're needing to check claim status on one patient, is that correct?
[CUSTOMER][NEUTRAL] Yeah, only one patient I have.
[AGENT][NEUTRAL] Yes, I can help you with that. And what is the member's policy number?
[CUSTOMER][NEUTRAL] Policy number starts with 0250709.
[CUSTOMER][NEUTRAL] 6
[AGENT][POSITIVE] Thank you, one moment please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And any information [PII] that I did provide for you today will be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh yeah, sure. Just a moment, I'll provide you my patient name and date of birth.
[CUSTOMER][NEUTRAL] Patient's name on this account as I can see I have is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you. The date of service and total bill amount please.
[CUSTOMER][NEUTRAL] I'm sorry, what do you need?
[AGENT][NEUTRAL] The date of service and total bill amount.
[CUSTOMER][NEUTRAL] The date of service is [PII] and the total bill amount is $2,523.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so this claim, one moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] This claim was received on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Processed on [PII].
[AGENT][NEUTRAL] The claim number is 3551046.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] This claim was denied, [PII].
[AGENT][NEUTRAL] And the denial remarks states calendar year maximum on diagnostic services has been met.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So maximum benefit has been met for the terms of visit, right?
[AGENT][NEUTRAL] Calendar year maximum on diagnostic services has been met.
[CUSTOMER][NEUTRAL] So how many diagnostic services were allowed in the calendar year?
[AGENT][NEUTRAL] 1
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And when the patient took uh when the patient last took the diagnostic services.
[AGENT][NEUTRAL] It was met on another provider's claim prior to yours being received.
[AGENT][NEUTRAL] I can't provide you information related to another provider's claim.
[CUSTOMER][NEUTRAL] But that is for the another provider, right? That's for that is for the different for this facility and that this is for the different facility.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] So it should be go for reprocess.
[AGENT][NEUTRAL] No, sir, if you want to file an appeal, you have 180 days from the date of the decision to send a formal appeal to our claims PO box attention appeals department.
[CUSTOMER][NEUTRAL] So can we bill this amount to the patient?
[AGENT][NEUTRAL] We do not determine patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] So we cannot bill to the patient, right?
[AGENT][NEUTRAL] We do not determine patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] So we can send the appeal with the complete medical records.
[AGENT][NEUTRAL] You may file the appeal to [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Do you have
[CUSTOMER][NEUTRAL] Do you have the tax number?
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII] attention appeals department.
[CUSTOMER][NEUTRAL] Appeal filing limit.
[AGENT][NEUTRAL] As I explained, it must be filed within 180 days from the date of the decision.
[CUSTOMER][NEUTRAL] 180 business or 100 days.
[AGENT][NEUTRAL] 180 days.
[CUSTOMER][POSITIVE] OK, no problem.
[CUSTOMER][NEUTRAL] And could you also fax me the UB?
[AGENT][NEUTRAL] You may print that directly from our portal by going to secured.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And actually, for the appeal, it must be submitted via mail, not via fax.
[CUSTOMER][NEUTRAL] Why we need to submit through this mail if we if if you provide the fax number.
[AGENT][NEUTRAL] That is the process. You asked me for the fax number, but I was in the process of giving you our claims mailing address.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can you repeat the mailing address again?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] So the address is [PII] [PII] [PII].
[AGENT][NEUTRAL] Well, you left off one word in the city. The name of the city is [PII].
[CUSTOMER][NEUTRAL] Is it right?
[AGENT][NEUTRAL] Both words, [PII].
[AGENT][NEUTRAL] And then the state is [PII].
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much uh.
[AGENT][NEUTRAL] And our portal website again for you to print your explanation of benefits is secured. [PII].
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] So the address is [PII].
[AGENT][NEUTRAL] Correct for a portal so that you can print the explanation of benefits, that is correct.
[CUSTOMER][POSITIVE] Thank you so much. And what is the timely filing limit for the fresh claims if we want to build any fresh claim in the future?
[AGENT][NEGATIVE] We do not have a timely filing limit. There is no timely filing limit.
[AGENT][NEUTRAL] But an appeal must be filed within 180 days from the date of the denial.
[CUSTOMER][POSITIVE] Thank you so much and can I get the call reference number?
[AGENT][NEUTRAL] My name in today's date.
[CUSTOMER][POSITIVE] Oh thank you for reminding me actually already told on the starting of the call. Thank you so much. Have a great day and bye for now. Bye for now, [PII].
[AGENT][NEUTRAL] Yeah, so that's OK.
[AGENT][POSITIVE] You're welcome. Yes, that's, that's all I can help you with, [PII]. Yes, you're well. Thank you again, [PII] for calling APL and I hope you have a nice day.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You too, bye.
[AGENT][POSITIVE] Uh, thank you. Bye-bye.