AccountId: 011433970860
ContactId: afd90789-ee84-408e-9968-524d3848ff35
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 2129879 ms
Total Talk Time (AGENT): 458856 ms
Total Talk Time (CUSTOMER): 501999 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/28/afd90789-ee84-408e-9968-524d3848ff35_20250228T17:41_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, so this is [PII] calling from provider office checking on the claim status.
[AGENT][NEUTRAL] Sure, I can assist you with claim status, Mr. [PII]. And may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure. It's [PII] direct line.
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Sure. It's 01888607.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] You don't have any other numbers? I think I'm missing a digit.
[CUSTOMER][NEUTRAL] Uh, let me repeat it again. It's 01888607.
[AGENT][NEUTRAL] OK, that's 38. Let me put that out.
[CUSTOMER][NEUTRAL] American
[AGENT][NEUTRAL] OK. And may I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] That's not who I got.
[AGENT][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] And you said the policy is 01888, that's 38007.
[CUSTOMER][NEUTRAL] Oh, I'm sorry. It's 01888607.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 607. OK.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK. All right. And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] How much is the total charge on the claim?
[CUSTOMER][NEUTRAL] It's $257 even.
[AGENT][NEUTRAL] OK, that was [PII] for 257.
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK, let me see if I can find this claim for you. And for future, you can check claim status online through our website at [PII] and that's just optional.
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Um
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so we received the claim on [PII], processed [PII]. Claim was denied stating that the service was rendered after coverage was terminated.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Total coverage.
[CUSTOMER][NEUTRAL] Terminated.
[CUSTOMER][NEUTRAL] And may I know if there is any other insurance for this number?
[AGENT][NEUTRAL] None through us.
[CUSTOMER][NEUTRAL] So, there is no any other insurance for this date of service, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] There is no any other insurance.
[CUSTOMER][NEUTRAL] for the service.
[CUSTOMER][NEUTRAL] So we can build the patient, right?
[AGENT][NEUTRAL] It's up to the provider's discretion.
[CUSTOMER][NEUTRAL] Sure, thank you. And yeah, I'm done with this claim and I have a few more claims and it's for the different member and the provider. Could you please help me with those?
[AGENT][NEUTRAL] Uh, sure. I just need to make a note on each one before I move forward. So let me make a note on this one.
[CUSTOMER][NEUTRAL] Sure, so the call reference number email the same for the entire call, right?
[AGENT][NEUTRAL] Yes my name in today's date.
[CUSTOMER][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] And uh just a moment, please. I'm pulling up the next number information.
[AGENT][NEUTRAL] Um, I'm finishing my notes, so OK, one moment, OK?
[CUSTOMER][NEUTRAL] Sure. Sure.
[CUSTOMER][NEUTRAL] What is that
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] OK
[AGENT][POSITIVE] OK, I'm ready for the next one whenever you are.
[CUSTOMER][NEUTRAL] Oh yeah, just a moment please, uh.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Oh, yeah. So the next member ID is
[CUSTOMER][NEUTRAL] 02277304
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII], [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, what's the date of service and the amount of the claims?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII] with $125 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, we received the claim [PII], processed [PII], and the claim was denied. The reason for this denial is that office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] Office is or.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Go.
[CUSTOMER][NEUTRAL] By the policy.
[CUSTOMER][NEUTRAL] So it is not covered as, as for the member's plan, right?
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] As for the member.
[CUSTOMER][NEUTRAL] And could you please tell me the member plan name?
[AGENT][NEUTRAL] This is a secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] Secondary supplemental.
[CUSTOMER][NEUTRAL] Bla
[CUSTOMER][NEUTRAL] To the major medical, right?
[AGENT][NEUTRAL] Mhm, right.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Uh, yeah, thank you so much and yes, I'm done with this claim as well. Just a moment please. I'm gonna explain my information.
[AGENT][NEUTRAL] OK, and I have to make my note one moment.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, what's the next policy number?
[CUSTOMER][NEUTRAL] Oh yeah, that's.
[CUSTOMER][NEUTRAL] 02116669
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] And uh Stanfield, [PII].
[AGENT][NEUTRAL] Alright, what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] [PII] with $526 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] You said it was $526?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK, let me see if this is the claim. One moment, OK.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK. We processed the claim [PII]. Um, the claim was received on.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, it was received on [PII] process [PII]. We send a benefit amount of um $205.93.
[AGENT][NEUTRAL] Uh, we cover the procedure. The office visit was denied, stating office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] OK. So the policy name will be the same, right?
[AGENT][POSITIVE] Mhm, correct.
[CUSTOMER][NEUTRAL] OK, just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And could you please tell uh what coding guidelines we need to refer?
[AGENT][NEUTRAL] Um, what do you mean?
[CUSTOMER][NEUTRAL] I mean, whether uh we need to refer the CMS guidelines or uh uh uh I mean, CMS guidelines or any other coding guidelines which we need to refer to build the procedure codes.
[AGENT][NEUTRAL] We cannot tell you about that.
[CUSTOMER][NEUTRAL] Or to change the procedure.
[CUSTOMER][NEUTRAL] OK. Sure.
[AGENT][NEUTRAL] We cannot tell you about that. Now, the only thing I can tell you is that office visits are not covered. We only cover office procedures under this policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, yeah, and you, yes, I'm done with this claim as well. And just a moment, please. I'm pulling up the next number. Yeah, sure.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, one moment, let me make a note.
[AGENT][NEUTRAL] OK, I'm finishing my notes, one moment.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Maybe.
[AGENT][NEUTRAL] OK, and let's see.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] What's the next policy number?
[CUSTOMER][NEUTRAL] Uh yeah. The policy number is 02.
[CUSTOMER][NEUTRAL] 462-791
[CUSTOMER][NEUTRAL] I have a
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII], date of birth, [PII].
[AGENT][NEUTRAL] OK, and what's the date of service and the amount of the claims?
[CUSTOMER][NEUTRAL] It's [PII] with 19 I'm sorry, it's $198 even.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] So this one is the same as the previous one which we paid the procedure, but we did not pay the office visit. The office visit has been denied um stating that it's not covered under the member's plan.
[AGENT][NEUTRAL] Um, let me give you that.
[CUSTOMER][NEUTRAL] Excuse me. Oh, yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And may I know the claim received and the processed date?
[AGENT][NEUTRAL] Yes, [PII] was the received date. [PII] was the process date.
[CUSTOMER][NEUTRAL] I'm sorry, [PII], right? Processed date?
[AGENT][NEUTRAL] And we send the
[AGENT][NEUTRAL] Uh, let me go back one moment.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh, so the plan name remains the same, right?
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, thank you. And yes, I'm done with this claim as well. Just a moment please. I'm bringing up the next information.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let me make a note on this one.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] All
[AGENT][NEUTRAL] Uh, what is the next policy number?
[CUSTOMER][NEUTRAL] It's 02462881.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Do you mind holding for me a minute?
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah, I
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding. May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Uh, sure. Uh, and I'm sorry, could you please spell out your name if you don't mind?
[AGENT][NEUTRAL] Yeah, sure, that's all, that's [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh yeah. Thank you. And just a moment, please. Uh, and yes, the next member ID is 02462881.
[AGENT][NEUTRAL] Thank you. What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][NEUTRAL] It's [PII], [PII].
[AGENT][NEUTRAL] OK, and what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] [PII] with $541 even.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] OK, let me pull this.
[AGENT][NEUTRAL] OK, um.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] It's on [PII].
[AGENT][NEUTRAL] OK, so we received the claim [PII] process [PII].
[AGENT][NEGATIVE] And we send $135.50 and the office visit is not covered.
[CUSTOMER][NEUTRAL] Uh, and the brand name.
[AGENT][NEUTRAL] I'm sorry, you're breaking up. Can you repeat?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, right.
[AGENT][NEUTRAL] Yes, it's a secondary supplemental plan to the major medical.
[CUSTOMER][POSITIVE] Thank you, and yes, I'm done with this.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEGATIVE] Yes, and the phone is breaking up. I'm not sure what's happening, but there's like a noise. I don't know if you can hear it.
[CUSTOMER][NEUTRAL] I'm sorry, just
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sorry?
[CUSTOMER][NEUTRAL] I'm audible now.
[AGENT][NEGATIVE] No, it's like a staticky sound.
[AGENT][NEUTRAL] Like if it was under the water or something like that.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, how about now?
[AGENT][POSITIVE] Oh yes, that's much better. OK.
[AGENT][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Uh yeah. Just a moment, please.
[AGENT][NEUTRAL] OK, I'm making the note.
[CUSTOMER][NEUTRAL] Oh yeah.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] My partner.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Um
[AGENT][POSITIVE] OK, I'm ready for the next one.
[CUSTOMER][NEUTRAL] Oh yeah. And the member ID is 01792144.
[AGENT][NEUTRAL] And what's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] It's [PII], [PII].
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] OK, what's the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] [PII] with $79 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, we received the claim [PII], process [PII], and the claim was denied stating office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] And the policy name is the same, right?
[AGENT][NEUTRAL] Yes. Mhm.
[CUSTOMER][NEUTRAL] OK, sure. Uh just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, I'm done with this claim as well. Just a moment please. I'm bringing up the next one my information.
[AGENT][NEUTRAL] OK, I'm making the note.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Uh, actually, the next claim is for the same number.
[AGENT][NEUTRAL] OK, what is the date of service?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] The same amount.
[CUSTOMER][NEUTRAL] It's $79 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so this one was received [PII], processed [PII], and it's the same denial reason office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK. And the policy name is the same, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, uh, yeah, and I'm done with this claim for this number. Just a moment, please. I'm bringing the information.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] I'm ready whenever you are, OK?
[CUSTOMER][NEUTRAL] Oh yeah. And yeah, and the next member ID is 018287667.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] Thank you. What's the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] [PII] with $196 even.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Sure
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, we receive um the primary EOB on let's see.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] And we process [PII].
[AGENT][NEUTRAL] And the claim was denied, the reason for the denial is that outpatient benefits for the calendar year has been met.
[CUSTOMER][POSITIVE] Patient benefits.
[CUSTOMER][NEUTRAL] For the calendar.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] And may I know,
[CUSTOMER][NEUTRAL] Uh, when it was my turn?
[AGENT][NEUTRAL] Uh, I cannot release that information, but I can tell you that calendar year maximum was 5000.
[CUSTOMER][NEUTRAL] I'm sorry, calendar year maximum?
[AGENT][NEUTRAL] Oh, I'm so sorry. I do apologize, that's the wrong denial. Let me give you the correct denial.
[AGENT][NEUTRAL] So sorry.
[CUSTOMER][NEUTRAL] Sure
[AGENT][NEUTRAL] OK, the correct denial is indicated that the full amount was applied towards the calendar year deductible, so we put the 1:30 um.
[CUSTOMER][NEUTRAL] It's OK.
[AGENT][NEUTRAL] Under the calendar, your deductible, this calendar year deductible is 1000.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Uh, the member exceeded the annual deductible, right?
[AGENT][POSITIVE] Correct, yeah.
[CUSTOMER][NEUTRAL] I mean the calendar deductible OK.
[AGENT][NEUTRAL] The calendar year deductible was not met and so the $130.20 was applied towards that year deductible.
[CUSTOMER][NEUTRAL] Oh OK
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. And it is for the procedure code 9 I mean 93306, right?
[AGENT][NEUTRAL] Mhm, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, so just for the confirmation, the claim got denied as full amount applied towards the calendar, your deductible as the member was not met, the calendar deductible, right?
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] OK. And may I know uh the amount once again how much is the uh deductible amount?
[AGENT][NEUTRAL] 1000 per covered person per calendar year.
[CUSTOMER][NEUTRAL] and uh
[CUSTOMER][NEUTRAL] Yeah, uh, 1000 and the member met nothing, right?
[AGENT][NEGATIVE] Oh, he has not met the full deductible.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Sure, and.
[CUSTOMER][NEUTRAL] Partner.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] OK, sure. Thank you so much. And uh yeah, could you please spell out your name if you don't mind, once again?
[AGENT][NEUTRAL] Sure. That's [PII], last initial [PII].
[CUSTOMER][POSITIVE] OK, sure. Thank you so much and that's it for the day. Have a great day. Bye-bye.
[AGENT][POSITIVE] You as well, Mr. [PII], and thank you for calling APL. Have a good day. Bye bye.
[CUSTOMER][POSITIVE] Thank you.