AccountId: 011433970860
ContactId: c1599791-25f8-4ea5-998e-f17c36066038
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 758859 ms
Total Talk Time (AGENT): 249567 ms
Total Talk Time (CUSTOMER): 266689 ms
Interruptions: 7
Overall Sentiment: AGENT=0.4, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/14/c1599791-25f8-4ea5-998e-f17c36066038_20250414T17:26_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from the provider's office. I required a claim status.
[AGENT][NEUTRAL] Sure, I can check on a claim for you and [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] Thank you. And then do you have that policy number?
[CUSTOMER][NEUTRAL] Yes, the policy number is 02564245.
[AGENT][NEUTRAL] OK, and what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] The member's first name is [PII] and the last name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Alright, thank you for verifying that [PII]. What was the date of service for this claim, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] So that was [PII]?
[CUSTOMER][NEUTRAL] we
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, what was that bill amount, please?
[CUSTOMER][NEUTRAL] The amount is $83,978. 65 cents.
[AGENT][POSITIVE] Got it thank you one minute.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII], was that the amount before or after a major medical paid?
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] What was the amount left over after major medical paid?
[CUSTOMER][NEUTRAL] This is total bill amount.
[AGENT][NEUTRAL] OK, what was the remaining balance after major medical paid?
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] At 6530 dollars.4 cents.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] I can I, can I get
[CUSTOMER][NEUTRAL] But there is no amount paid yet.
[AGENT][NEUTRAL] OK, can I get that uh tax ID from you, [PII]?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] OK thank you one moment.
[AGENT][NEUTRAL] OK, so I did find a claim for $83,407.96.
[AGENT][NEUTRAL] From this provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is that correct? Is this the one that we're looking for?
[CUSTOMER][NEUTRAL] Give me a moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Can you just repeat the amount again.
[AGENT][NEUTRAL] Sure, $83,407.96.
[CUSTOMER][POSITIVE] Yes, it's correct.
[AGENT][NEUTRAL] OK, so we did receive this claim, uh, we were unable to pay a benefit as the insured's primary insurance did provide full benefits, so there are no benefits payable.
[CUSTOMER][NEUTRAL] Uh, what exactly that means? Can you just explain me more about it because on the correspondence also it is mentioned same. In short, primary uh insurance provided full benefits. There are no benefits payable. So I didn't get it. Can you just explain me what exactly it is?
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Sure, so based off of the information that we received, the primary insurance, whoever they have as their primary, paid that full benefit amount, so there was nothing additional for us to pay.
[CUSTOMER][NEUTRAL] OK, so you wanna say that the primary uh.
[CUSTOMER][POSITIVE] Primary insurance has paid full amount.
[AGENT][NEUTRAL] Yes, for the information that we received.
[CUSTOMER][NEUTRAL] You have received it from?
[AGENT][NEUTRAL] Um, the provider.
[CUSTOMER][NEUTRAL] From the provider you have received this information.
[AGENT][NEUTRAL] Correct, that same tax ID that you gave me was this information.
[CUSTOMER][NEUTRAL] OK. Just give me one moment. Just be online.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Hello. Uh, can you just, uh, confirm me the amount, how much amount they have paid and what was the method?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, yes, so the billed amount we received was $83,407.96 for the information that we received with the claim.
[CUSTOMER][NEUTRAL] That was the amount
[AGENT][NEUTRAL] That was the amount total paid by their primary insurance, so there was nothing additional for us to pay.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So you want to say that $83,407.90 was paid by the uh patient primary insurance, correct?
[AGENT][NEUTRAL] For the information that we received, yes.
[CUSTOMER][NEUTRAL] OK, you have received this information. Can you just tell me what was the method of the payment that was paid by check or EFT?
[AGENT][NEGATIVE] I, I don't know how it was paid as it was paid to the provider.
[AGENT][NEUTRAL] I just see record of it being paid.
[CUSTOMER][NEUTRAL] So how we can get that details like how it was paid, how we get to know that.
[AGENT][NEUTRAL] That would be through the provider we don't have record of that only the information sent from the claim the primary EOB that's what shows what they paid.
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] To the provider.
[CUSTOMER][NEUTRAL] OK, you wanna say that we need to connect to the provider to get all this information.
[AGENT][NEUTRAL] Yes, as we didn't receive any.
[CUSTOMER][NEUTRAL] OK, just
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] OK. Just be online. Give me a second. I'll just confirm and I'll get back to you. Just be online.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh, thank you for your patience. I'm sorry for the long hold, but as I checked on the EOB from the primary, I have seen that there is a PTR or of amount of 70916 dollars.67. So I just want to confirm that you guys can adjust to uh your through or we need to bill it to the patient.
[AGENT][NEUTRAL] OK, yes, so for the information we received, there is nothing for us to pay if you wanted to file an appeal that had to have been done within 180 days of the claim being processed, which that was on [PII].
[CUSTOMER][NEUTRAL] There.
[CUSTOMER][NEUTRAL] What.
[CUSTOMER][NEUTRAL] was
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And we don't say what is patient responsibility that would be up to the provider.
[CUSTOMER][NEUTRAL] Up to the provider so we can uh bill it to you guys, no, I mean to say that.
[AGENT][NEUTRAL] Mm.
[AGENT][NEGATIVE] You did send it to us or the provider did send it to us but again based off of the information that we received there was nothing for us to pay.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So what we can do because we have the primary EOB and in the primary EOB it is mentioned that there is a PTR.
[AGENT][NEUTRAL] Again, you could have it sent an appeal. We're outside of that appeal date range that had to been with on 180 days of this claim being processed, so there's nothing that we are able to do additionally and if we don't say what is patient responsibility that is that is up to the provider.
[CUSTOMER][NEUTRAL] So, as per
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so we can.
[CUSTOMER][NEUTRAL] 0815
[CUSTOMER][NEUTRAL] OK, so we can appeal it. So can you just send me the appeal details on where we can send it?
[AGENT][NEUTRAL] The appeal had to have been done within 180 days of [PII].
[CUSTOMER][POSITIVE] You too. Thank you.
[CUSTOMER][NEUTRAL] 018.
[AGENT][NEUTRAL] So you would send the information to the same claims address along with a letter stating that it is for an appeal.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So, can you just reconfirm me with the address?
[AGENT][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that is [PII].
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] yeah yeah yeah.
[CUSTOMER][NEUTRAL] OK, so timely filing is for this also. It is 180 days now, as you said.
[AGENT][NEUTRAL] 108 days, 180 days from [PII].
[CUSTOMER][NEUTRAL] OK. From [PII]. That is the timely filing for this. OK. So we need to appeal for it. OK. So the last thing I'll request you to please help me with the call reference number and your name phonetically, then we are done for the day.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] For an appeal, yes.
[AGENT][NEUTRAL] Reference number would just be my first name, last initial, and today's date. Uh so my name is spelled [PII]
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Your name and today's date, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK, sir. Thank you so much for your help. Take care. Bye-bye. Have a nice day.
[AGENT][POSITIVE] Of course thanks on [PII] you too bye bye.