AccountId: 011433970860
ContactId: f19b633a-b718-4691-858b-db9a2ac84e83
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 896080 ms
Total Talk Time (AGENT): 231036 ms
Total Talk Time (CUSTOMER): 378658 ms
Interruptions: 7
Overall Sentiment: AGENT=0.6, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/27/f19b633a-b718-4691-858b-db9a2ac84e83_20250527T17:47_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] Hello?
[CUSTOMER][NEUTRAL] Hey [PII], this is [PII]. I've got a provider on the back line that's wanting to get claim status on the insured.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's policy number 18,520.
[CUSTOMER][NEUTRAL] 40. You're speaking to [PII].
[CUSTOMER][NEUTRAL] And she, um, the insured's been verified. [PII]'s callback number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And are you saying [PII]?
[CUSTOMER][NEUTRAL] And he said it was a claim.
[CUSTOMER][NEUTRAL] [PII], yeah, he said it was a claim, um, it's the provider, a claim from [PII], I believe is what he said. Maybe he said maybe the, uh, not May, [PII], [PII].
[AGENT][NEUTRAL] OK, you can send them through.
[CUSTOMER][NEUTRAL] But he didn't have a claim number.
[CUSTOMER][POSITIVE] All right, here he goes. Thank you.
[AGENT][POSITIVE] All right. You're welcome.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Hi, this is [PII] with um APL customer care, and she said her name was [PII].
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] Alright, and you're needing claim status for date of service [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] [PII]. OK, hold on one second.
[AGENT][NEUTRAL] And what is the total bills?
[CUSTOMER][NEUTRAL] The total bill amount is $59,612.53.
[AGENT][NEUTRAL] OK, here it is, hold on one moment.
[AGENT][NEUTRAL] And just for the call, can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure. The member's last name is [PII] and the first name is [PII] and the date of birth of the member is [PII]. That's [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And I believe I have the um claim here. Hold on one moment.
[AGENT][NEUTRAL] And the provider's office.
[CUSTOMER][NEUTRAL] Yes, yes, I have 888-6031923.
[AGENT][NEUTRAL] Um, can you repeat the, uh, can you provide, I'm sorry, the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yeah, sure. It's FKC VIP Home dialysis.
[CUSTOMER][NEUTRAL] [PII], yes.
[AGENT][NEUTRAL] All right, so I'm
[AGENT][NEUTRAL] So I'm showing the claim was received on [PII].
[CUSTOMER][NEUTRAL] That.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim number is 36039009.
[CUSTOMER][NEUTRAL] 3603909. Is that correct?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] And on which date you, we have received the, the cream?
[AGENT][NEUTRAL] And on [PII]
[AGENT][NEUTRAL] The claim was received on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it processed on [PII]?
[CUSTOMER][NEUTRAL] [PII]. Is that correct?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And the claim was denied because
[AGENT][NEUTRAL] The service was rendered in a place of service that's not covered by the policy.
[CUSTOMER][NEUTRAL] Sorry, can you repeat that? The service was rendered?
[CUSTOMER][POSITIVE] Thank you and may I know
[AGENT][POSITIVE] Yes, it is the service was rendered in a covered.
[CUSTOMER][NEUTRAL] I I.
[AGENT][NEUTRAL] was not rendered, I'm sorry, in a covered place of service. So it was a non-covered place of service. Let me see where it was.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] So can you check for that.
[AGENT][NEUTRAL] So it looks like it's
[AGENT][NEUTRAL] Wherever the dialysis was taken.
[CUSTOMER][NEUTRAL] Can you help me with the, OK, can you help me with the date of uh dinner?
[AGENT][NEUTRAL] Where
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] Again, the claim was denied on [PII].
[CUSTOMER][NEGATIVE] And what was the reason? Can you repeat that? It was denied because of non-covered plus.
[AGENT][NEUTRAL] A non-covered place of service.
[CUSTOMER][NEUTRAL] OK. Non-covered place of service.
[CUSTOMER][NEUTRAL] Can you please elaborate what exactly you required non-covered place of service.
[AGENT][NEUTRAL] So let me see if, so on this claim, it just shows as a facility. So wherever the dialysis was administered, it was not covered by the policy, so the policy can't pay out on it.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so you mean to say that whenever the dialysis is administered, so the policy, the pay, uh, the insurance company is not supposed to pay for that, right? Is that correct?
[AGENT][NEUTRAL] The place of service that where they were that did the dialysis treatment is not covered by the policy. So the policy cannot pay for it because it's not a covered place of service.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, got it, got it. OK, thank you for the information. OK, so for that, can I place your call on hold so that I can uh check, get the details and get back to you.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Thank you for being online, [PII].
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yeah, well, as I can see that for the same dialysis code and previously the date of service was [PII]. The claim was processed and uh.
[AGENT][NEUTRAL] OK, let me take a look at the claim.
[CUSTOMER][NEUTRAL] For the same CPT code. Yeah.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] And that was, uh, [PII].
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] The total bill is 77.
[AGENT][NEUTRAL] The total bills, uh, from what I see 7.
[AGENT][NEUTRAL] 100, hold on, $77,096.50.
[CUSTOMER][POSITIVE] That's correct.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] has not crossed me.
[CUSTOMER][POSITIVE] Yeah of course.
[AGENT][NEUTRAL] So that original claim was received on [PII], claim number 352-0984.
[CUSTOMER][NEUTRAL] All
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Automatic secondary billing from primary to secondary. 352
[AGENT][NEUTRAL] And on October.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] What was the claim number?
[AGENT][NEUTRAL] The claim number is 352-0984.
[CUSTOMER][NEUTRAL] Do with posting.
[CUSTOMER][NEUTRAL] OK. Yes.
[AGENT][NEUTRAL] And hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So may I know the CFT number?
[AGENT][NEGATIVE] And the claim was denied for the same reason. We received it again.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Um, so this claim was denied from APL.
[CUSTOMER][NEUTRAL] OK, this particular claim was also denied for you.
[AGENT][NEGATIVE] Yes, it was denied for APL and then you all resubmitted it in November and that was denied as a duplicate, but it was originally denied because it was a non-covered place of service like this one.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, but when was, uh, and when it was uh resubmitted back to you, then it was processed or it was also again denied?
[AGENT][NEGATIVE] The resubmission was denied as a duplicate.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, so you, uh, what was it just a moment.
[CUSTOMER][NEUTRAL] Can I place your call on hold again for a moment? Thank you.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Thank you for being online. Uh, so I just wanted to confirm, is that the patient's responsibility?
[AGENT][NEUTRAL] Uh, we don't determine patient responsibility because we're not the major medical insurance company. So it'll be whatever your, um, procedures are on outstanding balances or remaining balances.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] So is this claim process in your out of network?
[AGENT][NEUTRAL] No, this is their secondary insurance. There is no network.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] All right. So you mean to say it is a secondary insurance, so there is no out of network. Is that correct?
[AGENT][POSITIVE] Correct, that is what I explained. Yes, sir.
[CUSTOMER][NEUTRAL] Medicare
[CUSTOMER][NEUTRAL] OK, and is it, is it a Medicare plan? MDP Medicare plan.
[AGENT][NEUTRAL] Yes, this is the secondary medical insurance. So yes, this is a medical insurance policy.
[CUSTOMER][NEUTRAL] All right. Uh, just a moment. I just get the details and get back to you. Just give me a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][POSITIVE] Thank you for being online, [PII], and thank you for all the information.
[AGENT][NEUTRAL] You're.
[CUSTOMER][NEUTRAL] Uh, can you please help me with the call reference number?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] Sorry, can you repeat that?
[AGENT][NEUTRAL] Um, the first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] And your last initial is [PII] and your first name is [PII], right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And the today's date is
[CUSTOMER][NEUTRAL] [PII]. That's the call reference number, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][POSITIVE] All right, thank you enough for all the information. I appreciate your help. Have a great day.
[AGENT][POSITIVE] You're very welcome and thanks for calling APL. I hope you have a good day.
[CUSTOMER][POSITIVE] You too. Bye. Thank you.
[AGENT][POSITIVE] Thank you. Bye bye.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] What