AccountId: 011433970860
ContactId: e2ad4db1-3008-4352-9c7f-0527e7b64530
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 476010 ms
Total Talk Time (AGENT): 167853 ms
Total Talk Time (CUSTOMER): 109481 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/16/e2ad4db1-3008-4352-9c7f-0527e7b64530_20250116T19:27_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII]. I'm calling for
[CUSTOMER][NEUTRAL] Orange care physician partners of Florida to check the status of the claim. Please note this call will be monitored and recorded for quality and training purposes.
[AGENT][POSITIVE] OK, well, I'll be more than happy to assist you with the claim status, [PII], and how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Only one claim.
[AGENT][NEUTRAL] OK, may I have a good contact number in case we're disconnected and the member's policy number?
[CUSTOMER][NEUTRAL] [PII], no extension.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And the policy number whenever you're ready.
[CUSTOMER][NEUTRAL] 02444790 M for mama, L for Lima, 8.
[AGENT][NEUTRAL] Thank you for that. And [PII], can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Member's first name is [PII], [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bill for the claim you like me to check on?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII], the date of service.
[AGENT][NEUTRAL] OK, and the total bill amount?
[CUSTOMER][NEUTRAL] One second, uh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] $70.01.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And what is the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Orange Care Physician Partners of Florida.
[AGENT][NEUTRAL] OK, and I'm showing that the claim was received on [PII].
[AGENT][NEUTRAL] That claim number is 352.
[AGENT][NEUTRAL] 5508.
[CUSTOMER][NEUTRAL] Just a 2nd. 352.
[AGENT][NEUTRAL] 5508.
[CUSTOMER][NEUTRAL] Claim received date.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] It was received on [PII].
[CUSTOMER][NEUTRAL] Processed it, please.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And are you ready for the decision?
[CUSTOMER][NEUTRAL] Allowed amount $50. Paid amount, uh, allowed unpaid amount is $50 with no patient responsibility.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Would you like the decision for the claim? OK, so the claim was denied.
[CUSTOMER][POSITIVE] Yes, I'm ready.
[AGENT][NEUTRAL] Because the benefits are payable only if the major medical insurance provider provides benefits.
[AGENT][NEUTRAL] So if you have an explanation of benefits that shows their major insurance has paid towards this claim, just submit that explanation of benefits and we'll continue processing.
[CUSTOMER][NEUTRAL] You need the primary UB?
[AGENT][NEUTRAL] Do you have an explanation of benefits that shows the major medical insurance has paid towards this claim?
[CUSTOMER][NEUTRAL] Yes, we are the secondary, primary.
[CUSTOMER][NEGATIVE] Different pair, but it was not that paid, it got denied.
[AGENT][NEUTRAL] OK, the question, um, so this is what I'm asking, for the primary insurance, do you have an explanation of benefits that shows they paid to this claim or it shows that they did not?
[CUSTOMER][NEUTRAL] Day and night.
[AGENT][NEUTRAL] OK, so that's what our explanation of benefits is saying because primary did not apply anything, we as second cannot.
[AGENT][NEUTRAL] So that's why this claim was denied.
[CUSTOMER][NEUTRAL] OK. Primary.
[CUSTOMER][NEUTRAL] Primary not paid the claim means, uh, primary denied the claim means, secondary also denied the claim, correct?
[AGENT][MIXED] Correct. The secondary can't be applied if primary is not.
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] Could you please provide to me the correct mailing address?
[AGENT][NEUTRAL] Our claim's mailing address is [PII].
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yes, please. [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] Attention
[AGENT][NEUTRAL] APL claims department.
[CUSTOMER][NEUTRAL] Could you please provide to me the timely filing limit?
[AGENT][NEUTRAL] To submit a claim?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, there's no timely filing limit to submit a claim as long as the policy is active on the data service, you can submit at any time.
[AGENT][NEUTRAL] Or are you speaking in reference to an appeal?
[CUSTOMER][NEUTRAL] Like not
[CUSTOMER][NEUTRAL] Uh, correct the claim timely filing limit.
[AGENT][NEUTRAL] OK, again, there's no timely filing limit as long as the policy is active, you can file the claim at any time.
[CUSTOMER][NEUTRAL] No, payer ID please.
[AGENT][NEUTRAL] 60801.
[CUSTOMER][NEUTRAL] Could you please provide me your name?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Could you please provide me your name?
[AGENT][NEUTRAL] My name is [PII] The first [PII] my [PII] name [PII].
[CUSTOMER][NEUTRAL] Reference number.
[AGENT][NEUTRAL] Um, there's no call reference number, but you can use my name and today's date.
[CUSTOMER][POSITIVE] Thank you, [PII].
[AGENT][POSITIVE] You're welcome. Was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] Have a great day.
[CUSTOMER][NEUTRAL] No, it's clear.
[AGENT][POSITIVE] All right, thanks for calling APL. Have a great day.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Bye bye.