AccountId: 011433970860
ContactId: cfac72a4-dd86-44df-8a78-385185f46a4c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 454640 ms
Total Talk Time (AGENT): 130954 ms
Total Talk Time (CUSTOMER): 142786 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/28/cfac72a4-dd86-44df-8a78-385185f46a4c_20250328T13:32_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. I'm calling from provider office. I want to check the claim status.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, [PII], I can help you with claim status. Do you have a good callback number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Give the policy number for the patient?
[CUSTOMER][NEUTRAL] OK, uh.
[CUSTOMER][NEUTRAL] The policy number is
[CUSTOMER][NEUTRAL] 1,539,960. M as in Mike Lima, and the number 8.
[AGENT][POSITIVE] OK, I'm sorry. Can you repeat that back? I'm so sorry.
[CUSTOMER][NEUTRAL] 153996.
[CUSTOMER][NEUTRAL] 0, M as in Mike.
[CUSTOMER][NEUTRAL] Lima and the number 8.
[AGENT][NEUTRAL] And the patient name and date of birth?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what was that date of service?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] The bill charges?
[CUSTOMER][NEUTRAL] $417.98.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, I'm pulling that up. One moment.
[AGENT][NEUTRAL] Um, so this claim was denied. Benefits are only payable if major medical provides benefits.
[AGENT][NEUTRAL] So we would need an explanation showing benefits were paid to be considered.
[CUSTOMER][NEUTRAL] So is it uh under member or is it on the provider?
[AGENT][NEUTRAL] It is what under the patient responsibility or what are you referring to?
[CUSTOMER][NEUTRAL] Yeah, you said uh you need the benefit, right?
[AGENT][NEUTRAL] Explanation of benefits showing the uh showing that the primary processed the claim and considered it.
[AGENT][NEGATIVE] There's, I showed two charges for the for the office visit itself, that is not covered, but the other charge could could possibly be covered. Excuse me.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] OK, office visit. OK. Could you please tell me, uh, is it for the CBD 99214 is it denied for office visit?
[AGENT][NEUTRAL] Yes
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] And what about for the uh line 2 73,080?
[AGENT][NEUTRAL] So that line, we possibly um could process that, but the explanation of benefits we received shows that it wasn't considered by the primary insurance.
[AGENT][NEUTRAL] So that's why we have not paid on that.
[CUSTOMER][NEUTRAL] So do we need uh to bill with the primary hobby for this to be built?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] But, uh, [PII], yeah.
[CUSTOMER][NEUTRAL] It's already reflected on the claim form, right? The amount paid by the primary in the box number 29.
[CUSTOMER][NEUTRAL] $21.10.
[AGENT][NEUTRAL] Yeah, so
[AGENT][NEUTRAL] Um, let me pull up what what we have on file. Hold on one moment.
[AGENT][NEUTRAL] Give me just one moment, please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, pulling that up.
[AGENT][NEUTRAL] Yeah, so the, the second line 73,080.
[AGENT][NEUTRAL] It looks like that was paid in full by primary.
[CUSTOMER][NEUTRAL] OK. So it is uh like primary pay, the allowed amount of the secondary, right?
[AGENT][NEUTRAL] Correct, so if, if there's nothing, if there's no nothing left to pay, we, we don't have anything to pay on the claim.
[AGENT][NEUTRAL] So primary paid in full.
[CUSTOMER][NEUTRAL] OK, 44
[CUSTOMER][NEUTRAL] OK. So for the, for the uh first line, uh line one office visit, is it under member plan, member policy plan, or is it a provider?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I guess I don't understand the question. So for the first line the office visit, that's not covered under this policy. It's a non-covered service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much. Uh, what will, what is the claim number?
[AGENT][NEUTRAL] Uh, claim number is 354-0889.
[CUSTOMER][NEUTRAL] OK. Uh, please give me a second, uh, whether I can pull up in the APL, uh,
[AGENT][NEUTRAL] But
[CUSTOMER][NEUTRAL] Portal or not. Let me just try and if not, if I can pull up, I don't need to ask you for, to fax the EOB but
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] They thought, I, uh.
[AGENT][POSITIVE] Yeah, take your time.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] OK, I got the claim. Yes, I got the claim. So, I, uh, you don't have to fax the OVR OK, what will be the call reference number?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, the call reference number is my first name, [PII] Last initial is [PII], and today's date.
[AGENT][NEUTRAL] Is there anything else I can help with today, [PII]?
[CUSTOMER][POSITIVE] No, uh, [PII], that's all for now. Have a nice day and enjoy your weekend. Bye-bye.
[AGENT][POSITIVE] OK, thanks for
[AGENT][POSITIVE] Thank you for calling APL you as well.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Bye.