AccountId: 011433970860
ContactId: e533397f-1d60-4e73-8f94-60907038876a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 319630 ms
Total Talk Time (AGENT): 120087 ms
Total Talk Time (CUSTOMER): 89340 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/06/e533397f-1d60-4e73-8f94-60907038876a_20250306T17:20_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello, [PII]. I'm [PII]. I'm checking on claims. Could you please help me with that?
[AGENT][NEUTRAL] Sure, I can definitely help you with the claims and can you repeat your name for me please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] One claim.
[AGENT][NEUTRAL] Alright and may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] One minute, please. Uh, it's 023.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 58091.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, it's uh [PII] Date of birth would be [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. May I have the date of service for the claim?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, it's 10 level 24.
[AGENT][NEUTRAL] And the total bill amount?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] $902 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yeah, uh, it's Northern Duchess Hospital.
[AGENT][NEUTRAL] All right, so I'm showing to receive the claim on [PII].
[AGENT][NEUTRAL] The claim number is 3531061.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The covered diagnostic benefits are limited to MRI, CT scan, and colonoscopy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] This is um
[AGENT][NEUTRAL] The diagnostic testing that was completed is not covered under the policy.
[CUSTOMER][NEUTRAL] OK. Allow me a moment.
[CUSTOMER][NEUTRAL] So, like, uh, this diagnosis code is not covered like only CT scan and MRI are covered under the patient plan, is that what you're saying?
[AGENT][NEUTRAL] Correct, MRI, CT scans, and colonoscopy are the only diagnostic covered on this policy.
[CUSTOMER][NEUTRAL] OK, fine. Uh, so can we bill these charges to the patient?
[AGENT][NEUTRAL] Um, so we don't determine patient responsibility because we're not the major medical insurance. It would just be whatever your procedures are for outstanding or remaining balances.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So we have, we can bill, right? Uh, it's uh up to us, so like we can bill the patient or we can adjust the charges, that's it, right?
[AGENT][NEUTRAL] So, to answer your question, APL does not determine patient responsibility, so I cannot tell you to bill or to however to handle it. It would be whatever your policy is for outstanding balances or remaining balances. We just can't determine that for you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Fine, uh, what's the timely filing to, uh, bill patient? I'm sorry, what's the timely filing to send an appeal?
[AGENT][NEUTRAL] Um, there's 180 days from the denial date.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And actually, uh, we didn't receive the explanation of benefits for this one. So could you please uh fax the UB?
[AGENT][NEUTRAL] Sure, what's a good fax number for you?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] And should that be to attention, [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And that was [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Alrighty, so I'll go ahead and send this over to you now. Was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] me.
[CUSTOMER][NEUTRAL] Nothing else. Please help me with the call reference number and I do apologize. I didn't get your name. Could you please help me with that again?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name, which is [PII] The first initial to my last name is [PII], and then today's date.
[CUSTOMER][POSITIVE] Thank you, [PII]. Thank you. Thanks a lot for helping with this one. I'm done with the missions. Thank you. Have a nice day.
[AGENT][POSITIVE] You're welcome, [PII], and thanks for calling APL. Have a great day. Bye-bye.