AccountId: 011433970860
ContactId: d0158f60-c214-4248-a132-a94c09c9b5d6
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 751359 ms
Total Talk Time (AGENT): 278847 ms
Total Talk Time (CUSTOMER): 223618 ms
Interruptions: 3
Overall Sentiment: AGENT=0.5, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/15/d0158f60-c214-4248-a132-a94c09c9b5d6_20250415T19:19_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII]. I'm calling for Meas Orthopediatics PLLC. I verify the UB and this call is made for additional information about the denial. Please note the call will be monitored and recorded for quality and training purposes.
[AGENT][NEUTRAL] OK, so you have additional questions regarding a denied claim, is that correct?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][POSITIVE] Yes, ma'am. I can help you with that. And what is your name again?
[CUSTOMER][NEUTRAL] Uh, my name is [PII], initial, my last name is [PII].
[AGENT][NEUTRAL] OK [PII] thank you and your call back number?
[CUSTOMER][NEUTRAL] Sure. The callback number is [PII].
[AGENT][NEUTRAL] Thank you and I can help you with uh information on the denied claim. What is the member's policy number, [PII]?
[CUSTOMER][NEUTRAL] Sure. For this one, the policy number is gonna be um 01821740.
[AGENT][POSITIVE] Thank you. One moment.
[AGENT][NEUTRAL] And any information that I provide for you, [PII] will be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh, it's [PII] and the date of birth is on [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Again, what is the, the patient's name?
[CUSTOMER][NEUTRAL] The member's name is, it's [PII] and the date of birth is on [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] OK. All right, thank you.
[AGENT][NEUTRAL] And what is the date of service and total bill amount, please?
[CUSTOMER][NEUTRAL] For this one, the date of service is on.
[CUSTOMER][NEUTRAL] One second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For this one, the date of service is on, um, it's on [PII] with the total charge amount of $85.80.
[AGENT][NEUTRAL] 85.80. Is that correct?
[CUSTOMER][NEUTRAL] Yes, ma'am. Let me check here the whole amount once again.
[AGENT][NEUTRAL] And
[CUSTOMER][NEUTRAL] One second, ma'am.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For $366 even.
[AGENT][NEUTRAL] OK, and what is the claim number that you have, [PII]?
[CUSTOMER][NEUTRAL] Yeah, the claim number I can see is 3583962.
[AGENT][NEUTRAL] 39 what? What were the last numbers?
[CUSTOMER][NEUTRAL] It's 3583962.
[AGENT][NEUTRAL] OK, so first off, the policy number that you gave to me is an old policy that was not active for your date of service.
[AGENT][NEUTRAL] That policy number actually termed 111 of 2023.
[AGENT][NEUTRAL] And there is another policy number that you should have for this number?
[CUSTOMER][NEUTRAL] OK. Um, I don't have the policy number, ma'am.
[AGENT][NEUTRAL] The correct
[CUSTOMER][NEUTRAL] OK, one second. The policy number I can see here is 01821740. This is the member ID as well as the policy number. Uh, mhm.
[AGENT][NEUTRAL] OK. Yes, ma'am.
[AGENT][NEUTRAL] And that is an old, yes, ma'am. And as I just stated, that is an old policy number. That policy was not active for your data service. It had terminated prior to your data service.
[AGENT][NEUTRAL] So give me just a moment, the correct policy number that you should have.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is 0244.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 0266.
[AGENT][NEUTRAL] And this policy has an effective date of [PII] and is active, so give me just a moment to get that information pulled up please.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, which is like you're coming to state the patient was not eligible for the data service.
[AGENT][NEUTRAL] No, ma'am, that's not what I said.
[AGENT][NEUTRAL] I said that you had an incorrect policy policy number for the data service that you're calling about.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And the policy that you gave me was not active for the data service, but the policy number that I just gave to you was.
[CUSTOMER][NEUTRAL] OK, one second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So let me pull up the correct policy to see if the claim was processed under the correct policy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you said the total bill amount was 366, is that correct, [PII]?
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] I can see here that you are a secondary for this member.
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] We are not a major medical carrier, we would not be a primary insurance.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Uh, which is incorrect policy number and the provider was not eligible for the data service and it is effective from [PII] and.
[AGENT][NEUTRAL] No, no, ma'am.
[AGENT][NEUTRAL] So we process the claim under the correct policy number.
[CUSTOMER][NEUTRAL] Yeah, go ahead.
[AGENT][NEUTRAL] We received it under the old policy number, but we processed it under the number that I gave you, and the claim number that you gave me is under the correct policy number.
[AGENT][NEGATIVE] And yes ma'am, I do show that that claim was denied. One of the denial remarks is that office visits are not covered.
[CUSTOMER][NEUTRAL] OK, one second.
[AGENT][NEUTRAL] By the above number policy, the, the patient's plan doesn't cover office visits.
[AGENT][NEUTRAL] And the other remarks for the other three codes are the same. The service is not covered when performed in a doctor's office or clinic, and that is for the patient's plan.
[CUSTOMER][NEUTRAL] OK, I'll go for the same reason.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, the office visits are not covered and then the other code was that the service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] OK, one second, let me take both of. OK, ma'am. Let me, uh, correct me if I'm wrong. Incorrect policy number, the claim was processed, correct policy number, and you have received incorrect policy number. So you have given the correct one as 02440266. And all codes are denying for non-covered under the patient's plan. Is it correct?
[AGENT][NEUTRAL] That is correct. That is correct. And if you need a copy of this explanation of benefits with those remarks on there that I read to you, you can print thatam if you go to our portal.
[AGENT][NEUTRAL] And use the claim number you can pull that up and the portal website is secured.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] One second, ma'am.
[CUSTOMER][NEUTRAL] Uh, the one you have given us, the service was not covered when performed in the doctor's office. Another one what you stated, ma'am?
[AGENT][NEUTRAL] Or clinic.
[AGENT][NEUTRAL] And office visits are not covered.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK. What's the website you have given?
[AGENT][NEUTRAL] The website to for you to print the explanation of benefits if you need a copy of that with those remarks on there and that website is secured.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Public. Yes, ma'am.
[CUSTOMER][NEUTRAL] OK, one quick moment.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, if there is any specific form like reconsideration or appliment to submit for this one or no specific form, ma'am.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] There's no specific form, but an appeal must be filed within 180 days from the date of the decision and sent to attention appeals department.
[CUSTOMER][NEUTRAL] Or 80 days from the decision date what's the timely filing? What's gonna be the mailing address?
[AGENT][NEUTRAL] The same as claims.
[CUSTOMER][NEUTRAL] Attention to our police department.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, one second, correct me if I'm wrong.
[CUSTOMER][NEUTRAL] Is that [PII], OK. [PII].
[AGENT][POSITIVE] Yes ma'am, that is correct.
[CUSTOMER][NEUTRAL] OK. Once again.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK. [PII]. OK. Go ahead with the call reference.
[AGENT][NEUTRAL] It would be my name that I gave you along with today's date.
[CUSTOMER][NEUTRAL] [PII], sorry, [PII].
[AGENT][NEUTRAL] And it's [PII], uh-huh.
[AGENT][NEUTRAL] [PII] and the first initial to my last name is [PII], and today's date.
[CUSTOMER][NEGATIVE] Which is stress you on.
[CUSTOMER][POSITIVE] OK, ma'am. Thank you for assisting. Have a good day. Bye for now. Thank you.
[AGENT][POSITIVE] Well, you're welcome. Yes, you too, [PII]. If that's all I can help you with, thank you again for calling APL and I hope you have a nice day.