AccountId: 011433970860
ContactId: a6bb8ba7-5f5a-4eb2-b68d-5db7aee9254e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 389839 ms
Total Talk Time (AGENT): 173816 ms
Total Talk Time (CUSTOMER): 147995 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/12/a6bb8ba7-5f5a-4eb2-b68d-5db7aee9254e_20250212T19:41_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is speaking. May I help you?
[CUSTOMER][NEUTRAL] Hi, I'm [PII]. First initial of my last name is [PII] calling regarding claims.
[AGENT][NEUTRAL] OK, I can verify claim status for you, [PII], and what is the policy number, please?
[CUSTOMER][NEUTRAL] OK. The policy number is 018287774.
[AGENT][POSITIVE] OK, thank you so much. Give me one moment, please.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] I'm sorry, say that one more time, [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And [PII], verify the patient's name, date of birth.
[CUSTOMER][NEUTRAL] Patient's name is [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. And what was the date of service and the amount of the charge?
[CUSTOMER][NEUTRAL] [PII]. The bill amount is $1,259 even.
[AGENT][NEUTRAL] And do you have the balance after primary insurance has processed the claim?
[CUSTOMER][POSITIVE] Yes, I do have it.
[AGENT][NEUTRAL] OK, and that amount is?
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] That amount is uh
[CUSTOMER][NEUTRAL] $78.86.
[AGENT][NEUTRAL] OK, thank you, [PII]. Give me one moment. And while I'm looking up claim information let you know we do have an online service center where providers can check claim status as well as print out the EOB. That site is at secured. [PII].
[AGENT][NEUTRAL] And you are calling from?
[CUSTOMER][NEUTRAL] Saint Peter's Bone and Joint Surgery INC.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, I'm showing this claim processed and page 7886 and this was processed on, give me a moment.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Uh, [PII], and a check has been mailed.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And that's a balance of $70.70 dollars is patient's co-pay, right?
[AGENT][NEUTRAL] There is no co-pay with our policy. Uh, that's just the max benefit that's payable for the state of service. Uh, for the charge, well for the procedure 9921, I'm sorry, 99203, that portion processes office visits are not covered per the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Office visit are not covered per patient policy.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] the
[CUSTOMER][NEUTRAL] OK, what type of uh plan the patient has?
[AGENT][NEUTRAL] It's a secondary supplemental plan. It only covers procedures in office, outpatient or in hospital. It does not cover office visits.
[CUSTOMER][NEUTRAL] One minute. The patient has secondary.
[CUSTOMER][NEUTRAL] And the patient has secondary Medicare supplement policy, right?
[AGENT][NEUTRAL] No, this is not a Medicare supplemental. This is a secondary supplemental policy.
[AGENT][NEUTRAL] It's not part of Medicare.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Secondary supplement policy and uh what are the services covered and uh.
[AGENT][NEUTRAL] Services performed in an outpatient facility, physician's office clinic, or inpatient. It does not cover office visits.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, that's not cover of this visit. So is this a patient responsible, right?
[AGENT][NEUTRAL] We can give patient responsibility. We can only verify how we process the claim.
[CUSTOMER][NEUTRAL] OK. Can I get the claim number?
[AGENT][NEUTRAL] 355-755-555.
[AGENT][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK, then.
[CUSTOMER][NEUTRAL] Does not cover office visit as per the patient policy.
[CUSTOMER][NEUTRAL] OK. The other two cards have been paid.
[CUSTOMER][NEUTRAL] Can I get the reference number?
[AGENT][NEUTRAL] Uh, we don't give reference numbers. If you like, you may use my name of today's date. And [PII], is there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] No, and what was your name?
[AGENT][NEUTRAL] My name is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And, OK, by some, can I get the apple mailing address or the fax number in case if we want to send an apple.
[AGENT][NEUTRAL] Uh, the
[AGENT][NEUTRAL] If you're submitting an appeal, you must submit a letter stating the reason for the appeal, and you have up to 90 days from the time the claim, or I'm sorry, 180 days from the time the claim was processed and to submit an appeal. The address is [PII].
[CUSTOMER][NEUTRAL] one
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. Is there any fax number?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][POSITIVE] OK, thank you so much, [PII]. Have a happy week. Bye-bye.
[AGENT][POSITIVE] You too. Thank you for calling APL. Bye.