AccountId: 011433970860
ContactId: cc68dd5b-7fa0-453f-b2c6-ae9a271669a3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1044640 ms
Total Talk Time (AGENT): 274977 ms
Total Talk Time (CUSTOMER): 202564 ms
Interruptions: 0
Overall Sentiment: AGENT=0, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/18/cc68dd5b-7fa0-453f-b2c6-ae9a271669a3_20250218T14:28_UTC.wav
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[AGENT][NEUTRAL] Morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Hello?
[AGENT][POSITIVE] Good morning. Yes, good morning. This is Over IPO. How may I assist you?
[AGENT][POSITIVE] Hello, good morning.
[CUSTOMER][NEUTRAL] Hi, um, yeah.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah, good morning. Hi, I'm calling from provider's office, and my first name is [PII] and initial of my last name is [PII].
[AGENT][NEUTRAL] How do you spell that?
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][NEUTRAL] OK. All right. And how may I assist you today, Miss [PII]?
[CUSTOMER][NEUTRAL] Yeah, I want to check up on a claim status.
[AGENT][NEUTRAL] OK, sure, I can assist you with claim status. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yeah, sure, it's [PII].
[AGENT][NEUTRAL] OK, and may I have the patient's policy number, Miss [PII]?
[CUSTOMER][NEUTRAL] Yeah, sure. It's 19.
[CUSTOMER][NEUTRAL] Sorry, uh, may I repeat that? It's 01930679 M.
[CUSTOMER][NEUTRAL] L. 8.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah, member's first name is [PII] and last name is [PII]. and member's date of birth is [PII].
[AGENT][NEUTRAL] OK perfect thank you and may I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah, date of service is from [PII], and the total bill amount is $19,955 even.
[AGENT][NEUTRAL] OK. Let me see if I can find this claim for you. And for future, you can check claim status online through our website at [PII]. And you said it was [PII], correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] OK, let me pull this information one moment.
[AGENT][NEUTRAL] So it was processed twice. I'm gonna give you the original one because the last one was processed as a duplicate, OK? Bear with me just a second. I'm waiting on the original claim to pull up.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] All right, so it looks like the original claim was processed on [PII].
[AGENT][NEGATIVE] And it was denied. The reason for this denial is because based on the information included on the claim form, this service was not rendered in a covered place of service.
[CUSTOMER][NEUTRAL] OK, so you said it is denied for out of network.
[AGENT][NEGATIVE] No, uh oh. The place of service is not covered under this policy.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Just give me a moment please.
[AGENT][NEUTRAL] Mhm. Sure.
[CUSTOMER][NEUTRAL] OK. So can you please tell me the required place of service which is covered and what is the place of service we build on the claim?
[AGENT][NEUTRAL] OK, um, let me go ahead and pull out details. One moment.
[AGENT][NEUTRAL] OK, let me look at the benefits.
[AGENT][NEUTRAL] No
[AGENT][NEUTRAL] OK, I'm gonna put you on a brief hold, OK? One moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding and being patient for me, Miss [PII]. OK, so this is a dialysis center. We do not cover dialysis centers.
[CUSTOMER][NEUTRAL] Sorry, could you repeat that?
[AGENT][NEUTRAL] OK, based on the uh claim, this uh claim was coming from a dialysis center. We do not cover dialysis center.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] It's greater Miami dialysis.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Yeah, it's, uh, is it showing greater Miami dialysis?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um, but as I can check in my system it's showing.
[CUSTOMER][NEUTRAL] In network with the peer.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] But as I can check in my system, it is still showing in network with the payer.
[AGENT][NEUTRAL] We're not the primary insurance. We're the secondary insurance, and with this policy based on the scheduled benefits and the benefits that we have for this member dialysis, a dialysis center is not a covered place of service, so this one doesn't cover under the secondary policy. It's not covered by the member's plan.
[CUSTOMER][NEUTRAL] OK, just give me a moment please.
[AGENT][NEUTRAL] Mhm. Sure.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh, can you please tell me timely filing for corrected payment and timely filing for a bill?
[AGENT][NEUTRAL] You have 180 days to submit an appeal from the decision date.
[CUSTOMER][NEUTRAL] Uh, from last.
[AGENT][NEUTRAL] From last denial, and let me give you the last denial from the, not the last denial, the original denial, which it was [PII]. That was the original denial and you had 180 days to submit an appeal. It looks like that time is over now.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, no issue, and I have some more claims.
[AGENT][NEUTRAL] You have more claims that you need to check on.
[CUSTOMER][NEUTRAL] One for the
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Yeah, one for the same patient and one for the another patient. Can you please help me with that?
[AGENT][NEUTRAL] OK, bear with me, let me go ahead and finalize the note on this one.
[AGENT][NEUTRAL] And you say you have another one for the same number?
[CUSTOMER][NEUTRAL] No, for the same member.
[AGENT][NEUTRAL] OK, bear with me.
[AGENT][NEUTRAL] What is the date of service, the next date of service?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] Uh, OK, so another date of service is from [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It looks like it's gonna be the same denial. Um, let me look at the day that process.
[AGENT][NEGATIVE] OK, so it processed on [PII], and again it's the same denial, it's a non-covered place of service.
[CUSTOMER][NEUTRAL] OK, no issue. Just uh one more account for the different.
[CUSTOMER][NEUTRAL] Let me pull up that account.
[AGENT][NEUTRAL] OK, one moment. Let me make a note on this one for this claim. One moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] OK, and that policy number?
[CUSTOMER][NEUTRAL] Mm yeah, sure. It's 01986335.
[AGENT][NEUTRAL] Hm
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yeah, sure. Member's first name is [PII] and last name is [PII] and uh member's date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. What's the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah, it's from [PII] and the total bill amount is $14,594 even.
[AGENT][NEUTRAL] OK, can you repeat the date of service one more time?
[CUSTOMER][NEUTRAL] Yeah, it's from [PII].
[AGENT][NEUTRAL] First.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so this one has been processed several times, um.
[AGENT][NEUTRAL] 4 times. Let me pull the original 11 moment.
[AGENT][NEUTRAL] Which it looks like it's denied with the same denial reason as the one prior.
[AGENT][NEUTRAL] Um, one moment.
[AGENT][NEUTRAL] OK. So let's see.
[AGENT][NEGATIVE] We process the claim on [PII] and it is denied with the same denial reason as a non-covered place of service.
[CUSTOMER][NEUTRAL] OK, and you were saying that uh one is still in process?
[AGENT][NEGATIVE] No, we processed this claim 4 times. The last 3 times was processed and denied as a duplicate, and the original one was denied and processed as a place of service is not covered.
[CUSTOMER][POSITIVE] OK, no. Thank you so much for the information.
[AGENT][NEUTRAL] You.
[CUSTOMER][NEUTRAL] And is it appeal limit same for this one too?
[AGENT][NEUTRAL] Yes, 180 days from the decision date, which it was [PII].
[CUSTOMER][NEUTRAL] OK, thank you so much for the information. Just tell me your first name and initial of your last name with the call reference number for this call.
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will. My name is [PII], that's [PII]. Last initial is [PII].
[CUSTOMER][POSITIVE] OK, thank you so much for the information today and have a nice day.
[AGENT][POSITIVE] You're welcome. You as well, and thank you for calling ATL. Bye-bye, Miss [PII].
[CUSTOMER][POSITIVE] Yeah, thank you. Bye-bye.
[AGENT][POSITIVE] You're welcome. Bye-bye.