AccountId: 011433970860
ContactId: da6cb970-895c-4776-81be-d440cd54c3c9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 529570 ms
Total Talk Time (AGENT): 171940 ms
Total Talk Time (CUSTOMER): 153187 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/25/da6cb970-895c-4776-81be-d440cd54c3c9_20250325T17:16_UTC.wav
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[AGENT][NEUTRAL] APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah, this is [PII] calling to check on claims.
[AGENT][NEUTRAL] I can help you, [PII]. What's the policy number and a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] Um, sure, the policy number is 117.
[CUSTOMER][NEUTRAL] And then 3 consecutive 1 followed by 9.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the callback number is [PII].
[AGENT][NEUTRAL] OK, thank you and what's it?
[CUSTOMER][NEUTRAL] I'm sorry, your name again?
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][POSITIVE] OK thanks.
[AGENT][NEUTRAL] And what is the patient's name or date and date of birth, [PII]?
[CUSTOMER][NEUTRAL] [PII] with the date of birth [PII].
[AGENT][NEUTRAL] OK, thank you and you said you're checking claim status?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] For what date of service?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the total bill amount?
[CUSTOMER][NEUTRAL] $1,162 even.
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Thank you for holding [PII]. So I show that outpatient benefit is not covered under this plan, so no payment was made.
[AGENT][NEUTRAL] And did you have any other questions, [PII]?
[CUSTOMER][NEUTRAL] Um, yeah, so the outpatient service is not covered by the providers contract or the patient plan.
[AGENT][NEUTRAL] It's gonna be the patient's policy.
[CUSTOMER][NEUTRAL] OK, the patient doesn't have all the benefits.
[AGENT][NEUTRAL] OK, so this is an outpatient service. Outpatient services are not covered under the patient's policy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Can I have the patient's plan type, please?
[AGENT][NEUTRAL] It's a hospital indemnity policy.
[CUSTOMER][NEUTRAL] I'm sorry, that's coastal?
[AGENT][NEUTRAL] Hospital, like a hospital?
[CUSTOMER][NEUTRAL] OK. All right. Sorry.
[AGENT][NEUTRAL] The second word is indemnity.
[CUSTOMER][NEUTRAL] All right, in the policy. So for this one, do we have an option to appeal?
[AGENT][POSITIVE] You can appeal it.
[AGENT][NEGATIVE] But it's not covered, so it'll be denied. um, it's same as the claims address it's PO Box.
[CUSTOMER][NEUTRAL] Can I have the mailing address?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII] attention appeals.
[CUSTOMER][NEUTRAL] Do you have a fax number still?
[AGENT][NEUTRAL] Uh, it would need to be mailed.
[AGENT][NEUTRAL] The appeal would need to be.
[CUSTOMER][NEUTRAL] OK, what is the time the filing for an appeal? Yeah, sure, sorry.
[AGENT][NEUTRAL] 180 days from the date of denial and the claim was processed on [PII].
[CUSTOMER][POSITIVE] Thanks I appreciate it. I do have another client to check for today. Can you help me on it?
[AGENT][NEUTRAL] Is it for the same person?
[CUSTOMER][NEUTRAL] It's gonna be a different person.
[AGENT][NEUTRAL] OK, one moment while I document this call, and you can also check claim status online at [PII]. One moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah. OK.
[CUSTOMER][NEUTRAL] Uh, just wanna make sure on the previous one, can we build the patient?
[AGENT][NEUTRAL] We do not determine patients responsibility.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] And the next policy number, please?
[CUSTOMER][NEUTRAL] Um, yeah, sure. That's gonna be 025570537.
[AGENT][NEUTRAL] You have a copy of the card. I think that's one too many numbers.
[CUSTOMER][NEUTRAL] Uh, let me check. One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm, just have that. It's 0, OK, it's 02570537.
[AGENT][NEUTRAL] OK, so we'll remove one of the 5s, and what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah mhm.
[CUSTOMER][NEUTRAL] [PII] and the date of birth [PII].
[AGENT][NEUTRAL] OK thank you [PII] and what is the date of service in charge?
[CUSTOMER][NEUTRAL] [PII] and the charge is $1,273 even.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. So we denied it for a copy of the major medical explanation of benefits. Uh, let me go ahead and give you the claim number.
[AGENT][NEUTRAL] Um, it's 357-550-6.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And I'm showing that this claim was processed.
[AGENT][NEUTRAL] On [PII].
[CUSTOMER][NEUTRAL] OK, and you said, uh, can you repeat the denial? I'm sorry.
[AGENT][NEUTRAL] We need a copy of the major medical explanation EOB.
[CUSTOMER][NEUTRAL] OK, so yeah, we don't have the primary information with us. May I know who's primary?
[AGENT][NEUTRAL] OK, can you reach out to the patient for that information? I mean, are you directly with the provider's office or are you a third party?
[CUSTOMER][NEUTRAL] No, we don't show any primary for the patients at all. We have only one insurance for the member, which is the American Public Life Insurance.
[AGENT][NEUTRAL] Understood, I understand, but are you able to reach out to the patient to get their primary insurance information?
[CUSTOMER][NEUTRAL] OK, so there's no way like you can provide it to us because we have to know before.
[AGENT][NEUTRAL] I can, but I was just asking a question. Is there a way that you can reach out to the patient for their primary information?
[CUSTOMER][NEUTRAL] Yes, of course we can send a letter to find it out.
[AGENT][NEUTRAL] OK, it's AMed is what we show on our file, but you also wanna make reach out to the patient to confirm.
[CUSTOMER][NEUTRAL] OK, can you provide me the member ID of [PII]?
[AGENT][NEUTRAL] I, we don't have their information, ma'am. You would need to get that from the patient.
[CUSTOMER][NEUTRAL] OK, just
[CUSTOMER][NEUTRAL] Just the insurance name is mentioned as [PII] and you don't have the effective date as well.
[AGENT][NEUTRAL] OK, that's a different insurance company and we do not have their information.
[CUSTOMER][NEUTRAL] OK, so during the date of services shows the patient is having primary assignment. That's it, right?
[AGENT][NEUTRAL] That's what our records indicate.
[CUSTOMER][NEUTRAL] OK, that's clear, thank you. Can I please have the call reference number?
[AGENT][NEUTRAL] Mhm. Anything else?
[AGENT][NEUTRAL] It's gonna be my name in today's date.
[CUSTOMER][NEUTRAL] Yeah, [PII], do you have uh information like when the patient has last updated the coordination of benefits?
[AGENT][NEUTRAL] OK, currently I'm showing that that is their primary insurance carrier. If it's different, then you would need to reach out to the patient for confirmation.
[CUSTOMER][POSITIVE] Thank you. Have a nice day. Take care.
[AGENT][POSITIVE] You're welcome. Thank you for calling APL. Have a good day, [PII].
[CUSTOMER][NEUTRAL] You too.