AccountId: 011433970860
ContactId: a7e7a03c-e8d3-4147-8c86-e0bae32e4323
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1074979 ms
Total Talk Time (AGENT): 425509 ms
Total Talk Time (CUSTOMER): 354818 ms
Interruptions: 1
Overall Sentiment: AGENT=0, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/21/a7e7a03c-e8d3-4147-8c86-e0bae32e4323_20250221T16:49_UTC.wav
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[AGENT][NEUTRAL] Morning, thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yeah, hello. This is [PII] calling from Providence Medical Foundation. I'm looking for the status of the claim.
[AGENT][NEUTRAL] OK, sure, I can assist you with claim status Miss [PII], and may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yep.
[CUSTOMER][NEUTRAL] [PII]. Can I get your name once again, please?
[AGENT][NEUTRAL] Sure, my name is [PII]. That's [PII].
[CUSTOMER][POSITIVE] Thank you so much, so.
[AGENT][NEUTRAL] You're welcome, Miss [PII], and I'm sorry, may I have the name of the place that you said you're calling from?
[CUSTOMER][NEUTRAL] Providence Medical Foundation.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, and may I have the patient's policy number, Miss [PII]?
[CUSTOMER][NEUTRAL] 02104703 M as in Mike L as in Lima number 8.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] First name goes to [PII], last name [PII]. Date of birth, [PII].
[CUSTOMER][NEUTRAL] Oh yeah, apologies. The patient's first name [PII], last name [PII]. Date of birth, [PII].
[AGENT][NEUTRAL] OK, [PII], um, it's a dependent. Do you have the correct name or the correct date of birth?
[CUSTOMER][NEUTRAL] On checking.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The correct name.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Date of birth, [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And may I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] [PII] $271 even.
[AGENT][NEUTRAL] That was [PII] or [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]. Thank you. One moment, let me see if I can find this claim for you. And for the future, you can check claim status online through our website at [PII] and that's just optional.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And, OK, let me pull this up, give me one moment.
[AGENT][NEUTRAL] And we processed this twice. The last one was the process as a duplicate, so I'm gonna give you the information of the original claim, OK?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] The original claim was received on [PII], processed [PII], and it was denied stating office visits are not covered by this policy under the member's plan.
[CUSTOMER][NEUTRAL] Of the street.
[CUSTOMER][NEGATIVE] Not covered by member policy. One second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Can I get the claim number?
[AGENT][NEUTRAL] Sure. The claim number is 3493614.
[CUSTOMER][POSITIVE] 3493614. Have a great.
[AGENT][POSITIVE] Mhm, that's correct.
[CUSTOMER][NEUTRAL] Did you process as primary or secondary?
[AGENT][NEUTRAL] We are the secondary for this number.
[CUSTOMER][NEUTRAL] I do have a copy of UP each state different claim number 353-8159. It got 045.
[AGENT][NEUTRAL] That's a duplicate, that's a duplicate claim.
[CUSTOMER][NEUTRAL] Oh, that is a duplicate claim. OK. You process the secondary as per patient plan office visit is not covered. Am I correct?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] Can I get the patient plan name please, so?
[AGENT][NEUTRAL] Sure, this is a secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] Secondary supplement plan.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah. Yup, the primary processant paid.
[CUSTOMER][NEUTRAL] And left the $60 as your co-pay.
[CUSTOMER][NEGATIVE] But it did not cover the amount.
[AGENT][NEGATIVE] It's not.
[AGENT][NEGATIVE] It's not covered under the member's plan.
[CUSTOMER][NEUTRAL] Usually
[CUSTOMER][NEUTRAL] That's why I'm asking, what is the member's plan?
[AGENT][NEUTRAL] Secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] It's the same
[CUSTOMER][NEUTRAL] Is there any limited benefit like this, any other plan?
[AGENT][NEUTRAL] Mm, I'm sorry. Can you repeat that question? I didn't get that question.
[CUSTOMER][NEUTRAL] Um, is this limited benefit plan? I'm asking?
[AGENT][NEUTRAL] This is a secondary supplemental plan to the major medical. This one doesn't have office visit benefits. This will only cover outpatient facilities.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, ma'am.
[CUSTOMER][NEUTRAL] Oh, only cover outpatient visit. Thank you so much for the information. Shall I move on to the next patient, so next date of service the same patient.
[AGENT][NEUTRAL] New
[AGENT][NEUTRAL] Is it the same patient or is it a different member, different patient?
[CUSTOMER][NEUTRAL] Same patient, same patient, different date of service.
[AGENT][NEUTRAL] Um, OK.
[AGENT][NEUTRAL] OK, what's the next date of service?
[CUSTOMER][NEUTRAL] [PII] $44 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I don't have a claim for [PII] for.
[CUSTOMER][NEUTRAL] For the patient through, Jason, he don't have any, sorry.
[AGENT][NEUTRAL] We're looking at [PII]. Is it for [PII] or is it for [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I do have your UB stated, the patient name [PII], but in my end, it shows she love graces throat.
[CUSTOMER][NEUTRAL] [PII]. I do have a copy of UOB as well.
[AGENT][NEUTRAL] What is the uh EOV, the claim number?
[CUSTOMER][NEUTRAL] 343-238-3.
[AGENT][NEUTRAL] 3. OK, one moment, let me pull the image.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Not
[AGENT][NEUTRAL] One moment, I'm waiting on the image.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, um.
[AGENT][NEUTRAL] Let me have the date of birth for [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. Thank you. So yeah, this one is for [PII] based on the claim information, it says patient's name, insurer's name is the same. Um, so yeah, it is for [PII] and let me see.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] So this one was um processed on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] And it was denied. The reason for this denial is that let's see.
[AGENT][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Can you get the process statement once again.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Can I get the date?
[AGENT][NEUTRAL] Can you get the received date? Is that what you said?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, bear with me, let me pull that.
[CUSTOMER][NEUTRAL] [PII] or is in process from same date [PII].
[AGENT][NEUTRAL] Um, I can check for that. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, so it was let's see.
[AGENT][NEUTRAL] 3
[AGENT][NEUTRAL] OK, so it was.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] One moment trying to locate the claim here one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 2383, where are you?
[CUSTOMER][NEUTRAL] Hi
[AGENT][NEGATIVE] Oh, it's not even on this card in this policy. One moment, it's, it's not even here, one moment.
[AGENT][NEUTRAL] policy here we go.
[AGENT][NEUTRAL] OK, it's under this policy, OK.
[AGENT][NEUTRAL] Oh I see.
[AGENT][NEUTRAL] It was received on [PII].
[CUSTOMER][NEUTRAL] Claim number.
[AGENT][NEUTRAL] It's the same one you provided to me, the 343-2383. It's just on a different policy number.
[CUSTOMER][NEUTRAL] What the put the status.
[AGENT][NEUTRAL] I'm sorry, the what, what date?
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] What did you say? I didn't get.
[CUSTOMER][NEUTRAL] What about the
[CUSTOMER][NEUTRAL] What about the status of the claim?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEGATIVE] OK, again, it was processed on [PII], received [PII] and it was denied as non-covered service.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Non-covered service. is this per patient plan or provider contract?
[AGENT][NEUTRAL] Patients plan.
[CUSTOMER][NEUTRAL] You said you only cover office visit, not, you want to pay for outpatient, uh, sorry, you only cover outpatient visit, am I correct?
[AGENT][NEUTRAL] Uh, this one is different. This is a totally different policy number. And with this one, we do not cover office as well, correct.
[AGENT][NEUTRAL] But it's a different policy number, it's not the same.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You won't cover of a different policy number.
[AGENT][NEUTRAL] It's a different policy number.
[CUSTOMER][NEUTRAL] 021 047.
[CUSTOMER][NEUTRAL] M 02104703 M as in Mike L as in Lima number 7, am I correct?
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Can you get the member ID?
[AGENT][NEUTRAL] OK, and it's also on the explanation of benefits that we send is the correct policy number. The correct policy number for this one is 02406291.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Your voice is breaking.
[AGENT][NEUTRAL] The policy number is also on the explanation of benefits that we sent out is 02406291.
[CUSTOMER][NEUTRAL] Is this old policy or new policy, member ID?
[AGENT][NEUTRAL] This is the, this is the new policy.
[CUSTOMER][NEUTRAL] Can I get a new policy effective date?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's [PII] and it is active at the moment.
[CUSTOMER][NEUTRAL] Still active. What about the policy number 02104703?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's a different policy.
[CUSTOMER][NEUTRAL] Different policy mean old policy or any other policy?
[AGENT][NEUTRAL] Yeah, it's, it's an old policy.
[CUSTOMER][NEUTRAL] Or policy, can I get the effective date and termination date?
[AGENT][NEUTRAL] OK, one moment, let me pull up.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] This one was effective from [PII].
[CUSTOMER][NEUTRAL] Oh, it got terminated. But we build the claim under the member ID October, sorry, 02104703.
[AGENT][NEUTRAL] It has to process through the correct policy number based on the date of service, so it was processed under the correct policy.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, so, this policy as well only to cover this visit. It only cover outpatient visit. Am I correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, surely on to the last date of service with same patient.
[AGENT][NEUTRAL] OK, what's the date of service?
[CUSTOMER][NEUTRAL] And did you receive any duplicate claim for the date of service, [PII]? The previous notes, one of the representatives said claim God need of primary UOB it stated.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Did you receive any primary UP from us?
[AGENT][NEUTRAL] We do receive the primary AOB.
[CUSTOMER][NEUTRAL] You, you do have primary UV correct? Could you please tell me the primary U balance in your end?
[AGENT][NEUTRAL] Mhm, yes.
[AGENT][NEUTRAL] The co-pay of $24.88.
[CUSTOMER][NEUTRAL] Yeah, thank you, ma'am. Yup, sure. I want the last date of service.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Sure, what is the date of service?
[CUSTOMER][NEUTRAL] [PII]. The amount 2.
[AGENT][NEUTRAL] I'm sorry, can you repeat?
[CUSTOMER][NEUTRAL] [PII] $245 even 245.
[AGENT][NEUTRAL] OK, let me go to the old policy for this one. OK, one moment.
[CUSTOMER][NEUTRAL] And I do have a remittance this one as well.
[AGENT][NEUTRAL] OK, give me just a second because I have to move to another policy. You see the date of service is different and that's why you need to go [PII]r to the new policy, which is started [PII] or you need to go back to the one that ends on [PII]. In this case, since the date of service is [PII], I need to go back to the old policy. So bear with me just one second, let me go back to the old policy. OK, thank you.
[CUSTOMER][NEUTRAL] OK, then. I understood.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm. Mm.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] And that was [PII].
[AGENT][NEUTRAL] And is it for [PII] or is it for [PII]?
[CUSTOMER][NEUTRAL] Actually, the primary will be stated different name, but I, we submitted the claim for [PII] TRA2, [PII].
[AGENT][NEUTRAL] Um, it looks like it was for [PII]. Let me go ahead and pull this information. One moment.
[CUSTOMER][NEUTRAL] Yeah, OK. Actually, there is a colla collaboration with the EOBs, so the confusion, is this for [PII] or [PII]?
[AGENT][NEUTRAL] I'll have to check the documents for a moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] But it's a process on the shila.
[CUSTOMER][NEUTRAL] Because it
[CUSTOMER][NEUTRAL] Yeah, because in the end, the UB sorry, the claim form shows [PII], not for [PII], but the primary UB shows [PII]. So that's confusing.
[AGENT][NEUTRAL] OK, let me check and see what's on the documents itself, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, looks like it's for [PII]. It's not for China.
[CUSTOMER][NEGATIVE] Yeah, OK. Is this for [PII] or [PII]? I'm fucking confusing.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It's for [PII], but it was processed under [PII]. I'm not sure why, why it was processed on this, um.
[AGENT][NEGATIVE] But it was denied stating office visits are not covered, which that's the correct denial office visits are not covered, um.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me go ahead and
[CUSTOMER][NEUTRAL] Can I get the date and process it.
[AGENT][NEUTRAL] Yes, um, let me pull that information, one moment.
[AGENT][NEUTRAL] OK, so it was received [PII] process [PII].
[CUSTOMER][NEUTRAL] [PII] or [PII]?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, same number.
[AGENT][NEUTRAL] That is 337-443-5.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What the status, you said the offices is not covered.
[CUSTOMER][NEUTRAL] I understood.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Can I get the call reference for our call?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will.
[CUSTOMER][POSITIVE] Yeah, sure, thank you, bye bye.
[AGENT][POSITIVE] You're welcome. Thank you for calling APL. Have a good day. Mm bye bye.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes.