AccountId: 011433970860
ContactId: c077caf1-1dc5-401a-8cf6-6702bf34e73d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1553780 ms
Total Talk Time (AGENT): 437890 ms
Total Talk Time (CUSTOMER): 542818 ms
Interruptions: 3
Overall Sentiment: AGENT=0.5, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/c077caf1-1dc5-401a-8cf6-6702bf34e73d_20250109T17:48_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][POSITIVE] Uh, good morning, ma'am. May I have your name, please? I'm so sorry. I
[CUSTOMER][NEGATIVE] I didn't get your name please.
[AGENT][NEUTRAL] Sure. My name is [PII]. That's [PII]. Last initial is [PII].
[CUSTOMER][POSITIVE] OK, thank you so much. Just, ma'am, allow me a couple of seconds, please. Actually, I'm calling from provider's office and
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And my name is MD, [PII]. You have told your name is [PII], right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] And what's the initial of your last name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Thank you so much ma'am.
[CUSTOMER][NEUTRAL] Uh,
[AGENT][NEUTRAL] You're welcome, and may I have uh a call back number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Just one minute, ma'am, please.
[AGENT][NEUTRAL] You sure?
[CUSTOMER][NEUTRAL] Yeah. OK. So, member policy number starts with uh W as in, I'm sorry.
[CUSTOMER][NEUTRAL] Mm, yeah, it starts with 016.
[CUSTOMER][NEUTRAL] 597.
[CUSTOMER][NEUTRAL] 37
[CUSTOMER][NEUTRAL] MIL then numericate.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] May I have the name and date of birth of the patient, Mr. [PII]?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Member's name is [PII] and date of birth is from [PII].
[AGENT][NEUTRAL] OK, and uh you're calling um to get a claim status or is it eligibility benefits? What type of service?
[CUSTOMER][NEUTRAL] Actually, ma'am, I'm calling, I have called you regarding to know about the claim status.
[AGENT][NEUTRAL] Bank status, OK. And may I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yes ma'am, so date of services from [PII].
[CUSTOMER][NEUTRAL] Total bill amount is 828 dollars.12 cents. 828.12.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, alright, let me see if I can find this claim for you and that was [PII], correct?
[CUSTOMER][NEUTRAL] [PII], yes, that's correct.
[AGENT][NEUTRAL] OK, all right. And for future, you can check claim status online through our website at [PII] and that's just optional. And let me go ahead and see if this is your claim. One moment.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] You're waiting on the air base.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I'm still waiting.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I understand. Um, no, I don't see one for $828.12.
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] I don't have a claim for $828.12.
[CUSTOMER][NEUTRAL] OK, sure. OK then, not an issue, please provide me um.
[CUSTOMER][NEUTRAL] The patient's eligibility criteria.
[AGENT][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] All right, so we have an effective date of [PII], and it is active at the moment. This is one of our secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][POSITIVE] Thank you so much. What do we have the payer ID?
[AGENT][NEUTRAL] Uh, payer ID is 60801. Now, this is a secondary policy. We need the claim to be sent by mail or fax. We need uh the EOB, the primary EOB attached to it.
[CUSTOMER][NEUTRAL] OK. Is that OK? What, uh, I mean, if we build a claim on which we have put the amount which has been paid by the primary insurance, is that OK if we submit along with that?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I mean somehow you uh you just need, yeah, you, you just need the, I mean how much of the amount has been paid by the primary insurance, right?
[AGENT][NEUTRAL] We need the
[AGENT][NEUTRAL] The requirements are we need the 1500 form or the UB form together with the explanation of benefits from the primary insurance. Those are the requirements for claim.
[CUSTOMER][NEUTRAL] Uh, if we are, uh, if we just mm, submit a claim along with.
[CUSTOMER][NEUTRAL] The CMS 1500 claim, is that OK?
[CUSTOMER][NEUTRAL] Yeah, I mean, somehow I want to say electronically, is that OK, or are we supposed to bill the same claim via fax? I mean, how I just want to know that.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The the only thing I can tell you, Mr. [PII], is that we need both. We need the 1500 form and we need the explanation of benefits from the primary insurance. So we require both documents. It's just not one.
[AGENT][NEUTRAL] If you're trying to send just one it's not gonna be enough. It's just gonna be denied stating that we need that information to continue the processing of the claim.
[CUSTOMER][POSITIVE] OK, ma'am. Thank you.
[CUSTOMER][NEUTRAL] OK, not an issue, ma'am. Uh, not an issue, please. Uh, OK, I'll try to provide you the all required details. And please also, OK, you have told me the payer ID is 60801.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And please also hm help me with the timely filing limitation.
[AGENT][NEGATIVE] We don't have timely filing limits.
[CUSTOMER][NEUTRAL] Uh, there's no any timely filing limitation has been set for, for submission for submitting a claim. You sure?
[AGENT][NEUTRAL] Correct, there's, yes, there's no timely filing limits to submit a claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Uh just one please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you so much. OK. Uh, I do have two more claims as well. Can you help me with?
[CUSTOMER][NEUTRAL] Getting the claim status for rest to claims as well. No, I think the patient is going to be a different one.
[AGENT][NEUTRAL] Was it
[AGENT][NEUTRAL] Different, OK, yeah, that, that was my question if it was the same or different. So let me go ahead and make a note on this one so we can move forward to the next one. OK, one moment.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] And so, ma'am, one more thing I would like to ask you. Would you like to provide me the call reference number for the entire call or would you like to provide me the individually call reference number?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We don't have reference numbers you use my name in today's date.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Shall we move to the next one, [PII], ma'am?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, bear with me.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, ready for the next policy number.
[CUSTOMER][NEUTRAL] Yes, ma'am. Uh, OK, I do have the member ID. It starts with.
[CUSTOMER][NEUTRAL] It's 02456391.
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][POSITIVE] Yes, of course.
[CUSTOMER][NEUTRAL] Patient's name is [PII] and the date of birth is going to be [PII].
[AGENT][NEUTRAL] OK, what's the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah, date of services from.
[CUSTOMER][NEUTRAL] Uh, [PII] and total bill amount is $250.41.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see if I find this one.
[AGENT][NEUTRAL] 24.
[AGENT][NEUTRAL] 65.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Yeah I wanna
[AGENT][NEUTRAL] OK, it's gonna be a minute. I'm waiting to see if this is your claim.
[AGENT][NEUTRAL] OK, yes. All right, we process the claim [PII], and we send a benefit amount of $50 to the provider.
[CUSTOMER][NEUTRAL] $60 right?
[AGENT][NEUTRAL] 50.
[CUSTOMER][NEUTRAL] You know.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, I'm sorry, um, 60, right? 60 amount has been.
[AGENT][NEUTRAL] 550.
[CUSTOMER][NEUTRAL] Pay our superr.
[AGENT][NEUTRAL] 50 has been paid to the provider.
[CUSTOMER][NEUTRAL] I'm sorry.
[CUSTOMER][POSITIVE] OK, ma'am. I'm sorry for that.
[AGENT][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] Uh sure.
[CUSTOMER][NEUTRAL] Mm, may I also have
[CUSTOMER][NEUTRAL] The way the payment was made.
[AGENT][NEUTRAL] Mhm. Sure. This is a single check, a paper check.
[AGENT][NEUTRAL] Um, do you need a check number?
[CUSTOMER][POSITIVE] Yes ma'am, of course I do need that.
[AGENT][NEUTRAL] OK, the check number is 2015825.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Thank you so much, ma'am.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Do you need the claim number?
[CUSTOMER][NEUTRAL] Just one.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Uh, yes, I do need that as well.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK. The claim number is 3,534,840.
[CUSTOMER][POSITIVE] Thank you so much, ma'am.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Uh, uh, thank you so much. Just, so you have told me, claim was received on [PII], right? If I'm not wrong.
[AGENT][NEUTRAL] No, that's when we processed the claim. Uh, the claim was received in [PII], processed [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] Thank you so much, ma'am.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] Ma'am, may I know the status of rest amount? I mean, as we had.
[CUSTOMER][NEUTRAL] Billed almost $250. 41 cents.
[CUSTOMER][NEUTRAL] And the, I mean, you guys have just paid the $50 towards to the provider. So what's the status for the rest amount? Is that a provider discount?
[AGENT][NEUTRAL] Let me check the primary AOB. We're just a secondary, bear with me.
[CUSTOMER][POSITIVE] OK, no issue.
[CUSTOMER][NEUTRAL] No that's OK.
[AGENT][NEUTRAL] OK. So based on the primary EOB.
[AGENT][NEUTRAL] Um, the only amount they applied towards the car insurance was the $50.
[CUSTOMER][NEUTRAL] Yes ma'am.
[CUSTOMER][POSITIVE] OK, thank you so much, ma'am. Thank you so much. I appreciate you. Thank you, ma'am. OK, uh, shall we move to the next one? I do have one more claim if you provide me the status for that.
[AGENT][NEUTRAL] You're welcome. Mhm.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Bear with me just a minute, let me make a note on this one before we move forward to the next one.
[CUSTOMER][POSITIVE] OK, ma'am, you can have your time and uh literally you are really helping I mean representative I have, I have got, honestly, I appreciate you.
[AGENT][NEUTRAL] Mm
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Shall I let you know um the member ID which I do have.
[AGENT][NEUTRAL] OK, go ahead.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Member ID starts with 017405.
[CUSTOMER][NEUTRAL] 02
[CUSTOMER][NEUTRAL] Then [PII] as in Mike L as in Lima, then numeric 7.
[AGENT][NEUTRAL] OK, thank you. And what's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah, sure. Patient's name is [PII], and the date of birth is from [PII].
[AGENT][NEUTRAL] OK, um, [PII], OK, so it's gonna be for part 3. And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah, sure, uh, ma'am, actually.
[CUSTOMER][NEUTRAL] The data service which I have is from.
[CUSTOMER][NEUTRAL] [PII] and total bill amount is $490.56.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Right
[CUSTOMER][NEUTRAL] No this.
[AGENT][NEUTRAL] 190.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] What is the procedure code?
[CUSTOMER][NEUTRAL] Yes, ma'am. OK, procedure codes.
[CUSTOMER][NEUTRAL] The single CPT was billed 99213.
[AGENT][NEUTRAL] OK. Um, can you verify the uh amount one more time for that single code?
[CUSTOMER][NEUTRAL] Yeah, sure. $245.28. And let me check more.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] I'm so sorry. I think, uh, I'm, I'm literally sorry for that. I think I, I told you the different one build amount.
[AGENT][NEUTRAL] Yeah, that's fine.
[CUSTOMER][NEUTRAL] 245.28.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] All right. So for this one, let's see.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. So we received this claim on [PII], processed [PII].
[AGENT][NEUTRAL] And the claim was denied. The denial reason is office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] Can you hear me, so, ma'am?
[AGENT][NEUTRAL] I can hear you now.
[CUSTOMER][NEUTRAL] Uh, so, ma'am, actually, uh, I was trying to ask you that.
[CUSTOMER][NEUTRAL] As you told me, office visit and covered by the policy, right? So, is this going to be the patients.
[AGENT][NEUTRAL] Of visits are not covered.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, so it's this going to be the patient's responsibility, I mean, what we are supposed to do.
[AGENT][NEUTRAL] OK, we don't have any contractual involvement on the remaining of the claim because we're just the secondary, um, so when it's not payable by us, it goes back to the primary. So if the primary apply this towards the deductible copay or coinsurance, since it's not paid by us, it's still gonna be under members responsibility based on the primary EOB.
[CUSTOMER][NEUTRAL] Do we need to
[CUSTOMER][NEUTRAL] OK. Thank you so much, So, ma'am. And one more thing I would like to ask you. Can you please let me know the structure of the total bill amount? I mean, how much has been sent over to the patient and how much has been denied. This, this is what I'm trying to understand.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] From the primary?
[CUSTOMER][NEUTRAL] No, I mean by your end only.
[AGENT][NEUTRAL] Oh no, we, we don't do that. We're not the major medical, so we don't do that. Um, again, what we do as a secondary is we help with the deductibles, co-payment, and co-insurance from the major medical. But in this type of claim, because it's an office visit, is not covered by us.
[CUSTOMER][NEUTRAL] AL.
[AGENT][NEUTRAL] So, um, we base everything off the major medical EOB.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Ma'am, could you please help me with the claim number?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, sure. The claim number is 352-266-6.
[CUSTOMER][POSITIVE] Thank you so much, ma'am. I appreciate you. OK. Mm. And one more thing, ma'am, I would like, yes, yes. Uh, one more thing I would like to ask you. So, ma'am. So the thing is going to be, I would be required to have
[AGENT][NEUTRAL] Mhm. You're welcome. Is there anything else? OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I mean, having the EOB dissolve uh the claims you have just given me the status, right? So can you please help me with the EOB though I can provide you my fax number.
[AGENT][NEUTRAL] Uh, uh, give me just a second, uh, let me see if I still have them up. If not, I will have to go back to each policy and pull them up again.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Yeah, bear with me just a moment.
[CUSTOMER][POSITIVE] I'm so sorry for that, ma'am, that I, I, I mean, I.
[CUSTOMER][NEUTRAL] Earlier I was trying to realize this, but I didn't get the same thing at the same time so I've, I've just got this.
[CUSTOMER][NEUTRAL] Uh, you know that I'm supposed to ask you because I would be required to have a EOP.
[AGENT][NEUTRAL] Mm mm, OK. Um, yeah, I don't think I got the other one pulled up. Bear with me.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] See this Sunday that one.
[AGENT][NEUTRAL] OK, so the first one was not on file, so that one doesn't have anything.
[AGENT][NEUTRAL] So it's gonna be just the 2nd 1.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] What is the fax number?
[CUSTOMER][NEUTRAL] Yes ma'am, fax number I do have.
[CUSTOMER][NEUTRAL] [PII]. And please
[CUSTOMER][NEUTRAL] Um, mention my neighbor, uh, my name over there on attention [PII].
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] OK. Just [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah, of course, and [PII], that is going to be my last of in I mean the initial of my last name.
[AGENT][NEUTRAL] Initial, OK.
[AGENT][NEUTRAL] OK, so that's [PII]. Attention MDA.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, do you mind holding for me while I send this out to you?
[CUSTOMER][NEUTRAL] Though you, you
[CUSTOMER][POSITIVE] Uh, I mean you can take your time. I think I've done with my, mm, I mean whatever the question I had to ask you and as well as you also have provided me the claim status so you can easily just take your time whenever you're free you can share me the.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Uh, I mean those EOBs on my fax number. I appreciate you. Thank you so, so much, so you are, I mean.
[AGENT][NEUTRAL] So you cannot wait on the line for me, Mr. [PII]?
[CUSTOMER][POSITIVE] No, I can wait for you.
[AGENT][POSITIVE] I'd rather send them now. If you don't mind holding, I can go ahead and send them now.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] I gave it to you so, so no issue.
[AGENT][POSITIVE] OK, thank you so much. OK, one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding Mr. [PII]. OK, I went ahead and send it over so it should be there in a few minutes. Is there anything else I'm gonna help you with today?
[CUSTOMER][POSITIVE] No, thank you so much, [PII]. I appreciate you for providing me the details. Thank you so much.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] You're welcome and thank you for calling APL. Have a good day. Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.