AccountId: 011433970860
ContactId: e02abb83-46ee-4ba0-b21d-b9e65067f6d3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 773380 ms
Total Talk Time (AGENT): 188489 ms
Total Talk Time (CUSTOMER): 204435 ms
Interruptions: 5
Overall Sentiment: AGENT=1, CUSTOMER=-0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/30/e02abb83-46ee-4ba0-b21d-b9e65067f6d3_20250130T20:43_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hello, this is uh [PII]. I'm calling from the provider's office. I'm looking for the claim status.
[AGENT][NEUTRAL] Sure, Mr. [PII], I can assist you with claim status. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, yes, just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you, one moment.
[AGENT][NEUTRAL] OK, right, and um may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Uh, it's 02049543.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Uh [PII] is the name of the patient and uh
[CUSTOMER][NEUTRAL] [PII] is the date of birth.
[AGENT][NEUTRAL] OK, and may I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Uh, date of service is November 11, 2024. And the uh bill amount is, uh, just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 369 dollars.25 cents.
[AGENT][NEUTRAL] OK. So, that is November 11 of 2024, correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you. And for future, you can check claim status online through our website at [PII] and that's just optional.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And uh let me pull this up one moment.
[AGENT][POSITIVE] Oh nice.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Hey
[AGENT][NEUTRAL] OK, I'm, I'm waiting on the system, bear with me.
[CUSTOMER][POSITIVE] Just take your time.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Even
[AGENT][NEUTRAL] OK, so we process the claim on [PII] and we send a benefit amount of $7.69 to the provider.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. Uh, but actually,
[AGENT][NEUTRAL] OK, the code E13 uh-huh.
[CUSTOMER][NEUTRAL] Yes, there is a code E0431.
[CUSTOMER][NEUTRAL] And uh we received the denial on that one, yes.
[AGENT][NEUTRAL] That's the
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] No, that's the one we pay. 04 0431 is the one we pay $7.69. The one that it was denied was E1390. The E13190 was denied because outpatient benefits for the calendar year was met. So with the payment of that $7.69 she already exhausted all her benefits.
[CUSTOMER][NEUTRAL] Uh, not
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, but actually, I can see in my system it shows the exact opposite of this one because uh the payment is made for the uh code A1390.
[CUSTOMER][NEUTRAL] And deniallo E 0431. Can you please recheck your system for this one?
[AGENT][NEUTRAL] I can send you a copy of the EOB so you can fix your system because I'm looking at the EOB.
[CUSTOMER][NEUTRAL] OK, uh, just a moment, let me check the A also.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh, actually, we didn't receive the UV for from your side. Can you please send me your passport UV?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, I can fax you a copy. What is the fax number?
[CUSTOMER][NEUTRAL] Yes, I'm sharing with you just a moment. Fax number is [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, um, [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Do you mind holding for me while I send this out to you right now while I got you on the line? OK.
[CUSTOMER][NEUTRAL] And the
[CUSTOMER][NEUTRAL] Sure. Sure, sir. Yes.
[AGENT][POSITIVE] Thank you. One moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for me. OK, I went ahead and send that over to you. It should be there in a few minutes. Is there anything else I may help you with today?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, yes, actually, just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And my and they uh as you can see that the uh the denial code was E1 uh which was that one.
[AGENT][NEUTRAL] The denial one is E1390.
[CUSTOMER][NEUTRAL] 39. OK. I suppose that's the oxy related equipment related to the oxygen and uh you should get the payment for 36 months.
[CUSTOMER][NEUTRAL] The rental, uh, it's a rental item and it's for 364.
[AGENT][NEUTRAL] I'm, I'm sorry, um.
[CUSTOMER][NEUTRAL] And we received only for the
[AGENT][NEUTRAL] Can you repeat? Because I'm not, I'm not really understanding. Mhm.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Actually, yes. OK. Uh, there's a rule that in the oxygen item, we can get the payment for 36 rental and uh we only received the payment for only 12 months.
[CUSTOMER][NEUTRAL] So can you please recheck that uh what will be the rental period for this item?
[AGENT][NEUTRAL] That's not something we determine. Um, we have a, um, this member has a secondary supplemental plan to the major medical with us. So what we do is we go to the major medical explanation of benefits. We see how much they apply towards the deductible, co-payment and co-insurance, and that's when we see how much we need to cover.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] In this case, the only amount that the member had available at the time that we received the claim was $7.69 and that's the reason we only sent $7.69 and the rest was denied because she don't have any other benefits available for this type of product or type of service because she already exhausted her benefit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][POSITIVE] Not to worry. OK. OK. So can you please give me your name and uh your call reference number so I can just get the call and thank you for the information.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You're welcome. My name is [PII]. That's [PII], the last initial.
[CUSTOMER][NEUTRAL] Sorry.
[CUSTOMER][NEUTRAL] Sorry, I was not hearing. Can you please uh repeat your name again?
[AGENT][NEUTRAL] That's [PII]. Last initial is [PII].
[CUSTOMER][NEUTRAL] Well.
[CUSTOMER][NEUTRAL] 10.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] And the reference number is?
[AGENT][NEUTRAL] We don't have reference numbers you can use my name in today's date.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] To date, OK. Thank you and have a good day.
[AGENT][POSITIVE] You as well, Mr. [PII], and thank you for calling ATL. Bye-bye.