AccountId: 011433970860
ContactId: c08b71d8-e991-4854-92bb-3193d6005042
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 836929 ms
Total Talk Time (AGENT): 175305 ms
Total Talk Time (CUSTOMER): 411615 ms
Interruptions: 4
Overall Sentiment: AGENT=0.7, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/c08b71d8-e991-4854-92bb-3193d6005042_20250416T13:25_UTC.wav
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[AGENT][POSITIVE] Thank you for calling
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hello? Can you hear me?
[AGENT][NEUTRAL] Hi, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, hi, this is [PII] calling for Christy Southern New Mexico. Please be informed that this call is being recorded and monitored for the quality and training purposes. I verified that you will be and this call is made for the additional information about the denial, and I'm sorry I missed your name. Could you please repeat that again?
[AGENT][NEUTRAL] OK, so you're needing clarification of a denied claim?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, my name is [PII]
[AGENT][NEUTRAL] First initial last name is [PII]
[CUSTOMER][POSITIVE] Thank you so much, [PII] for that.
[AGENT][NEUTRAL] As in [PII], and if you could spell your first name, please?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, sure, uh my name is [PII].
[CUSTOMER][NEUTRAL] I ice cream in November.
[AGENT][NEUTRAL] OK, and if I can get the policy number in.
[CUSTOMER][NEUTRAL] And the last name initial will be [PII]. Yeah, sorry for that.
[AGENT][POSITIVE] Thank you. I can get the policy number and claim number please.
[CUSTOMER][NEUTRAL] Yeah, sure. Uh, the member ID number is?
[CUSTOMER][NEUTRAL] 024
[CUSTOMER][NEUTRAL] 28218. And the claim number is, just a moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] OK, thank you so much for patiently staying connected.
[AGENT][POSITIVE] OK. No worries.
[CUSTOMER][POSITIVE] And the claim number, OK. Thank you so much, [PII] for that.
[CUSTOMER][NEUTRAL] OK. And the claim number is 3584683.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][POSITIVE] Go for it.
[AGENT][NEUTRAL] And the patient's name and date of birth please?
[CUSTOMER][NEUTRAL] Yeah, sure. Name of the patient is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] OK, and if you can read the denial remark code on the explanation of benefits that you have and we can further discuss.
[CUSTOMER][NEUTRAL] Uh, uh, we have received it says that it does not, uh, provide any information over here.
[AGENT][NEUTRAL] Can you turn to the back of the explanation?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm, let me check it again.
[AGENT][NEGATIVE] There should be a denial description on the back.
[CUSTOMER][POSITIVE] Um, unable to see that and that's why we made a call. I'm really sorry for that, [PII].
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I'm unable to see that that's why I made a call. I'm sorry for that.
[AGENT][NEUTRAL] OK, so you need it, you said you need a clarification of the denial?
[CUSTOMER][NEUTRAL] Yes, for the code 9921496127.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, office visits are not covered under this policy, so therefore no payment was made.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, so it's not, uh, OK, thank you so much for the clear information. So it's denied as non-covered as per the payer guidelines, right?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] As per the patient's policy.
[CUSTOMER][NEUTRAL] Oh, OK, so it's not covered as per the patient's be OK, patient's policy, is that right?
[AGENT][NEUTRAL] That is correct. Any other questions?
[CUSTOMER][POSITIVE] Thank you so much. Yes, I do have. Just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Just a moment, please.
[CUSTOMER][NEUTRAL] OK, OK. May I know when did you receive this claim?
[AGENT][NEUTRAL] Receive date is [PII]. Process is [PII].
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] [PII]. Thank you so much. Just a moment.
[CUSTOMER][NEUTRAL] I like to verify the timely filing limit?
[AGENT][NEUTRAL] To submit a claim?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEGATIVE] To submit a claim, there's no timely.
[CUSTOMER][NEUTRAL] Oh, no, for an appeal.
[AGENT][NEUTRAL] 180 days from the date of denial.
[CUSTOMER][POSITIVE] Thank you so much. Just a moment. 180 days.
[CUSTOMER][POSITIVE] From denied it. Thank you very much. Just a moment. Just a moment please.
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Just a moment please.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I would like to verify just a moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Could you please go ahead and just a moment verify the mailing address.
[AGENT][NEUTRAL] [PII], State is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] I would like to reconfirm it is [PII] sorry it's [PII].
[CUSTOMER][NEUTRAL] [PII]. Is that right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK, just a moment, thank you so much, just a moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The final question.
[CUSTOMER][NEUTRAL] OK, just a moment please.
[CUSTOMER][POSITIVE] OK, thank you so much for that. And I would like to get the call reference number before going to the claim.
[AGENT][NEUTRAL] My name in today's date and you can also check status online at [PII]. [PII] and I can help you set up that account while we're on the phone. Let me know when you're ready.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah, sure. Thank you so much. Your name and today's date will be the call reference number. Thank you so much. Moving to the next claim, [PII]. Shall I start with the member ID?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, I can help you set that up. I can help you set up the account. Let me give you the web address. It's a [PII].
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And then I'll show you how to check status online.
[CUSTOMER][NEUTRAL] Uh, no, we need a live representative. We don't want to, we don't want to check in portal. So could you please help me with this claim, please?
[AGENT][NEUTRAL] OK, how many statuses do you have?
[CUSTOMER][NEUTRAL] Only 4 more.
[AGENT][POSITIVE] OK, I can do one more.
[CUSTOMER][POSITIVE] OK then. Thank you so much for that.
[AGENT][NEUTRAL] Policy number please.
[CUSTOMER][NEUTRAL] Yes, uh, the member ID number is um 02428218.
[AGENT][NEUTRAL] OK, that's the same policy that we're on currently.
[CUSTOMER][NEUTRAL] Oh I'm sorry, I'm sorry that, sorry, the policy number is uh.
[CUSTOMER][NEUTRAL] 025856551
[AGENT][NEUTRAL] And what's a good um data of service and the charge?
[CUSTOMER][NEUTRAL] Date of service will be.
[CUSTOMER][NEUTRAL] [PII]. And the total amount is?
[CUSTOMER][NEUTRAL] 2 $89.20.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] And what is your callback number?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII] and that's a direct line.
[CUSTOMER][NEUTRAL] Of
[AGENT][NEUTRAL] And what is the patient's name and date of birth for the next policy number?
[CUSTOMER][NEUTRAL] Patient name is [PII]. I'm sorry, name of the patient is uh [PII] and the date of birth is [PII], I'm sorry, it's [PII].
[AGENT][NEUTRAL] What's it, OK.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Still looking one moment.
[CUSTOMER][POSITIVE] Yeah, sure, no problem. Take your time.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what are the procedure codes on the claim?
[CUSTOMER][NEUTRAL] Yeah, the procedure code is.
[CUSTOMER][NEUTRAL] Just a moment please.
[CUSTOMER][NEUTRAL] Just a moment please. OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] This
[CUSTOMER][NEUTRAL] Let me check here.
[CUSTOMER][NEUTRAL] G 2211. G as in girl, 2211.
[AGENT][NEUTRAL] OK, is that the only procedure code on the claim?
[CUSTOMER][NEUTRAL] Yeah, that's the one to go I'm checking yeah.
[AGENT][NEUTRAL] OK, what is the other procedure code on the claim?
[CUSTOMER][NEUTRAL] Only one court is denied in our end.
[AGENT][NEUTRAL] OK, I, I understand, but what was the other procedure code that's on the claim that that was submitted?
[CUSTOMER][NEUTRAL] 99203.
[AGENT][NEUTRAL] OK, so the $75 payment was for the 99203 code and that's the maximum benefit per office per day.
[CUSTOMER][NEUTRAL] Yeah, but, yeah, that code is fine and I'm not checking that code. That code is got paid full. I'm checking only the code G as in Golf 2211, which is uh $42 a month.
[AGENT][NEUTRAL] The maximum benefit of $75 has been paid, so the, the benefit is exhausted.
[AGENT][NEUTRAL] For this day.
[CUSTOMER][NEUTRAL] OK, so the G2211 is denied as benefit exhausted. Is that right?
[AGENT][POSITIVE] Correct, because the max was paid on the office visit code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Benefi exhausted.
[CUSTOMER][NEUTRAL] May I know the exhausted date?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] May I know the exhausted date, please?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][NEUTRAL] It's a daily benefit of $75.
[CUSTOMER][NEUTRAL] Yeah, [PII] or [PII]?
[AGENT][NEUTRAL] Yeah, the date that this claim was processed, ma'am, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] May I know the received date, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] The claim was received [PII].
[AGENT][NEUTRAL] Processed on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Any other questions?
[CUSTOMER][NEUTRAL] Mm, OK. Yes, yes, just a moment. Received on [PII] and processed on [PII], right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Thank you. Just a moment. April, just a moment, please.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] So that code G2212, I'm sorry, the code G2211 is paid in the office visit code that is 99203 and that is the maximum allowed amount and you can't pay more than that. Is that right?
[AGENT][NEUTRAL] Could you repeat the question?
[CUSTOMER][NEUTRAL] Yeah, the code G221 got paid in the office visit code that is 99203 and uh you paid the maximum allowed amount $75 and you got that code cannot be paid more than that. Is that right?
[AGENT][NEUTRAL] Yeah, the maximum office visit benefit is, is been paid.
[AGENT][NEUTRAL] So yes.
[CUSTOMER][POSITIVE] OK. Thank you so much for that.
[CUSTOMER][NEUTRAL] OK, just a moment.
[CUSTOMER][NEUTRAL] Shall I take the time defining limit on the mailing address as we discussed for the previous claim, would that be fine?
[AGENT][NEUTRAL] It's the same.
[CUSTOMER][POSITIVE] OK, so thank you so much for that and thank you so much.
[CUSTOMER][POSITIVE] Uh, for your assistance as well. Have a great day. Take care. Bye for now.
[AGENT][POSITIVE] You're welcome. You're welcome, [PII]. Thanks for calling APL. Have a good day.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Right