AccountId: 011433970860
ContactId: adf72357-3d6d-449d-9559-5f932c83bd4e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 568250 ms
Total Talk Time (AGENT): 194592 ms
Total Talk Time (CUSTOMER): 114692 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/15/adf72357-3d6d-449d-9559-5f932c83bd4e_20250515T16:09_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], this is [PII] with Elham City Indian Clinic, and I received a denial letter for this claim, and I'm just wondering if it's the policy is still active.
[AGENT][NEUTRAL] OK, I can check on a claim for you.
[AGENT][NEUTRAL] Can you give me a good call back number in case we get disconnected?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] You said [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Oh, I'm sorry.
[AGENT][NEUTRAL] And do you have the policy number?
[CUSTOMER][NEUTRAL] 02462788
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Give me just a second.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] Can you give me the patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK. Thank you so much for verifying that with me. Give me one second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I am showing that this policy is active with an effective date of [PII]. Do you have the claim number?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] There's a reference number, but it's, it's the policy number. OK, claim number 3596543.
[AGENT][POSITIVE] OK, thank you so much.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Looks like there were several charges on this, so give me just a moment while I look up by each one.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] OK. Looks like one of the denials is because office visits are not covered under this policy.
[AGENT][NEUTRAL] One of them was denied because of the major, this is a secondary gap policy so if the primary insurance uh does not cover this then this policy will not cover it. It's showing the benefits are payable only if major medical insurance provides benefits. If this claim is later paid by their major medical, then you can send an explanation of benefits showing that those were paid.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That's actually for 2, that's actually for 2 of them.
[AGENT][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Is that the durable medical equipment?
[AGENT][NEUTRAL] Yes, yes, ma'am.
[CUSTOMER][NEUTRAL] Or the nonco
[AGENT][NEGATIVE] And then it looks like 5 in, so I'll look up what that is in just a second. The office visit was not covered.
[CUSTOMER][NEUTRAL] Is that the 99214?
[CUSTOMER][NEUTRAL] Procedure code.
[AGENT][NEUTRAL] Oh, let me look up the procedure code. That might be a little bit more helpful. One second.
[AGENT][NEUTRAL] You said 99214?
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] That one was an office visit, which means it was not covered.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Procedure 3288S and L3480 needs the major medical will need to pay those first. If the major medical ends up paying those then you or the the claimant can.
[AGENT][NEUTRAL] Uh, provide the explanation of benefits showing that those were paid first by the primary and then we can reprocess this.
[CUSTOMER][NEUTRAL] OK, so you said 3288.
[CUSTOMER][NEUTRAL] Uh, and what was the second one that you mentioned?
[AGENT][NEUTRAL] Yes. Mhm.
[AGENT][NEUTRAL] Uh, the durable medical L3480.
[AGENT][NEUTRAL] So those two we need to check their primary, we'll need their primary uh EOB first to see that they paid that first.
[CUSTOMER][NEUTRAL] Oh OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, let me see.
[CUSTOMER][NEUTRAL] I know they paid.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEGATIVE] I don't know what they paid.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yeah, it might just be that we didn't get the the explanation of benefits or anything showing that it did pay first so um.
[AGENT][NEUTRAL] If you have that and you can send it in, we could reprocess the claim.
[CUSTOMER][NEUTRAL] OK, who would we send that to?
[AGENT][NEUTRAL] You would send that to us, uh, if you want to do you want to fax it or mail it or you can upload it through our online portal at [PII].
[AGENT][POSITIVE] Whichever one you prefer and I can give you the information.
[CUSTOMER][POSITIVE] Secure
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And or then you said we could um what how else would we do that?
[AGENT][NEUTRAL] Uh, you can also fax it or mail it in.
[CUSTOMER][NEUTRAL] OK, and what's the fax number?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, and then the mailing address, would that be the [PII] address?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] I have [PII].
[AGENT][NEUTRAL] Correct, and you said [PII], right?
[CUSTOMER][NEUTRAL] Is that right?
[CUSTOMER][NEUTRAL] [PII], yeah.
[AGENT][POSITIVE] Yes ma'am, yes ma'am.
[AGENT][NEUTRAL] That's our mailing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and can I get a call reference number?
[AGENT][NEUTRAL] So we don't have call reference numbers, but you can use my name and last initial so it's [PII] and today's date.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] All right, is there anything else I can help you with?
[CUSTOMER][NEUTRAL] OK. Well, thanks.
[CUSTOMER][NEUTRAL] Um, no, I guess that would be it. You know what? How can we verify instead of calling we've been trying to verify, um, is there, do you have a website we can verify through?
[AGENT][NEUTRAL] You can verify that they have a policy with us?
[CUSTOMER][NEUTRAL] That the policy is active.
[CUSTOMER][NEUTRAL] Like if they have to call back or you know verify again.
[AGENT][NEUTRAL] You'll want to call back and verify again.
[CUSTOMER][NEUTRAL] Oh, we'll have to call?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][POSITIVE] OK. All right, thank you very much.
[AGENT][POSITIVE] Great, thank you so much, [PII] and have a great day. Thank you for calling APL.
[CUSTOMER][POSITIVE] Thank you bye.