AccountId: 011433970860
ContactId: ad790c67-f2ae-4a74-bf2b-d93ae0cfc679
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 598359 ms
Total Talk Time (AGENT): 267347 ms
Total Talk Time (CUSTOMER): 207597 ms
Interruptions: 0
Overall Sentiment: AGENT=0, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/ad790c67-f2ae-4a74-bf2b-d93ae0cfc679_20250428T18:48_UTC.wav
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[AGENT][NEUTRAL] For contacting ATL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from provider's office to check on the team status.
[AGENT][NEUTRAL] OK, can I have the claim status. What's the policy number, please?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] My policy number will be.
[CUSTOMER][NEUTRAL] 01847980 M as in Mike, L as in Lima, 8.
[AGENT][NEUTRAL] Thank you. And the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Member's name will be [PII], and the date of birth will be [PII].
[AGENT][POSITIVE] I appreciate that. Is there a callback number I can have in the event we're disconnected?
[CUSTOMER][NEUTRAL] The callback number will be [PII].
[AGENT][NEUTRAL] Thank you. What data service we're looking for, for Scholar?
[CUSTOMER][NEUTRAL] The services will be [PII].
[AGENT][NEUTRAL] OK, thank you. Is there a callback number I should have? I mean, not a callback number, but I'm sorry, is there a bill amount that I should have?
[CUSTOMER][NEUTRAL] There will be $4,582 even.
[AGENT][NEUTRAL] OK, thank you. Um, your claim number is 33.
[AGENT][NEUTRAL] 83
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] Like
[AGENT][NEUTRAL] 430.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And it looks like the policy doesn't have any um outpatient services. So this policy is strictly for inpatient services only, um, or at least that's what it's looking like or not, I'm sorry, inpatient or outpatient. It looks like it might be um.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] For uh
[AGENT][NEUTRAL] Let me just check.
[AGENT][NEUTRAL] At home services I just wanna see what.
[AGENT][NEUTRAL] It looks like it was denied that. Let me just check and see what we've got here.
[CUSTOMER][NEUTRAL] And previously we have submitted the appeal on.
[AGENT][NEUTRAL] OK, yes, it's
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Uh, I beg your pardon?
[CUSTOMER][NEUTRAL] Yeah, previously we have submitted the appeal on [PII]. Will you be able to check on it?
[AGENT][NEUTRAL] Uh yes, let me see.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So what I've got for this or the the claims that I have for this data service.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, we hang up process and all this is.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, it looks like they've all been processed, so we received um.
[AGENT][NEGATIVE] The claim uh twice it looks like. Uh, now the first time it was denied because home services are not, um.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] are not covered, uh, under uh or durable medical is not covered under this policy.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Um, so that was what was listed on, on this, um.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that's what we have. So we have 22 denials. Uh, one of them says that home services aren't covered and one of them says that durable medical isn't covered, but either way the uh
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The CPT code uh is not covered under this, uh, under this policy.
[AGENT][NEGATIVE] So they're, they're both denials.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] I can give you um copies of the ELBs if you would like, if you didn't receive that.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] OK. The code is not cover as per member's policy. I uh.
[CUSTOMER][NEUTRAL] Insurance policy.
[AGENT][NEUTRAL] Through the, through the member's policy, through the, um, we're the secondary insurance and it's not covered through the secondary insurance policy.
[CUSTOMER][NEUTRAL] OK. Uh, will you be able to check on the Apple status which we have previously submitted?
[AGENT][NEGATIVE] OK, it's not open. It, it was denied.
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] So it's
[AGENT][NEGATIVE] So it looks like we, we did receive the, the exact same claim again, um, and, and it was denied.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, you mean there's no pay on file?
[AGENT][NEUTRAL] Uh
[AGENT][NEGATIVE] Well, no, no. The, the only thing that we have is, is showing where it was, where it was denied.
[CUSTOMER][NEGATIVE] I mean, the appeal has been denied.
[AGENT][NEUTRAL] Uh, let's see, let me see if I can find an appeal. I'm not sure that I have. Let me just check one other place. Let's see.
[AGENT][NEUTRAL] OK. Could you excuse me just one moment, please? I'll be right back.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, yes, we did receive the appeal, um.
[AGENT][NEUTRAL] It's uh it looks, it looks like that, uh.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] It was not approved, so it's not, doesn't look like it was uh.
[AGENT][NEUTRAL] and I see where, where it was sent in, but, um, it was reviewed and, and, uh, the, these, these types of, of, uh, helmets or, or what I mean, uh, durable medical, it's not approved or not uh covered by the, by the policy. So it looks like it did go through the appeal process and it looks like that was not covered.
[CUSTOMER][NEUTRAL] OK. I mean the app was received.
[AGENT][NEUTRAL] Yes, it looks like the appeal was received and it looks like it was just processed. No, um.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] May I know the date?
[AGENT][NEUTRAL] That you mean the day that it was that it was um.
[AGENT][NEUTRAL] Denied or or what?
[CUSTOMER][NEUTRAL] The date of a receipt.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Let me just check that.
[CUSTOMER][NEUTRAL] Oh what are you doing?
[AGENT][NEUTRAL] OK, it looks like we
[AGENT][NEUTRAL] Received it.
[CUSTOMER][NEUTRAL] right
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] On the [PII] and we processed it on the [PII].
[AGENT][NEUTRAL] Excuse me, I'm sorry, we received it on the [PII] of, yes, and processed it on the [PII], excuse me.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. And it was denied as no one covered for durable medical except, am I correct?
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, as for, I mean the patient's plan.
[AGENT][NEUTRAL] Under the patient's plan, that these are not covered.
[CUSTOMER][NEUTRAL] OK, thank you. Uh, could you please spell me your name?
[AGENT][NEUTRAL] My name is [PII]. The first letter of my last name is [PII], and we're gonna use that in today's date as our reference. Is there anything else that I can help with?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Because
[AGENT][NEUTRAL] Uh, I'm sorry, my phone is kind of getting out.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Could you please spell me your name?
[AGENT][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] Thank you, [PII]. Um, I would like to request the upheld letter via fax, I mean the app upheld letter. Will I be able to fax it?
[AGENT][NEUTRAL] Yes, and, and what is your fax number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] The fax number will be [PII] I'm sorry, the fax number will be [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, is there anything else at all that I can help with?
[CUSTOMER][NEUTRAL] May I know why the second level of appeal is possible on the claim?
[AGENT][NEUTRAL] Uh, you should receive it uh by the end of the day.
[CUSTOMER][NEUTRAL] I mean, um, may I know whether the second level of appee is possible on the claim?
[AGENT][NEUTRAL] OK, so you want, you want a copy of the appeal as well as the, as the, as the original claim, is that correct?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Cause I'm, I'm sorry, your phone's cutting in and out. It's uh.
[CUSTOMER][NEUTRAL] I do apologize for that. I'd like to request for the second level of appeal is possible on the client.
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] OK, you want to appeal again. Is that what you're saying?
[CUSTOMER][NEUTRAL] Yes, is it possible?
[AGENT][POSITIVE] Yeah, you can appeal it as many times as you, yeah, absolutely, you can appeal it if you like.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Certainly, um, you would send it to the same place. Um, our mailing address is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] That is in [PII].
[CUSTOMER][NEUTRAL] Alright.
[AGENT][NEUTRAL] Our zip code is [PII].
[AGENT][NEUTRAL] 24
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] May I also know the fax number?
[AGENT][NEUTRAL] Yes, our fax number is [PII].
[AGENT][NEUTRAL] 365.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the filing limit to some of the second level of appeal.
[AGENT][NEUTRAL] Uh, you have 180 days, um, after the original claim was was received and it looks like that was in November.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] And thank you so much for assisting um.
[CUSTOMER][NEUTRAL] And call reference number will be your name in today's date. Am I correct?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][POSITIVE] Thank you and thank you so much for your assistance. So that's all for today.
[AGENT][POSITIVE] Alright, thanks for contacting AP have a.