AccountId: 011433970860
ContactId: eec38f2d-0363-4a09-a7c2-add65b298aed
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1386359 ms
Total Talk Time (AGENT): 243061 ms
Total Talk Time (CUSTOMER): 351135 ms
Interruptions: 4
Overall Sentiment: AGENT=0, CUSTOMER=1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/16/eec38f2d-0363-4a09-a7c2-add65b298aed_20250516T19:40_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. May I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling for provider to check on claim status. Please note this call will be monitored and recorded for quality and training purposes.
[AGENT][NEUTRAL] OK, I can verify claim status for you, [PII]. Uh, what is the policy number, please?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] That is 0166.
[CUSTOMER][NEUTRAL] 973 5.
[AGENT][NEUTRAL] Thank you. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] Yes, that is [PII].
[AGENT][NEUTRAL] OK. And verify the patient's name, date of birth.
[CUSTOMER][NEUTRAL] Sure. The member name is [PII] [PII], and the date of birth is [PII].
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Sure
[AGENT][NEUTRAL] OK, and what was the date of service and amount of the charge?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The date of service is [PII], and the total bill amount is on the claim end. Just a moment, it is loading.
[CUSTOMER][NEUTRAL] Yes, that is $309 even.
[AGENT][NEUTRAL] OK, and what was the balance after primary?
[CUSTOMER][NEUTRAL] Yes, uh, that is $35 even.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you're calling from?
[CUSTOMER][NEUTRAL] Sure. Like the street?
[AGENT][NEUTRAL] What is the name of the provider's office?
[CUSTOMER][NEUTRAL] Sure. That is [PII].
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] This is for dental.
[AGENT][NEUTRAL] Or from medical.
[CUSTOMER][NEUTRAL] Uh, medical.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Medical.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] And the name of the provider's office again?
[CUSTOMER][NEUTRAL] Sure. That is [PII].
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Sorry, give me one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm showing 2 claims for that office for that data service. Can you verify the procedure codes for me, please?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The procedure code is 9921436415.
[CUSTOMER][NEUTRAL] 68, sorry, 38,510.
[CUSTOMER][NEUTRAL] 1036 F. 1126 F. 1159F. 1160 and 1170 and 3008F. 3074 F. 3078F. and uh 3725F. And the last one is 1000 F.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] I'm showing that claim process says office visits are not covered per the policy, and for the other codes, this policy does not provide benefits for services which no charges were incurred.
[CUSTOMER][NEUTRAL] OK. Like, can I get to know the uh when the claim was received, that I received it?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Um, the claim was received on [PII], processed on [PII].
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][NEUTRAL] Oh, I'm sorry, [PII], process on [PII] at [PII].
[CUSTOMER][NEUTRAL] OK, just a moment.
[CUSTOMER][NEUTRAL] Like, uh, uh, this claim is denied. There is no payment?
[AGENT][NEUTRAL] Yes, correct. It processes office visits are not covered, nor procedures where there is no charges that incurred.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. Like, could you please uh confirm the, uh, denialization? Is it like, um,
[CUSTOMER][NEUTRAL] OK, just a moment.
[CUSTOMER][NEUTRAL] Can I get to know the exact denial reason because uh it is for the documentation.
[AGENT][NEUTRAL] Well, I just gave you the exact denial reason. Office visits are not covered, and charges that, uh, charges that don't have, uh, well, procedures that don't have a charge that incurred is not covered under the policy.
[AGENT][NEUTRAL] So there are charges on this claim.
[CUSTOMER][NEGATIVE] It is not covered as well.
[AGENT][NEUTRAL] Per the patient's policy with our company, it does not cover office visits, and the other charges did not have charges to them. There was no charges incurred, so there's no benefits payable.
[CUSTOMER][NEUTRAL] Yes, sorry.
[CUSTOMER][NEUTRAL] Like, uh, just to confirm for the CID code 99214 as per the member contract with your payer.
[AGENT][NEUTRAL] Per the patient's policy, office visits are not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, just a moment.
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Just to confirm, it is non-covered as per the member plan, right? As per it is office.
[AGENT][NEGATIVE] Per the patient's policy with our company, it is not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Uh, can I put you on a brief hold just one minute?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] Thank you so much. Just one.
[CUSTOMER][POSITIVE] Just a moment, ma'am. I'm so sorry for the delay.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Just a moment, ma'am.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][POSITIVE] Thank you so much for your patience, ma'am. Actually, I have one more thing. Could you please help me with it?
[AGENT][NEUTRAL] For the same patient or a different patient?
[CUSTOMER][NEUTRAL] A different patient.
[AGENT][NEUTRAL] OK, one moment, please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and what's next policy number?
[CUSTOMER][NEUTRAL] Sure. The policy ID is
[CUSTOMER][NEUTRAL] Just it is loading. I'm so sorry. There is some system issue.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you for understanding. Just.
[CUSTOMER][NEUTRAL] Yes, that is 02.
[CUSTOMER][NEUTRAL] 107801.
[AGENT][NEUTRAL] OK, and the patient's name, date of birth?
[CUSTOMER][NEUTRAL] Sure. That is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] OK, data service amount on the charge.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] The date of service is [PII], and the total amount on the claim is
[CUSTOMER][NEUTRAL] $555 even.
[AGENT][NEUTRAL] OK, and the balance after primary?
[CUSTOMER][NEUTRAL] Sure. That is $20 even.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] And it's the same provider?
[CUSTOMER][NEUTRAL] Uh, just a moment. I'm just double checking that.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] So sorry, just a minute. Yes, it is the same provider.
[AGENT][NEUTRAL] OK, and I'm showing this claim also processes office visits are not covered, and this policy does not provide benefits for services in which no charges were incurred.
[CUSTOMER][NEUTRAL] OK, like, uh, it is also like the previous thing?
[AGENT][NEUTRAL] Yes, office visits are not covered, nor the policy cover any procedures where charges were not incurred.
[CUSTOMER][POSITIVE] Thank you sir.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It is as per the uh member policy, right, with your company.
[AGENT][NEUTRAL] Per, yes, it's gonna be per the patient's policy with our company. It is not covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much. Can I get the, uh, like the receipt date and the dinner date?
[AGENT][NEUTRAL] Received [PII] process on [PII].
[CUSTOMER][POSITIVE] Thank you so much. And also, can I get the claim number?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure. Claim number 3593654.
[CUSTOMER][POSITIVE] Oh, I'm so sorry. Just a minute.
[CUSTOMER][NEUTRAL] And also, can I get the claim number for the previous one? I just forgot to ask that. I'm so sorry.
[AGENT][NEUTRAL] 358-095-7.
[CUSTOMER][POSITIVE] Thank you so much for that one. Just a moment, ma'am.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm sorry. Just give me one minute.
[CUSTOMER][POSITIVE] Thank you so much for your patience, ma'am. Just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 2358045.
[CUSTOMER][NEUTRAL] I'm just checking the summary. Just a moment.
[CUSTOMER][POSITIVE] It's loading. I'm so sorry, just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] As per checking here, uh, ma'am, thank you so much for your patience. Like, uh, previously, we got paid for the CPT code.
[CUSTOMER][NEUTRAL] Uh, could you please double check and send the claim back for you.
[AGENT][NEUTRAL] For the same patient?
[AGENT][NEUTRAL] No, because the policy doesn't cover office visits, so I will not send a request back for review. Can you give me another data service for this patient where you show we pay for that office visit before?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] I'm just checking for the details of this which is previously paid system.
[CUSTOMER][NEUTRAL] OK. As per checking for the previous member, [PII], like on the data service [PII], uh the it got paid for the CPT code 99214.
[AGENT][NEUTRAL] And what's that policy number for that patient?
[CUSTOMER][NEUTRAL] And also, I'm checking for this number also.
[CUSTOMER][NEUTRAL] Uh yes. Uh,
[CUSTOMER][NEUTRAL] That is 01669735.
[AGENT][NEUTRAL] And that patient's name again?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and what was the date of service?
[CUSTOMER][NEUTRAL] Uh sure. The date of service is [PII].
[AGENT][NEUTRAL] And you said that you should be paid on this claim?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] But do you have a claim number or a check number where you show we paid on that claim?
[CUSTOMER][NEUTRAL] Yes, I'm just checking for that only. Just a moment.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Because I don't show we received a claim for the patient for the data service.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][POSITIVE] OK. Just a minute. I'm just checking for that, uh, just a moment. I'm so sorry for the delay.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] I'm just checking, ma'am. Just, sorry for the delay.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEGATIVE] I'm not able to find the check number.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Because.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sorry, I'm like, I'm not able to get the same number.
[AGENT][NEUTRAL] And like I said, I don't show we received a claim for the patient for that data service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And last 11 more time, I will just double check with that.
[AGENT][NEUTRAL] For a different patient or the same patient, you're gonna check for the next one?
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Uh, uh, for the same patient only, like, uh, is it paid on any other date of service? I'm just checking for that.
[CUSTOMER][NEUTRAL] OK. Sorry for that. So I'm not getting any.
[CUSTOMER][NEUTRAL] Uh, like, I'm not getting any claim number or the check number, so sorry for that. And thank you so much for providing all the details. And can I get the call reference number for this call?
[AGENT][NEUTRAL] Uh, we don't give reference numbers. If you like, you may use my name in today's date and it's [PII].
[CUSTOMER][POSITIVE] OK. Thank you so much for your assistance, [PII], and have a great day and happy weekend.
[AGENT][POSITIVE] You're welcome. Mhm, thanks for calling APL bye.
[CUSTOMER][POSITIVE] Thank you. Bye-bye.