AccountId: 011433970860
ContactId: ba657a71-61f0-4d2e-bdda-737807876dbf
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 837979 ms
Total Talk Time (AGENT): 184052 ms
Total Talk Time (CUSTOMER): 370228 ms
Interruptions: 10
Overall Sentiment: AGENT=0.8, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/17/ba657a71-61f0-4d2e-bdda-737807876dbf_20250217T15:11_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][POSITIVE] Thank
[CUSTOMER][NEUTRAL] Uh, looking for the claim status. This is [PII]. Last initial name is [PII] calling from provider office.
[AGENT][NEUTRAL] OK, [PII], I can help you with claim status. Can you give me your callback number, please?
[CUSTOMER][NEUTRAL] [PII], I can help you with claim status. Can you give me your call back?
[CUSTOMER][NEUTRAL] That is [PII] [PII].
[AGENT][NEUTRAL] Thank you, sir. And then what is the patient's name?
[CUSTOMER][NEUTRAL] Uh, first name is [PII].
[CUSTOMER][NEUTRAL] Last name is [PII]
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][NEUTRAL] And what is the policy number, please?
[CUSTOMER][NEUTRAL] And what is the
[CUSTOMER][NEUTRAL] That is 589-744-467.
[AGENT][NEUTRAL] OK, that doesn't sound like one of our policy numbers.
[CUSTOMER][NEUTRAL] OK, that doesn't sound like one of our policy numbers.
[AGENT][NEUTRAL] Do you have another number?
[CUSTOMER][NEUTRAL] Mm, one moment, let me double check in 64.
[CUSTOMER][NEUTRAL] One moment, just a moment. Let me double check, uh, let me check through patient ID.
[AGENT][NEUTRAL] Yes sir.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Here I have a member's ID card. However, there is not listed which member ID cards. Can you?
[CUSTOMER][NEUTRAL] Please check with the data service, is that OK for you? Is that any possible way?
[AGENT][NEUTRAL] Uh yes, sir. Yes, sir. Let's go ahead and get the spelling of the first name.
[CUSTOMER][NEUTRAL] Uh, yes, yes, sir, let's go ahead and get the spelling of the first name.
[CUSTOMER][NEUTRAL] Oh yeah sure thank you remember first name will be spelled as [PII].
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Last name spelled as [PII].
[AGENT][NEUTRAL] OK, I'm gonna have to have you spell the last name one more time because the phone had a little glitch in it.
[CUSTOMER][NEUTRAL] I'm gonna have to have you spell the last name one more time because the phone had a little glitch in it.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII]. OK, let me look that up real quick.
[CUSTOMER][NEUTRAL] Yeah [PII].
[AGENT][NEUTRAL] OK, what state does [PII] live in?
[CUSTOMER][NEUTRAL] OK, what state does [PII] live in?
[CUSTOMER][NEUTRAL] Mm one moment, let me double check again members info.
[CUSTOMER][NEUTRAL] Uh, that is in [PII].
[AGENT][NEUTRAL] OK, let me see if I can find and what is his date of birth?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what was his date of birth?
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][NEUTRAL] OK, let me look.
[AGENT][NEUTRAL] OK, I think I have him.
[CUSTOMER][NEUTRAL] OK, I think I have it.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me see if he has any policies that are active.
[CUSTOMER][NEUTRAL] A
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, what is the day the service?
[CUSTOMER][NEUTRAL] OK, what is the
[CUSTOMER][NEUTRAL] That is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and what is the charge amount?
[CUSTOMER][NEUTRAL] OK, and what is the charge ma'am? That is $264.56.
[AGENT][NEUTRAL] And the charges after primary paid their part?
[CUSTOMER][NEUTRAL] Charges after primary paid their part.
[CUSTOMER][NEUTRAL] Uh, no, the primary is, uh, uh, the uplis towards the coinsurance.
[CUSTOMER][NEGATIVE] They didn't pay.
[AGENT][NEUTRAL] OK, what, what is um the name of the facility?
[CUSTOMER][NEUTRAL] OK, what
[CUSTOMER][NEUTRAL] What is um the name of the facility?
[CUSTOMER][NEUTRAL] Uh, that is.
[CUSTOMER][NEUTRAL] Loman and Zerrin.
[AGENT][NEUTRAL] Lomon and.
[CUSTOMER][NEUTRAL] You mean the you're talking about the provider right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Oh yes, the provider will be Loman and Mona [PII] and Moina under the provider that will be [PII] and [PII].
[AGENT][NEUTRAL] OK, I'm gonna put you on a brief hold while I search for this claim for you and I'll be right back.
[CUSTOMER][NEUTRAL] OK, I'm gonna put you on a brief hold while I search for this claim for you and I'll be right back. Sure, please take your time.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, [PII], this is Tory back with you again.
[CUSTOMER][NEUTRAL] OK [PII], this is Tory back with you again. Mhm.
[AGENT][NEUTRAL] I did find the claim. The claim number is 341-318-1.
[CUSTOMER][NEUTRAL] Did find the claim. The claim number is 3.
[CUSTOMER][NEUTRAL] 34, could you please repeat the claim number again 3341 right?
[AGENT][NEUTRAL] Yes, 341-318-1.
[CUSTOMER][NEUTRAL] Yes, 341-318-1.
[CUSTOMER][NEUTRAL] 31813.
[CUSTOMER][NEUTRAL] 31881.
[AGENT][NEUTRAL] No, just, just 18.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Just 18
[CUSTOMER][NEUTRAL] OK. Let me repeat that it is 341-318-1.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh, when did you receive this claim?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII] the
[CUSTOMER][NEUTRAL] [PII]. [PII].
[CUSTOMER][NEUTRAL] [PII] or [PII]?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Um, can I get a process each?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK I'm gonna say this.
[AGENT][NEUTRAL] The claim was denied because.
[CUSTOMER][NEUTRAL] The claim was denied.
[AGENT][NEUTRAL] The benefits have been met for the calendar year for outpatient services.
[CUSTOMER][NEUTRAL] Calendar year for.
[AGENT][NEUTRAL] And office visits are not covered under the patient's policy.
[CUSTOMER][NEUTRAL] Be
[CUSTOMER][NEUTRAL] the
[CUSTOMER][NEUTRAL] Oh, you say benefit coverage has made?
[AGENT][NEUTRAL] Yes, the maximum was met for the calendar year.
[CUSTOMER][NEUTRAL] Yes, the maximum was met for.
[CUSTOMER][NEUTRAL] Benefit has.
[CUSTOMER][NEUTRAL] Need 4.
[CUSTOMER][NEUTRAL] Calendar years.
[CUSTOMER][NEUTRAL] And you say that claim was denied due to benefit has met for calendar years and for office visit or inpatient. What did you say again?
[AGENT][NEUTRAL] Office visits are not covered under the patient's policy.
[CUSTOMER][NEUTRAL] Office visits are not covered under the patients.
[CUSTOMER][NEUTRAL] Office visit.
[CUSTOMER][NEUTRAL] Uh, office visits are not covered under the patient policy, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Office visit.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Cover
[CUSTOMER][NEUTRAL] Under the under the policy.
[CUSTOMER][NEUTRAL] So is this, this is the member responsibility to pay?
[AGENT][NEUTRAL] We don't give patient responsibility because that's determined by the provider.
[CUSTOMER][NEUTRAL] We don't give patient responsibility because that's.
[CUSTOMER][NEUTRAL] Provider
[CUSTOMER][NEUTRAL] So it should be a provider write off.
[AGENT][NEUTRAL] I can't, I can't say it's up to the provider.
[CUSTOMER][NEUTRAL] I can't, I can't say it's up to the provider.
[CUSTOMER][NEUTRAL] Benefit has met, uh, when, when did you meet this um member has already met on benefit? Can I get a detail for that? When was it made?
[AGENT][NEUTRAL] I can't give that date because it could be a different provider and that's patient information that's protected.
[CUSTOMER][NEUTRAL] I can't give that date because it could be a different provider.
[CUSTOMER][NEUTRAL] Is there any way to appeal?
[AGENT][POSITIVE] Yes, you can appeal
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] You have to appeal within a.
[CUSTOMER][NEUTRAL] You wanna get a mailing address? Uh huh you have to appeal within 10 days from the date the claim was initially processed. Uh huh.
[AGENT][NEUTRAL] You have to appeal within 180 days from the date the claim was initially processed.
[AGENT][NEUTRAL] And you need to send a letter why you want to appeal.
[CUSTOMER][NEUTRAL] why you want to appeal.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Can I get a mailing address?
[AGENT][NEUTRAL] Yes, it's APL claims.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] That's [PII].
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] [PII] right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] [PII]. What is the timely filing for this?
[AGENT][NEUTRAL] You have to file it within 180 days from the date the claim was processed.
[CUSTOMER][NEUTRAL] You have to file it with a 1088.
[CUSTOMER][NEUTRAL] From the date the claim was processed.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you'll need a letter why you want to appeal.
[CUSTOMER][NEUTRAL] And you'll need a letter wiping work.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, let me repeat the denial reasons you said that the claim was denied due to benefit estimate for calendar years. Office visits are not covered under the policy.
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Correct
[CUSTOMER][NEUTRAL] OK, got it and can you please provide me the call reference number?
[AGENT][NEUTRAL] Yes, sir. You can use my name, [PII].
[CUSTOMER][NEUTRAL] Use my name [PII].
[AGENT][NEUTRAL] And today's date.
[CUSTOMER][NEUTRAL] Could you please spell
[AGENT][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] [PII], OK, got it thank you so much, nice talking with you.
[AGENT][POSITIVE] You too, [PII]. I hope you have a good rest of your week.
[CUSTOMER][POSITIVE] [PII], I hope you have a good rest of your week. OK, you too.
[AGENT][POSITIVE] Thank you for calling APL.
[CUSTOMER][POSITIVE] Thank you
[CUSTOMER][NEUTRAL] OK bye.
[AGENT][NEUTRAL] Mm.