AccountId: 011433970860
ContactId: eac6b526-7862-4831-86a8-ae3bc291d06b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 605500 ms
Total Talk Time (AGENT): 222012 ms
Total Talk Time (CUSTOMER): 175149 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/04/eac6b526-7862-4831-86a8-ae3bc291d06b_20250604T19:09_UTC.wav
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[AGENT][NEUTRAL] Afternoon, thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. May I get your name again? I didn't get it.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII] and I'm calling from the provider's office called Mount Sinai Hospital Medical Center. Uh, uh, I've got a claim that has been.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh, actually I've got a claim that has been denied, uh, due to, uh, 96% over uncovered charges. So can you explain me a bit about that?
[AGENT][NEUTRAL] OK, so you have a question on the denied claim, the reason for the denial?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, I can help you with that, [PII]. And what is your callback number?
[CUSTOMER][NEUTRAL] Yes, sure, give me a moment.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Say that again.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you. And the member's policy number, please.
[CUSTOMER][NEUTRAL] [PII], give me a moment.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] 024.
[CUSTOMER][NEUTRAL] 77
[CUSTOMER][NEUTRAL] 690.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][POSITIVE] Take your time.
[AGENT][NEUTRAL] And any information that I did provide for you [PII] will be a verification of benefits and not a guarantee of payment. What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] That's [PII] and date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the date of service and total bill amount?
[CUSTOMER][NEUTRAL] Uh, data service is [PII] and bill amount is uh.
[CUSTOMER][NEUTRAL] 482.
[AGENT][NEUTRAL] I'm sorry, what is the bill amount? 126?
[CUSTOMER][NEUTRAL] 126
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] No, no, it's 482.6 cents.
[AGENT][NEUTRAL] $482.06. Is that correct?
[CUSTOMER][NEUTRAL] 26 cents. 26 cents.
[AGENT][NEUTRAL] And what is the claim number?
[CUSTOMER][NEUTRAL] Uh, just give me a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's 360.
[CUSTOMER][NEUTRAL] 1712.
[AGENT][NEUTRAL] Mm, I'm sorry. What was your claim number?
[CUSTOMER][NEUTRAL] It's 360.
[CUSTOMER][NEUTRAL] 17
[CUSTOMER][NEUTRAL] 12.
[AGENT][NEUTRAL] OK, that's not a valid claim number.
[AGENT][NEUTRAL] The correct claim number is 3601476.
[CUSTOMER][NEUTRAL] So what
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the reason
[CUSTOMER][NEUTRAL] I guess, uh,
[AGENT][NEUTRAL] Yes, I'm not yeah, that's not a valid claim number.
[CUSTOMER][NEUTRAL] I got the valid claim number so can you give?
[AGENT][NEUTRAL] That you have.
[AGENT][NEUTRAL] And the reason for the denial.
[CUSTOMER][NEUTRAL] No, I don't have it, but you can.
[AGENT][NEUTRAL] Yes, sir. I just gave that to you. 360-1476.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] It's the correct claim number.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And the reason for the.
[CUSTOMER][NEUTRAL] And the reason for denial.
[AGENT][NEUTRAL] Uh-huh. states covered diagnostic benefits are limited to MRR.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] An MRI.
[AGENT][NEUTRAL] A CT
[AGENT][NEUTRAL] A colonoscopy.
[AGENT][NEUTRAL] Other diagnostic testing is not covered under this policy.
[CUSTOMER][NEUTRAL] Oh I see.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] And see
[CUSTOMER][NEUTRAL] Can you just be a bit slow because I need to note it down.
[CUSTOMER][NEUTRAL] To cover diagnosis.
[CUSTOMER][NEUTRAL] Then.
[AGENT][NEUTRAL] No, covered?
[AGENT][NEUTRAL] Diagnostic.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Benefits
[CUSTOMER][NEUTRAL] St
[AGENT][NEUTRAL] are limited to.
[AGENT][NEUTRAL] Number one
[AGENT][NEUTRAL] MRI
[AGENT][NEUTRAL] 2 CT scan.
[AGENT][NEUTRAL] Number 3, colonoscopy.
[CUSTOMER][NEUTRAL] The 3 colonos.
[AGENT][NEUTRAL] Uh-huh. Then after that, it states.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Let's see
[AGENT][NEUTRAL] Other
[CUSTOMER][NEUTRAL] And after that it is.
[AGENT][NEUTRAL] After the word colonoscopy, the next sentence is other diagnostic testing.
[CUSTOMER][NEUTRAL] I do.
[AGENT][NEGATIVE] Is not covered.
[CUSTOMER][NEUTRAL] Testing
[AGENT][NEUTRAL] Under this policy.
[AGENT][NEUTRAL] Therefore,
[CUSTOMER][NEUTRAL] C
[AGENT][NEGATIVE] No benefits.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] are payable.
[AGENT][NEUTRAL] For this date of service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, would that be all?
[AGENT][NEUTRAL] Yes sir, it is.
[CUSTOMER][NEGATIVE] And [PII], one thing more, what should be the next step in order to resolve this because I don't think so that you're gonna be be paying for it.
[AGENT][NEUTRAL] That's correct. At this time, the claim was denied. You do have 180 days to file an appeal.
[AGENT][NEUTRAL] From the date of the decision and that must be submitted in writing and sent to our appeals department.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So it's 180 days to file an appeal.
[AGENT][NEUTRAL] From [PII]. That is correct.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Why is it [PII]?
[AGENT][NEGATIVE] I didn't say [PII]. I said [PII]. That is the date that it was reviewed and processed and denied.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I did
[CUSTOMER][NEUTRAL] So, uh, the only option that I have is to send an appeal.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] And it is [PII] and it is 180 days from [PII].
[CUSTOMER][NEUTRAL] And I guess we are in the appeal.
[CUSTOMER][NEUTRAL] Time frame right?
[AGENT][NEUTRAL] Yes sir.
[CUSTOMER][NEUTRAL] Yes, so may I have the appeal address?
[CUSTOMER][NEUTRAL] Or it's going to be the same address that's uh it's mentioned in the form. Let me just.
[CUSTOMER][NEUTRAL] Uh, [PII] that it's IMC IMA INC [PII]. Uh, is it correct or do you want me to send an appeal to some other.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Uh, actually, for the appeal would be, yes, the address that you would send the appeal to is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] That is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Hello
[CUSTOMER][NEUTRAL] City
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] The zip code is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And send it to attention appeals department.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So I guess we are done with this uh uh case and appeal will be sent on this address.
[AGENT][NEUTRAL] OK, and
[AGENT][NEUTRAL] And if you need a copy of that explanation of benefits, [PII], with the remarks that I read to you, you can print that by going to our portal, which is located at [PII].
[AGENT][NEUTRAL] And is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Uh yes, [PII], that's just the call reference number.
[AGENT][NEUTRAL] Yes, so you would use my name along with today's date.
[CUSTOMER][NEUTRAL] So it's [PII], it's gonna be [PII] and today's date, right?
[AGENT][POSITIVE] Yes, sir. That is correct.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] OK, [PII], I guess that was all that I had.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All right then. Well, it was my pleasure in speaking to you, [PII], and I hope that you have a nice rest of your day and thank you again for calling APL.
[CUSTOMER][NEUTRAL] Um