AccountId: 011433970860
ContactId: d2cca993-7ef3-4e77-91d9-02ff6065fc81
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1067859 ms
Total Talk Time (AGENT): 259458 ms
Total Talk Time (CUSTOMER): 264821 ms
Interruptions: 1
Overall Sentiment: AGENT=1.9, CUSTOMER=0.9
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/08/d2cca993-7ef3-4e77-91d9-02ff6065fc81_20250108T17:31_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, my name is [PII], and my initial to the last name is [PII]. I'm calling from provider's office to check on the current status.
[AGENT][POSITIVE] OK, I'd love to help you with claim status today, Ms. [PII], and do you mind if I start off by grabbing a quick call back number from you?
[CUSTOMER][NEUTRAL] Yeah, my callback number is [PII].
[AGENT][NEUTRAL] Thank you. And may I have that member's policy number, please?
[CUSTOMER][NEUTRAL] Yeah, sure. Uh, before that, I just wanted to confirm you. I have totally 2 clients to check on it. Could you please help me with that?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] And I'm so sorry, could I help you with what? I'm sorry?
[CUSTOMER][NEUTRAL] I have, uh, totally 2 clients to check for it. So the status. Could you please check? Yes.
[AGENT][POSITIVE] Two claims? No worries, I can help you with both of them.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Um, and on that first one, what's the policy number?
[CUSTOMER][NEUTRAL] Yeah, sure. So it's 0245.
[CUSTOMER][NEUTRAL] 7351
[CUSTOMER][NEUTRAL] M. Mike L. Lima 7.
[AGENT][POSITIVE] Thank you so much, and give me 1 2nd to get that policy pulled up and loaded.
[CUSTOMER][POSITIVE] OK, take your time, please.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Can you please verify for me your patient's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, sure. The patient's first name is [PII] and the last name is [PII].
[CUSTOMER][NEUTRAL] And the date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Perfect. I do see [PII] right here and do you have a claim number you're looking to follow up on or are you wanting to search with date of service?
[CUSTOMER][NEUTRAL] Uh, I just wanted to know, uh, check with the data service. I don't have the card number.
[AGENT][NEUTRAL] No worries. What is the date of service for your claim on [PII]?
[CUSTOMER][NEUTRAL] Yeah, uh, so the date of service is [PII], with the total charge, $600 and even.
[AGENT][NEUTRAL] Wonder.
[AGENT][POSITIVE] Perfect thank you so much and would you verify for me please the name of the facility on file?
[CUSTOMER][NEUTRAL] Yeah, sure. It's Pediatrics Medical Group of Florida INC.
[AGENT][POSITIVE] Perfect thank you so much. I do see your claim here it looks like we received your claim on.
[AGENT][NEUTRAL] [PII] and we processed it on [PII]. Your claim number is 3,519,860.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it looks like the claim was denied. The reason stating is that office visits are not covered by the above numbered policy.
[CUSTOMER][NEUTRAL] Yeah, I do see here the claim has been denied. It's been denied for the non-covered charges.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, could you please repeat the denial again?
[AGENT][POSITIVE] Yeah, let me read it over to you again I'm so sorry it says.
[AGENT][NEUTRAL] Office visits?
[AGENT][NEGATIVE] are not covered by the above numbered policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So it's been denied for the office visit, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. Uh, OK, I'll just place this call on hold for a minute. I'll just verify with my side. Bear with me a moment, please.
[AGENT][POSITIVE] No worries, take your time.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Thank you for your patience on being on hold.
[AGENT][POSITIVE] No worries.
[CUSTOMER][NEUTRAL] OK, can we bill the patient, can we bill the patient for this one?
[AGENT][NEUTRAL] Oh, because we're a secondary insurance, we're not allowed to determine patient responsibility.
[CUSTOMER][NEUTRAL] So as this is the secondary insurance, you're not allowed to bill the patient.
[AGENT][NEUTRAL] No, we're not allowed to determine patient responsibility.
[CUSTOMER][NEUTRAL] OK. Is there any
[CUSTOMER][NEUTRAL] Um, any other options?
[AGENT][NEUTRAL] I APL cannot make any decisions in that matter. That's going to be up to the provider group.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] OK. OK. Can I get the call reference number?
[AGENT][NEUTRAL] Yeah, you bet you. It's going to be my name [PII], first [PII] and today's date.
[CUSTOMER][NEUTRAL] Uh, could you please spell it again? It's [PII]
[AGENT][NEUTRAL] Yes, sorry, [PII]
[CUSTOMER][NEUTRAL] Mhm. Initial of the last name, please.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, and this date, right?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK. Thank you, [PII]. Uh, and I do have one more client. Bear with me a moment, please. Let me check that one for you also.
[AGENT][POSITIVE] Absolutely.
[CUSTOMER][NEUTRAL] Yeah, bear with me a moment.
[CUSTOMER][NEUTRAL] Thank you for your patience on being on hold. Um, I, uh, I have uh
[CUSTOMER][NEUTRAL] Clarification in the previous one. Could you please help me with that?
[AGENT][POSITIVE] Yeah, back on the previous one how can I help you with that?
[CUSTOMER][NEUTRAL] Yeah. Uh, you said the claim has been denied for non-covered for the above number of policy, right?
[AGENT][NEUTRAL] It says office visits are not covered by the above numbered policy.
[CUSTOMER][NEUTRAL] Office visits are not covered. OK. So, is this for uh covered by the provider site?
[AGENT][NEUTRAL] What do you mean?
[CUSTOMER][NEUTRAL] Just a moment, please.
[CUSTOMER][POSITIVE] OK. OK, I got it. Thank you for that. OK, I'll just go to the next one. Sorry for that o[PII].
[AGENT][POSITIVE] No worries.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, bear with me moment. Let me
[CUSTOMER][NEUTRAL] Go to the next one.
[CUSTOMER][NEUTRAL] Yeah, I'm gonna do the next data. Do you, do you want the claim number?
[AGENT][NEUTRAL] Um, for the next one, yeah, if you have that claim number handy I can start there for you.
[CUSTOMER][NEUTRAL] Uh, yeah, just a moment. Let me check here. Uh, is there any claim number?
[CUSTOMER][NEUTRAL] I'm sorry, I don't have the claim number for this one.
[AGENT][POSITIVE] No worries, we can start with that policy number instead.
[CUSTOMER][NEUTRAL] Yeah, OK. So the policy ID number is 02480036.
[AGENT][POSITIVE] Perfect. Hang tight while that pulls up.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] All righty. And can you verify for me, please, your patient's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, sure. The patient's first name is [PII] and the last name is [PII]. And the date of birth, [PII].
[AGENT][POSITIVE] Perfect, thank you so much and
[AGENT][NEUTRAL] Let me see what is the date of service?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] Perfect, thank you.
[AGENT][NEUTRAL] All right, I.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] I have your claim here. It looks like your claim was reported on 6-13-2024. It was processed on the following day, 6-14-2024, and your claim number is going to be 3469011.
[AGENT][NEUTRAL] And it looks like this claim denied with the same reason, it's going to say that office visits are not covered by the above numbered policy.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so, so it's for the same denial, right?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. OK. I'll just, please just call on hold for a minute.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, I have to clarify it again. Um, apologies. I'll just, yeah, thank you.
[AGENT][POSITIVE] No worries.
[CUSTOMER][POSITIVE] Thank you for your patience on being on hold.
[AGENT][POSITIVE] No worries.
[CUSTOMER][POSITIVE] I do really appreciate
[CUSTOMER][NEUTRAL] Yeah, um.
[CUSTOMER][NEUTRAL] OK, can you take this claim back for the process as the
[CUSTOMER][NEUTRAL] Can you hear me?
[AGENT][NEUTRAL] I'm so sorry. I thought you were going to say more, um, so I'm so sorry, we, if you want to appeal the claim, you can submit an official appeal, um.
[CUSTOMER][NEUTRAL] No, this is.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, can I get a copy of UB?
[AGENT][POSITIVE] Yeah absolutely let me.
[AGENT][NEUTRAL] Get that pulled up.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, can you please send it through mail, mailing, sorry, can I please send it through the fax?
[AGENT][NEUTRAL] Yes, I can fax it. I'm just waiting for it to load.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] Alright, and would you like me to make that attention to you, [PII] or attention to the patient account number?
[CUSTOMER][NEUTRAL] My attention to my name.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And give me 1 2nd.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Alright, and what is the fax number we're sending that to?
[CUSTOMER][NEUTRAL] Yeah, uh, it's [PII].
[AGENT][NEUTRAL] Alright, I have um [PII] as the fax, is that correct?
[CUSTOMER][NEUTRAL] Yes, uh, I need the fax for the previous claim also. Can you please send it for the previous one and the current one?
[AGENT][NEUTRAL] Um, yep, you're just gonna have to give me a couple of minutes because I've already exited out of the previous one.
[AGENT][NEUTRAL] Um,
[CUSTOMER][POSITIVE] Yeah, take your time, please. No problem.
[AGENT][POSITIVE] No worries. All right, so I'm hitting send on this first one.
[AGENT][NEUTRAL] And then
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Hang tight while I find.
[AGENT][NEUTRAL] The other one for you.
[AGENT][NEUTRAL] I'm just waiting for that fax box to load for this one, but I'm almost done.
[CUSTOMER][POSITIVE] OK, take your time, please. No problem. No worries.
[AGENT][NEUTRAL] Alright, and I just hit send on that other EOB, so the both of those between the two of them, they typically take 5 to 15 minutes to come through, so hopefully you have those pretty shortly. And then is there anything else I can do to help you, Ms. [PII]?
[CUSTOMER][NEUTRAL] No, that's all from this, uh, my side, and the call reference is going to be the same for this one also, your name and followed by the date, right?
[AGENT][POSITIVE] Yep you bet you.
[CUSTOMER][POSITIVE] Yeah, thank you, thank you Eli that so from my side. Have a nice day.
[AGENT][POSITIVE] You too, Miss [PII], thanks for calling APL you take care.
[CUSTOMER][POSITIVE] Thank you have a nice day you too.
[AGENT][NEUTRAL] You too bye bye.