AccountId: 011433970860
ContactId: b0bef6f1-79b7-4a64-baaa-d07c2895fd5b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 706739 ms
Total Talk Time (AGENT): 242779 ms
Total Talk Time (CUSTOMER): 327963 ms
Interruptions: 4
Overall Sentiment: AGENT=1.3, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/15/b0bef6f1-79b7-4a64-baaa-d07c2895fd5b_20250115T21:31_UTC.wav
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[AGENT][NEUTRAL] Afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling for the provider Saint John's Physicians Incorporated to check on our claim status and briefly informed that this call is being recorded and monitored for quality and training purposes. And by the way, could you please spell out your name financially for me.
[AGENT][NEUTRAL] I can, [PII]. It's, I'm sorry, [PII], it's [PII]. Sorry about that.
[CUSTOMER][POSITIVE] Oh, no problem.
[CUSTOMER][POSITIVE] OK, no problem.
[CUSTOMER][POSITIVE] OK, thank you very much, [PII].
[AGENT][NEUTRAL] And [PII], what is the callback number?
[CUSTOMER][NEUTRAL] Uh, may I provide you the member ID?
[CUSTOMER][NEUTRAL] Yes, the callback number is [PII] and it's a direct line, no extensions.
[AGENT][NEUTRAL] All right, thank you. And the policy number for the patient, please.
[CUSTOMER][NEUTRAL] Yes, the member ID number is D as in Delta 4793035.
[AGENT][NEUTRAL] That that is not the APL policy ID number. Do you happen to have the claim number or the policy certificate number?
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] Uh, the policy number's gonna start with a 0.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, let me check, um, mm.
[CUSTOMER][NEUTRAL] OK, I have um.
[CUSTOMER][NEUTRAL] Claim number and provide you that.
[AGENT][NEUTRAL] OK, what's the claim number? Yes, sir, please.
[CUSTOMER][NEUTRAL] It's 333346-366.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What is the patient's name?
[CUSTOMER][NEUTRAL] It's um [PII], is that correct?
[AGENT][NEUTRAL] And what is, that is correct. What is her date of birth?
[CUSTOMER][NEUTRAL] OK. The date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. I can give you her correct policy ID number for APL.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Just tell me when you're ready.
[CUSTOMER][POSITIVE] Yes, I'm ready, [PII].
[AGENT][NEUTRAL] Our policy number is 021.
[AGENT][NEUTRAL] 371-83
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, 02137183, is that correct?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][POSITIVE] OK, thank you very much, [PII], for providing me the correct number ID.
[AGENT][POSITIVE] Sure, it's my pleasure.
[CUSTOMER][NEUTRAL] And may I provide you with the date of service? Welcome.
[AGENT][POSITIVE] Yes, data service and build out please.
[CUSTOMER][NEUTRAL] Yes, the date of service is [PII] and it's billed with $222 even.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, thank you, and y'all did receive the $100 maximum payment for that data service?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I'm sorry, could you please repeat that for me, [PII]?
[AGENT][NEUTRAL] Did you receive the maxi, the payment of $100 for that data service?
[CUSTOMER][NEUTRAL] Mm, let me check. Yes, we have uh received it.
[AGENT][NEUTRAL] OK. And that is the maximum that we can pay per day for that office visit.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] For that data service.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Maximum payable amount is $100.
[AGENT][POSITIVE] That is correct. So we did pay the maximum. That's correct.
[CUSTOMER][NEUTRAL] For office is that correct?
[CUSTOMER][POSITIVE] OK, thank you very much, [PII]. Just a moment let me make a note of that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm, OK, sure, I understand. And could you please provide me the receipt date of this claim, please?
[CUSTOMER][NEUTRAL] And I have the previous information. May I verify that with you? Would that be easy for you?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yes, that's fine.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] It shows that uh.
[CUSTOMER][NEUTRAL] The paid claim, uh, was paid with $100 even.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And you know we just paid on uh.
[CUSTOMER][NEUTRAL] [PII], is that correct?
[AGENT][POSITIVE] Correct. That is correct.
[CUSTOMER][NEUTRAL] OK, so, OK, anyways, OK, could you please start the received and denied date please? Then I'd wait for the remaining amount.
[AGENT][NEUTRAL] The received date was [PII], the processed date was [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Proceed and denied on [PII].
[AGENT][POSITIVE] Yes, sir, that is correct.
[CUSTOMER][POSITIVE] OK, thank you very much. And the maximum allowed amount um.
[CUSTOMER][NEUTRAL] When it was met was $100 even.
[AGENT][POSITIVE] Yes, so that's correct.
[CUSTOMER][NEUTRAL] OK, let me check the remaining payments that has been received from.
[CUSTOMER][NEUTRAL] Your end, I'm checking that. Please bear with me.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No payments were received.
[CUSTOMER][NEUTRAL] OK and.
[CUSTOMER][NEUTRAL] OK, may I know the mode of submission, please? Is that through, uh, like a correct the claim or is an appeal?
[AGENT][NEUTRAL] Uh, this claim was the original claim.
[CUSTOMER][NEUTRAL] OK, so there's no extension for the remaining amount to get paid, is that correct?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK. But for, just for uh documentation purpose, may I have the correct claims mailing address, please?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] You just
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, sir. That is for a corrected claim.
[CUSTOMER][NEUTRAL] OK just a moment.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Is that [PII]?
[AGENT][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, [PII]. And may I have uh
[CUSTOMER][NEUTRAL] The timely filing limit for the credit line, please.
[AGENT][NEGATIVE] For [PII] to claim there's no timely filing.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK OK.
[CUSTOMER][NEUTRAL] OK, and now we may um you know go for the appeals mailing address.
[AGENT][NEUTRAL] The appeal's mailing address is the same address. Attention appeals. The appeals time frame is 180 days from the date of denial. It's outside the appeal time frame.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] 180 days from the date of denial.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. And is the the night you will be need to be attached when if it is sent for an appeal?
[AGENT][NEUTRAL] Yes sir, and then we'll need a formal appeal letter stating the reason that the this claim decision is being appealed.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, and is there any specific form for an appeal?
[AGENT][NEUTRAL] No form for an appeal, just the uh formal letter explaining the reason that you are appealing the claim decision.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] No medical documents needed.
[CUSTOMER][NEUTRAL] OK, letter for appealing the claim decision. You need a letter for a billing, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Mm thank you very much for that. Just a moment.
[CUSTOMER][NEUTRAL] And uh.
[CUSTOMER][NEUTRAL] OK, may I have the claim number for this claim, please?
[AGENT][NEUTRAL] Claim number is the one you gave me. It is the 334.
[CUSTOMER][NEUTRAL] Uh, OK.
[AGENT][NEUTRAL] 6366. Yeah.
[CUSTOMER][NEUTRAL] Yes, I got that.
[CUSTOMER][NEUTRAL] 334. I'm sorry 3437559, is that correct?
[AGENT][NEUTRAL] The claim number you gave me is the 3346366.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] For data service 81823 for $222.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Like
[AGENT][NEUTRAL] Now you may have a, let me check and see.
[CUSTOMER][POSITIVE] Thank you very much.
[AGENT][NEUTRAL] Give me just a second, [PII], let me see if we have another claim for that data service.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Sure, sure, no problem, let me check.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Uh, you may have the duplicate claim number. Looks like we've received that claim several times.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so this claim number which I provided make the correct claim.
[AGENT][NEUTRAL] But the pay claim number.
[AGENT][NEUTRAL] Yeah, the paid claim number is the 3346366.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, thank you very much [PII], and may I have the call reference number for this call, please?
[AGENT][NEUTRAL] Call reference number is my name and today's date, and I spell my name [PII].
[AGENT][NEUTRAL] Anything else I can help you with today, [PII]? I'm sorry.
[CUSTOMER][NEUTRAL] OK, and by the way.
[CUSTOMER][NEUTRAL] Yes. Um, last thing, could you please fax a copy of the ID of it, please?
[AGENT][NEUTRAL] EOBs are obtainable on our provider portal at.
[AGENT][NEUTRAL] Secured and that's [PII].
[AGENT][NEUTRAL] It's self registration using the tax ID number and the patient's account number listed in box 26 on the HFA.
[AGENT][POSITIVE] And then just create an account and you'll have that EOB instantly you won't have to wait for it to be faxed.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, [PII]. And it's secured. [PII]. Is that correct?
[AGENT][POSITIVE] That's correct and if, if you need it, I'll be happy to assist you to create an account.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] Oh, no, that's fine. Thank you for asking, by the way, and thank you for your wonderful time and information, [PII]. Thank you for assistance. Have a great day. Take care and stay safe.
[AGENT][POSITIVE] OK. Thank you for calling APL. It's been my pleasure to help you with that claim status. I hope you have a wonderful day as well. Take care.
[CUSTOMER][POSITIVE] Sure. Thank you so much.
[CUSTOMER][POSITIVE] Yes, you too. You too. Bye-bye. Take care.
[AGENT][NEUTRAL] Bye-bye.