AccountId: 011433970860
ContactId: b5ae6497-1682-49f7-9e5a-bfdb388be91c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 854289 ms
Total Talk Time (AGENT): 134742 ms
Total Talk Time (CUSTOMER): 405662 ms
Interruptions: 4
Overall Sentiment: AGENT=0.3, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/28/b5ae6497-1682-49f7-9e5a-bfdb388be91c_20250328T14:53_UTC.wav
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[AGENT][NEUTRAL] Calling APL, my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] calling for the provider email uh Tajoy to check on a claim status. Please be informed that this call is being recorded and monitored for quality and training purposes.
[AGENT][POSITIVE] I'll be happy to assist with.
[AGENT][NEUTRAL] Benefits and eligibility and claims, uh, may I have the policy number please?
[CUSTOMER][NEUTRAL] Yeah, sure. It's uh 02290398.
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] The patient name is?
[CUSTOMER][NEUTRAL] [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] And what's the date of service?
[CUSTOMER][NEUTRAL] The date of service is uh [PII].
[AGENT][NEUTRAL] And what's your tax ID?
[CUSTOMER][NEUTRAL] Yeah, sure. Just a moment. I'll provide the tax ID. Before that, I just wanted to know that your name is uh [PII].
[AGENT][NEUTRAL] [PII] mhm.
[CUSTOMER][NEUTRAL] OK, [PII].
[CUSTOMER][NEUTRAL] And you are asking for the tax ID, so tax ID is [PII].
[AGENT][NEUTRAL] Thank you for that information. I'm showing the claim was denied because office visits are not covered under the policy.
[CUSTOMER][NEUTRAL] OK. Just a moment.
[CUSTOMER][NEUTRAL] OK, you just mentioned that the not cover under the member's policy.
[AGENT][NEUTRAL] That's correct. Office visits are not covered under the policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a moment. Actually, I just need to get some information from your side.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Can you just uh help me with the received date for the claim?
[AGENT][NEUTRAL] Claim was received on [PII]. Claim denied on [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much and the denial uh for the office visit and uh not cover under the member's plan. Thank you so much for that.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] OK. So there are uh two CPT codes. So the both are not covered under the member's plan or the only one?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] It's the place the treatment was done that's not covered.
[AGENT][NEUTRAL] And treatment in an office or clinic setting is not covered under this policy. That is why the claim denied.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, just a moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, uh, so, uh, as for you though.
[CUSTOMER][NEUTRAL] The treatment where was done, uh, the, that is not covered under the plan.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] OK, thank you so much.
[CUSTOMER][NEUTRAL] If I have to
[CUSTOMER][NEUTRAL] I'm, I'm.
[CUSTOMER][NEUTRAL] OK, so, uh.
[AGENT][NEUTRAL] Was there anything else I could assist with today?
[CUSTOMER][NEUTRAL] Yes, ma'am. Uh, just, uh, help me with the, what, what are the allowed service amount per time frame?
[AGENT][NEGATIVE] I don't understand the question.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Uh, what are the allowed services amount per time frame?
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] The allowed service amount per time frame uh.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEGATIVE] I don't understand what that means.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh, when, when was the last service bill?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] When was the last service billed?
[AGENT][NEGATIVE] I don't understand.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, just a moment. Actually, I need to check the uh once again.
[CUSTOMER][NEUTRAL] Just give me a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, I'm really sorry. Uh, thank you so much for your patience.
[CUSTOMER][NEUTRAL] So, uh
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Just help me with the uh
[CUSTOMER][NEUTRAL] OK, uh, timely filing to submit a corrected claim.
[AGENT][NEGATIVE] There's no timely filing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] And uh can you just help me with the mailing address to submit the corrected claim?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] And that's in [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] OK. It's uh the city name is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much. And zip code is [PII], correct?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Thank you. And uh for uh is there any timely filing for the appeal?
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] For appeals it's 60 days from the date of denial.
[CUSTOMER][NEUTRAL] 60 days.
[CUSTOMER][NEUTRAL] From the date of denial. Thank you so much.
[CUSTOMER][NEUTRAL] And can you just help me with the mailing address to submit an appeal? Is it the same?
[AGENT][NEUTRAL] It's the same.
[CUSTOMER][POSITIVE] Thank you. And uh
[CUSTOMER][NEUTRAL] Is there any specific form for a pill?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Thank you. And uh uh as you required the uh denial you will submit your appeal?
[AGENT][NEUTRAL] No.
[CUSTOMER][POSITIVE] Thank you, thank you so much for that.
[CUSTOMER][NEUTRAL] And uh just help me with the uh claim number for that claim.
[AGENT][NEUTRAL] 3556638
[CUSTOMER][NEUTRAL] Oh boy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. It's 3556638, correct?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. So, uh, actually, I have the another claim. Uh, so can you just help me with that claim also?
[AGENT][NEUTRAL] Is it the same patient or a different patient?
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] OK, just a moment.
[CUSTOMER][NEUTRAL] It is for the different patient, [PII].
[AGENT][NEUTRAL] OK, what's that policy number?
[CUSTOMER][NEUTRAL] OK, I'll try the policy number. So the call reference will be same for the both claim or uh different, different?
[AGENT][NEUTRAL] It's the same [PII]t my name and today's date and time.
[CUSTOMER][NEUTRAL] OK, got it. So the policy number for the second one, it is uh
[CUSTOMER][NEUTRAL] 02297072 M as in Mike, L as in Lima, 8.
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] The patient name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] And the date of service for the claim?
[CUSTOMER][NEUTRAL] The date of service is [PII].
[AGENT][NEUTRAL] And your tax ID?
[CUSTOMER][NEUTRAL] The tax ID is [PII].
[AGENT][POSITIVE] Thank you for that.
[AGENT][NEUTRAL] OK, I'm showing the claim denied because the office visits is not covered under the policy.
[CUSTOMER][NEUTRAL] OK, so same denial for the both claims.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much. And uh can you just help me with the date and the date for that, ma'am?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Claim was received on [PII]. Claim denied on [PII].
[CUSTOMER][NEUTRAL] OK, [PII] is the denial date.
[CUSTOMER][NEUTRAL] Yes. And uh uh
[AGENT][NEUTRAL] You need the claim numbers?
[CUSTOMER][NEUTRAL] So for that claim, is there any uh specific, uh, for that claim, is there any uh specific if it is not covered or for the patient policy?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] The office visit is not covered under the policy.
[CUSTOMER][NEUTRAL] OK. Under the member policy, correct?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. Is there, uh, so there is no any, uh, uh, timely filing to collect your claim, right?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK. Let me reconfirm with the mailing address uh for the correct claim. Is it a [PII]?
[CUSTOMER][NEUTRAL] Uh, [PII]. Is it correct?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. And the time to submit an appeal is 60 days from the date of denial, correct?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. And the mailing address for appeal will be same uh with the corrected claim. And uh there is no specific form for appeal and no required denial you will be submitting an appeal. And just help me with the uh claim number if that's all the uh correct one.
[AGENT][NEUTRAL] Claim number is 3558339.
[CUSTOMER][POSITIVE] OK. It's 355-833-9. Thank you so much for the help. Uh, just, uh, uh, give me a callback number for that.
[AGENT][NEUTRAL] You said give you what?
[CUSTOMER][NEUTRAL] Yeah, just uh help me with the callback number, uh call reference number.
[AGENT][NEUTRAL] What's the callback number?
[AGENT][NEUTRAL] Oh, the reference number is just my name and today's date and time.
[CUSTOMER][POSITIVE] I'm really sorry call reference yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm, just a moment, [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So call reference will be your name and today's date and the time.
[AGENT][POSITIVE] That's correct. That's correct.
[CUSTOMER][POSITIVE] Thank you, thank you so much, [PII]. Yes, I got the information. Thank you so much for your help.
[AGENT][POSITIVE] Thank you for calling APL you have a good day.
[CUSTOMER][POSITIVE] Yeah, thank you so much.
[AGENT][NEUTRAL] Mhm.