AccountId: 011433970860
ContactId: aae366c2-cdf7-49ba-9285-0239d43958b0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 509070 ms
Total Talk Time (AGENT): 98488 ms
Total Talk Time (CUSTOMER): 151118 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/10/aae366c2-cdf7-49ba-9285-0239d43958b0_20250210T17:52_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] and I'm calling you from the hospital or facility. And I need your help regarding the medical claims.
[AGENT][NEUTRAL] OK, [PII], I'm happy to check a claim for you. What's the patient's policy number?
[CUSTOMER][NEUTRAL] OK, the policy number is.
[CUSTOMER][NEUTRAL] OK, give me a second. Let me open the account. I have the policy number that is going to be 0480060.
[AGENT][NEUTRAL] OK, let me pull this up here one moment.
[AGENT][NEUTRAL] And if I could have the patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII], the patient name is [PII]. Date of birth is going to be
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the policy number you have is 480,060.
[CUSTOMER][NEUTRAL] No, it's 01480060.
[AGENT][NEUTRAL] Alright. 0148.
[CUSTOMER][NEUTRAL] 0060.
[AGENT][POSITIVE] Thank you.
[AGENT][POSITIVE] Thank you and then data service.
[CUSTOMER][NEUTRAL] It was [PII].
[AGENT][NEUTRAL] And the build out.
[CUSTOMER][NEUTRAL] OK, the bill amount $70,0035 even.
[AGENT][NEUTRAL] Do you have an amount after the primary?
[CUSTOMER][NEUTRAL] Uh yes.
[AGENT][NEUTRAL] What is the billed amount after the primary?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's going to be $5,184.79.
[AGENT][POSITIVE] Thank you, one moment.
[AGENT][NEUTRAL] So claim was received on [PII].
[AGENT][NEUTRAL] Uh, there was a benefit payment sent in the amount of $2,979.91. This was sent on [PII].
[AGENT][NEUTRAL] This is the max benefit payable.
[CUSTOMER][NEUTRAL] I have a specific question about this.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. As I'm looking here.
[CUSTOMER][NEUTRAL] We have submitted an appeal for the underpayment. I just need an update over that appeal.
[AGENT][NEUTRAL] Oh, OK. One moment.
[AGENT][NEGATIVE] It looks like the denial was upheld.
[CUSTOMER][NEUTRAL] OK. Can you please confirm the date when you received the appeal?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Do you have any document control number for that one?
[AGENT][NEUTRAL] Uh, it would be 354.
[AGENT][NEUTRAL] 562 1.
[CUSTOMER][NEUTRAL] Thank you, sir. Just allow me a second. I think uh
[CUSTOMER][NEUTRAL] I have to take a look into this recent EOB.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Uh, [PII], you're right. We have received the EOB from your side in which, uh, the claim number which you just told me has been denied. This is stating that the above reference claims appears to be a duplicate of previously submitted expenses.
[CUSTOMER][NEUTRAL] Is this right?
[AGENT][POSITIVE] Mhm. Correct.
[CUSTOMER][NEUTRAL] OK, [PII]. So, can you please confirm, does this claim uh does this claim qualify to submit an appeal?
[AGENT][NEUTRAL] Um, the decision date on that was back in September, so no, because you have 180 days to file an appeal.
[CUSTOMER][NEUTRAL] OK, so as I told you earlier that uh we have submitted a bill back on [PII].
[CUSTOMER][NEUTRAL] So till that date we have not passed 180 days yet.
[CUSTOMER][NEGATIVE] And now you are denying this appeal as a uh duplicate claim that is totally incorrect.
[AGENT][NEUTRAL] So,
[CUSTOMER][NEUTRAL] So can you please take a look and escalate this uh appeal which you have received for the review.
[AGENT][NEUTRAL] One moment, please.
[AGENT][NEUTRAL] I'll reach out to the claims examiner to uh reexamine this and then send a new explanation of benefits for it, [PII].
[CUSTOMER][NEUTRAL] OK, thank you. So uh what would be the turnaround time to get this completed?
[AGENT][NEUTRAL] 5 to 7 days.
[CUSTOMER][POSITIVE] 5 to 7 days. Sounds good. Uh thank you very much for understanding this issue and helping me. Uh, [PII], is there any call reference number from your site for me?
[AGENT][NEUTRAL] That would be my name with my last initial and today's date. My last initial is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you, sir. That's all for today. Have a great day.
[AGENT][NEUTRAL] You too. Bye-bye.