AccountId: 011433970860
ContactId: aff99761-fa1e-4c2c-a585-4467b007eee8
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 717159 ms
Total Talk Time (AGENT): 230463 ms
Total Talk Time (CUSTOMER): 209841 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/13/aff99761-fa1e-4c2c-a585-4467b007eee8_20250213T16:30_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I help you?
[AGENT][POSITIVE] Thank you for calling A
[CUSTOMER][NEUTRAL] Yeah, hi, my
[CUSTOMER][NEUTRAL] Yeah, hi, my name is [PII] and I'm calling from facility regarding claims. You said the name is [PII].
[AGENT][NEUTRAL] That is correct. You're checking on a claim status?
[CUSTOMER][NEUTRAL] Uh, actually I'm looking for the appeal status.
[AGENT][NEUTRAL] OK, and you're calling on behalf of which office?
[CUSTOMER][NEUTRAL] Del Rey Medical Center.
[AGENT][NEUTRAL] OK, you have the policy number that [PII]?
[CUSTOMER][NEUTRAL] Oh yes, the policy number I have here is just.
[CUSTOMER][NEUTRAL] OK, so policy number.
[CUSTOMER][NEUTRAL] It's not popping up here.
[CUSTOMER][NEUTRAL] OK. 148.
[CUSTOMER][NEUTRAL] 1847
[CUSTOMER][NEUTRAL] M as in Mary, L.
[CUSTOMER][NEUTRAL] As in Lima, #8.
[AGENT][NEUTRAL] OK, and what's a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII] it's a direct line.
[AGENT][POSITIVE] Thank you. One moment.
[CUSTOMER][NEUTRAL] Mhm, so.
[AGENT][NEUTRAL] And what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is
[CUSTOMER][NEUTRAL] [PII], uh, OK, uh, one moment.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] The patient's first name is?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And [PII]'s date of birth?
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] And the date of birth is one moment.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. And you said that you're checking on an appeal. Uh, what claim did are you appealing? Do you have that claim number?
[CUSTOMER][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Uh yes, the claim number I have here is 3477.
[CUSTOMER][NEUTRAL] 965.
[AGENT][NEUTRAL] OK give me one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what are you appealing regarding this claim?
[CUSTOMER][NEUTRAL] For underpayment.
[AGENT][NEUTRAL] OK, so the remark code on that claim says with this check, the maximum benefit payable for this state of service has been met, and so what that means is the maximum outpatient benefit is exhausted. When did you send in the appeal?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] When was the appeal submitted?
[CUSTOMER][NEUTRAL] It was sent on
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. OK, one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] I'm still looking.
[CUSTOMER][POSITIVE] Mhm. Sure. Take your time.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What is the billing address for the dispute?
[CUSTOMER][NEUTRAL] Uh, just allow me a moment checking.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] The address, uh-huh here is OK.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Is that the information that was on the appeal? I'm showing a different PO box that the response was mailed to.
[CUSTOMER][NEUTRAL] Oh, you mean, uh, our address?
[AGENT][NEUTRAL] Mhm, which, yes, for the appeal, what is your appeal's address?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a moment here.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] A your address.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] This would be
[CUSTOMER][NEUTRAL] OK. So, dispute. [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you. That's what I show and I show that the pay response letter is dated [PII], mailed to that address, and I believe we received it a second time.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And another letter was mailed to that same address on [PII], um, the states that the claim was processed correctly in accordance to the policy contract as the maximum benefit for outpatient was exhausted.
[AGENT][NEUTRAL] So no additional benefits are due?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] But the letter was mailed twice to that address, so do you receive the correspondence? If not, you may wanna check with that department because it was sent twice.
[CUSTOMER][NEUTRAL] OK. Um, have you
[CUSTOMER][NEUTRAL] OK. Uh, yes, we received, uh, we sent a few.
[CUSTOMER][NEUTRAL] To 2nd level and we submit a 3rd level of appeal on [PII]. Have you, have you received?
[AGENT][POSITIVE] Both have been responded to. One was responded. The initial one was responded to on [PII].
[AGENT][NEUTRAL] The second one was responded to on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And letters were mailed out each time to the address that you verified.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So was that a final level of appeal or we still have, uh, we can still submit next level.
[AGENT][NEUTRAL] I don't know why. I mean, you can appeal it, but the reason is, is that the claim, the the the determination is that the claim was processed correctly in accordance with the policy contract. Do you understand the reason that 500 was paid?
[AGENT][NEUTRAL] Or do you have a copy of the explanation of benefits that was submitted with the check?
[CUSTOMER][NEUTRAL] That that is fine.
[AGENT][NEUTRAL] Let's go over that.
[CUSTOMER][NEUTRAL] Yes, I do have that information. Yes, we received that.
[AGENT][NEUTRAL] Can you look at the 2nd page or maybe the back and read that explanation to me?
[CUSTOMER][NEUTRAL] OK, just allow me a moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Oh,
[CUSTOMER][NEGATIVE] Well, I do have only one page, uh, and it says that this product does not have a provider participation network benefit has not benefit has not been made, has
[CUSTOMER][NEUTRAL] Had not been reduced, stated that.
[AGENT][NEUTRAL] Yeah, that's not our remark code. That's not from American Public Life.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Checking. OK, got it here.
[CUSTOMER][NEUTRAL] OK. So, in the 2nd page, it says that with this check, the maximum benefits payable for this date of service has been made.
[AGENT][NEUTRAL] Right, the maximum benefit per calendar day is $500 which is what was paid, so you can continue to appeal, but it'll be denied citing the same thing.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, and
[AGENT][NEUTRAL] And then you have your uh explanation as to why only 500 was paid, so.
[CUSTOMER][NEUTRAL] OK. And I just want to know, have you received any appeal after [PII]?
[AGENT][NEUTRAL] We received the first appeal on [PII], processed it on [PII] by sending a letter.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We then received the second one on [PII] and processed a response to that letter or appeal on [PII], each time a letter was mailed to the address that you verified. Are you saying that another one was sent?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, we sent on [PII]. The another one.
[AGENT][NEGATIVE] Yeah, I don't show another one received.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So I just want to confirm the address. Is, is this the correct address? Uh, just allow me a moment.
[AGENT][NEUTRAL] We've already received 2 of your appeals, so it is the correct address and we've responded to both of those.
[AGENT][NEUTRAL] So the 3rd response is gonna be the same.
[CUSTOMER][NEUTRAL] OK, so you haven't.
[CUSTOMER][NEUTRAL] OK, so just want to know that you haven't received the 3rd level, right?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. May I have call reference number, please?
[AGENT][NEUTRAL] My name and today's date, [PII] initial, last name is [PII]. Did you have any other questions I could help out with today?
[CUSTOMER][POSITIVE] No, this is all for today. Thank you so much. You have a good rest of your day.
[AGENT][NEUTRAL] And you're welcome. And did you want the claim numbers that the appeal responses are attached to?
[CUSTOMER][NEUTRAL] Mhm. Uh, I do have the claim number.
[AGENT][NEUTRAL] Not the original claim that we denied, but we had signed a claim number to each appeal that was submitted.
[CUSTOMER][NEUTRAL] OK. Uh, can you please provide me the, the last one?
[AGENT][NEUTRAL] So the first one that what you was submitted the claim number is 351-7790.
[AGENT][NEUTRAL] And the second one submitted, the claim number is 3532153, and then I'll document that we've provided those numbers regarding the appeal that you submitted.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Well, thank you so much for the information. You have a good rest of your day. Thank you.
[AGENT][POSITIVE] You're welcome. Thank you for calling APL have a good day.