AccountId: 011433970860
ContactId: f245e6c1-3098-4074-bb18-abd5afb29e7d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1545959 ms
Total Talk Time (AGENT): 384137 ms
Total Talk Time (CUSTOMER): 631821 ms
Interruptions: 10
Overall Sentiment: AGENT=1.3, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/f245e6c1-3098-4074-bb18-abd5afb29e7d_20250416T14:21_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], this is [PII] and I'm calling for Kevins. I'm sorry, [PII] MDP. Please be informed that this call is being recorded and monitored for the quality and training purposes. I verified the EOB and this call is made for the additional information about the denial.
[AGENT][NEUTRAL] OK, I can help you with your claim, Ms. [PII], and can you spell out the name of the facility you're calling from for me, please?
[CUSTOMER][NEUTRAL] Yeah. My name is Celine, C as in Charlie, E Echo, L Lima, I ice cream in November, and the name of the facility is Kevin J K or MTPA.
[AGENT][NEUTRAL] OK, and can you spell the name of the facility for me, please, Ms. [PII]?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, sure. It's K as in Kilo, E Echo, V as in Victor, I India in November, J, that is J as in Juliet. Kesler is K kilo, E echo, S E R I Sierra, L Lima, E echo, R for Romeo, M D P A.
[AGENT][POSITIVE] Thank
[AGENT][POSITIVE] Yes, thank you I appreciate you doing that for me and may I please get your callback number just in case the call is disconnected.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] You're very welcome. And the callback number is [PII].
[CUSTOMER][NEUTRAL] [PII]. That's a direct line.
[AGENT][NEUTRAL] Thank you. And then what can I get the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Name of the patient is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is the patient's policy number, please?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, sure. The name of the policy number, I'm sorry, the patient policy number is 02369826.
[AGENT][NEUTRAL] Thank you and can I get the date of service and the charge amount?
[CUSTOMER][NEUTRAL] Uh, OK. It's [PII].
[CUSTOMER][NEUTRAL] And the charge amount is?
[CUSTOMER][NEUTRAL] $318 even.
[AGENT][NEUTRAL] OK, and then what's the charge amount after the primary insurance paid their part?
[CUSTOMER][NEUTRAL] Yeah, that is $318.
[AGENT][NEUTRAL] OK, and you said that you had.
[AGENT][NEUTRAL] an EOB that was denied. Can I please get the claim number?
[CUSTOMER][NEUTRAL] Yeah, sure. The claim number in the EOB is?
[CUSTOMER][NEUTRAL] 3585034.
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold, Miss [PII]. I'll be right back with you OK? I'm gonna look up this claim.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, sure. Yeah, sure.
[AGENT][POSITIVE] Thank you, ma'am.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK, Ms. [PII], thank you very much for holding for me. I do have the claim pulled up. Let me give you the correct policy number.
[AGENT][NEUTRAL] The the good policy number is 251.
[AGENT][NEUTRAL] 8261.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] And you're welcome and the claim was denied because the uh outpatient benefit had been met for the calendar year.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so it, uh it's denied as um
[CUSTOMER][NEUTRAL] Maximum benefit uh payable has met the, has been met, right?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Oh, OK. And the, and the code will be paid only one time, is that right?
[AGENT][NEUTRAL] I'm sorry, what was that question? You can repeat it for me, please?
[CUSTOMER][NEUTRAL] And that code.
[CUSTOMER][NEUTRAL] Yeah, sure, yeah, sure. And the code will be paid only one time as it has reached its um maximum limit. Is that right?
[AGENT][NEUTRAL] Well, it depends on the amount.
[AGENT][NEUTRAL] Of the outpatient benefit, the outpatient benefit amount had been exhausted for the year.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK. Outpatient benefit has been exhausted.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much for that. Mm.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] May I know when did you receive this claim?
[AGENT][NEUTRAL] Uh, let me check for you.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] We received the claim on [PII] and processed it on [PII].
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] Thank you so much for that, just a moment.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] [PII] and [PII]. Thank you. And the timely filing limit is 180 days from the date of denial, right?
[AGENT][NEUTRAL] That's for appeal.
[CUSTOMER][NEUTRAL] Yes, the app here.
[AGENT][NEUTRAL] Yes, that's to appeal. It's 180 days and you will need to send a letter while you are appealing.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mm mm.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][POSITIVE] OK, thank you so much for that and.
[CUSTOMER][NEUTRAL] Uh, the, I'd like to verify the.
[CUSTOMER][NEUTRAL] Timely, I'm sorry, you would like to verify the mailing address as well?
[AGENT][NEUTRAL] Yes, ma'am, that will be [PII] and that is [PII].
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And that is in [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] Hm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much for that.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Hi.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Could you please go ahead, OK, so the policy, OK, it's denied reason is the.
[CUSTOMER][NEUTRAL] Um, OK. Outpatient benefits has been exhausted and it will be paid only one, time and the policy, OK, and the uh the ben benefit payable has been met. Is that right?
[AGENT][NEUTRAL] It's not only paid one time.
[AGENT][NEUTRAL] Once the benefit amount is exhausted for the calendar year then it doesn't pay.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK just a moment.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, but we have received the payment for that code one time. So could you please take the claim back for the process or we should submit for an appeal there.
[AGENT][NEGATIVE] The benefit amount for the calendar year, the amount of money for the year on this policy has been exhausted, so nothing will be paid because there isn't the money's gone now. They've used it up.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you so much for that.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Oh, that's
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Mm OK.
[CUSTOMER][NEUTRAL] Could you please go ahead and provide the call reference number before moving to the next client?
[AGENT][NEUTRAL] Yes, um, the call reference number will be my name, [PII], and today's date.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Thank you so much story.
[AGENT][POSITIVE] You're very welcome.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] And thank you so much. Could you please help me with the next claim?
[AGENT][NEUTRAL] Yes, may I get the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Yeah, sure, sorry.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, policy number is 02.
[CUSTOMER][NEUTRAL] 474-464
[CUSTOMER][NEUTRAL] M as in Mike Lima 8.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what's the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Name of the patient is [PII]. The date of birth is [PII].
[AGENT][NEUTRAL] OK, and may I get the date of service and the charge amount?
[CUSTOMER][NEUTRAL] Date of services [PII]. The charge amount is $60 even.
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] And that's 60?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yes, correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And then what is the charge amount after the primary insurance paid their part?
[CUSTOMER][NEUTRAL] OK. OK, let me check it again.
[CUSTOMER][NEUTRAL] The charge amount will be.
[CUSTOMER][NEUTRAL] Just a moment, please, please.
[AGENT][POSITIVE] Yes, ma'am. Take your time.
[CUSTOMER][POSITIVE] OK, the charge amount, thank you so much for that. The charge amount is $570 even.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] $570.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] It is correct, hm.
[AGENT][NEUTRAL] That's after the primary paid their part?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, that's the, um, I updated total bill amount over here.
[AGENT][NEUTRAL] OK, so the total bill amount is $570 and then after primary was $60.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It.
[CUSTOMER][NEUTRAL] No, yeah, the total amount is $570.
[AGENT][NEUTRAL] OK, and
[AGENT][NEUTRAL] Where did the $60 come from? Is that after the primary paid?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. All right. And is it for the same facility?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh yeah. No, it's under a different facility.
[AGENT][NEUTRAL] OK, what is that, please?
[CUSTOMER][NEUTRAL] You get the same.
[CUSTOMER][NEUTRAL] Miami Associates in Pediatric Surgery, PA.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Alright, I'm gonna put you on a quick hold while I look up this claim for us and I'll be right back. Thank you, ma'am.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, sure. Yeah, sure.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you very much for holding for me. I have the claim ready for you. The claim number is 35842992.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim was denied because office visits are not covered under the patient's policy.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][POSITIVE] OK, so thank you so much for that.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][POSITIVE] Thank you so much for that, just a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Just a moment please.
[AGENT][POSITIVE] Yes ma'am, take your time.
[CUSTOMER][POSITIVE] And sorry, yeah, thank you.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, I know when did you receive this claim?
[AGENT][NEUTRAL] We received the claim on.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] We received the claim on [PII] and processed it on [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] [PII]. Just a moment.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] Would like to verify timely. OK. Just a moment, please.
[CUSTOMER][NEUTRAL] Could you mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Shall I take the time to filing limit and the mailing address as we discussed on the previous claim? sorry.
[AGENT][NEUTRAL] What is the timely filing limit?
[CUSTOMER][NEUTRAL] Will that be
[CUSTOMER][NEUTRAL] 180 days for an 180 days from the denied date.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] And mailing address.
[CUSTOMER][NEUTRAL] OK, so it's not office visitor is not covered as for the patient plan benefit. I'm sorry, it's not covered as for the patient's plan, right? OK, thank you so much for that.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And shall I move the last claim num uh may remember?
[AGENT][NEUTRAL] Yes, ma'am. What is the next member's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK. Name is [PII] and the date of birth is [PII].
[CUSTOMER][NEUTRAL] And the policy number is 0198.
[CUSTOMER][NEUTRAL] 6343.
[AGENT][NEUTRAL] OK, let me pull up that policy real quick.
[CUSTOMER][NEUTRAL] That it
[CUSTOMER][NEUTRAL] Oh yeah, sure.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and then what is the date of service and the charge amount?
[CUSTOMER][NEUTRAL] Date of service is [PII] and the total amount is $50 even.
[AGENT][NEUTRAL] OK, and the
[CUSTOMER][NEUTRAL] Let me check it, please.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. The toable amount is
[CUSTOMER][NEUTRAL] $264.57.
[AGENT][NEUTRAL] OK, and then what is the name of the facility, please?
[CUSTOMER][POSITIVE] Thank you. Bye.
[CUSTOMER][NEUTRAL] OK. Name of the facility is?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Midvise LLC.
[CUSTOMER][NEUTRAL] I, yeah.
[AGENT][NEUTRAL] OK, alright, I'm gonna put you on a brief hold again so I can check this claim for us and I'll be right back.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah, sure, no problem, take your time. You are on hold.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Right.
[AGENT][POSITIVE] Thank you very much for holding for me. I've got the claim pulled up.
[CUSTOMER][NEUTRAL] Mhm. Mhm.
[AGENT][NEUTRAL] The claim number is 3586043.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thanks. Uh-huh. Thank you.
[AGENT][NEUTRAL] And the claim was denied because we need the explanation of benefits from the primary insurance carrier.
[CUSTOMER][NEUTRAL] So you are the secondary or needing the primary EOB, is that right, story?
[AGENT][POSITIVE] That's right. That's correct.
[CUSTOMER][NEUTRAL] OK. We have received the, we have received the same denial previously and after which we have submitted the primary EOB as well. So could you please check that?
[AGENT][NEUTRAL] Uh, I did check to see if we have received it and we did not, we did, um.
[CUSTOMER][NEUTRAL] That's.
[AGENT][NEGATIVE] Get the same information that was sent previously without the EOB and it was denied as a duplicate claim.
[AGENT][NEUTRAL] So we're still needing the EOB.
[CUSTOMER][NEUTRAL] But you received the UOB, but the UOB, uh, which you received is not, that's not containing the same information which you received without the UB, is that right?
[AGENT][NEGATIVE] The EOB was not received.
[CUSTOMER][NEUTRAL] But we have submitted on [PII]. Did you receive that?
[AGENT][NEUTRAL] No, ma'am.
[CUSTOMER][NEUTRAL] Which is most recent. So you did not receive the UOB at all, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Oh, OK then.
[CUSTOMER][NEUTRAL] Um, is there any, uh, option to send fax because we have keep on sending the EOB but you guys are not receiving it, right?
[AGENT][NEUTRAL] Right, uh, yes, ma'am. Let me give you the fax number.
[AGENT][NEUTRAL] The fax number is [PII].
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] 942 [PII].
[CUSTOMER][NEUTRAL] Thank you. [PII]. Is that right?
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][POSITIVE] Thank you so much for that.
[CUSTOMER][NEUTRAL] May I know when did you become secondary?
[AGENT][NEUTRAL] When did we become secondary?
[CUSTOMER][NEUTRAL] Are you
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] The policy effective date is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][POSITIVE] OK, thank you so much for that. OK, so, you did not receive the UB, so we are reading the UB, is that right? Thank you.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thank you so much for your assistance and patience as well. Just a moment. I'm just requesting you to stay online just a moment, OK?
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much for your patience and assistance as well. And may I know when did you receive this claim, sorry?
[AGENT][NEUTRAL] Let me check for you.
[CUSTOMER][POSITIVE] Yeah, sure. First of all, thank you so much for patiently staying connected, OK?
[AGENT][POSITIVE] You're very welcome.
[AGENT][NEUTRAL] We received the claim on [PII] and processed it on [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK then thank you so much. And shall I take the time to filing limit and the mailing address as we discussed for the previous time? Will that be fine?
[AGENT][NEUTRAL] I'm sorry, you were talking too fast. Can you slow down and repeat the question?
[CUSTOMER][NEUTRAL] Uh, I'm, I am. My apologies for that.
[AGENT][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] Shall I take the timely filing limit and uh shall I take the timely filing limit and the mailing address as we discussed from the previous claim?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thank you so much for your assistance and patience as well. Have a great day, take care. Bye for now.
[AGENT][POSITIVE] You're very welcome.
[AGENT][POSITIVE] OK, you have a wonderful day too. Thank you very much for calling APL. Is that everything I can help you with?
[CUSTOMER][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] Yeah, I'm totally satisfied with this service story. Thank you so much for your assistance and patience as well. Have a great day take care bye for now.
[AGENT][POSITIVE] Bye-bye. You have a wonderful day. Thanks for calling APL.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes