AccountId: 011433970860
ContactId: f451a4f3-fe96-46c5-9b1c-cb6a78cc2f97
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 421980 ms
Total Talk Time (AGENT): 159132 ms
Total Talk Time (CUSTOMER): 123989 ms
Interruptions: 1
Overall Sentiment: AGENT=2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/21/f451a4f3-fe96-46c5-9b1c-cb6a78cc2f97_20250421T17:23_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 [PII], this is [PII]. I'm calling from Pros office for claims.
[AGENT][NEUTRAL] OK, [PII], you're needing to check claim status. Is that correct?
[CUSTOMER][NEUTRAL] Mm, I know the check the claim sir, um, we have a service, so I just need the information over the I.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, you need additional information on the denial reason, is that correct?
[CUSTOMER][POSITIVE] That's right. That's correct.
[AGENT][POSITIVE] Yes, [PII], I can help you with that. OK. What is a good callback number for you, please?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you. And the member's policy number, please.
[CUSTOMER][NEUTRAL] It's uh 1988265.
[AGENT][POSITIVE] OK, thank you. Give me a couple of moments, [PII] to get the member's information pulled up please.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And any information that I do provide today will be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Sure. The patient's name is [PII], and the date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you, one moment.
[AGENT][NEUTRAL] And what is the date of service and total bill amount place [PII]?
[CUSTOMER][NEUTRAL] Sure, the date of service is [PII] with the total charge amount of $163 even.
[AGENT][NEUTRAL] OK, thank you and the claim number?
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] Thank you so much for your patience and the claim number I have, it's uh 3572965.
[AGENT][POSITIVE] OK, thank you one moment.
[AGENT][NEUTRAL] OK, so yes sir, I do have that claim pulled up. How can I help you with that?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So this one was denied non-covered charges. May I know is it non-core as for the patient plan of the providers plan?
[AGENT][NEUTRAL] This is for the patient's plan, office visits are not covered.
[CUSTOMER][NEUTRAL] OK. I just like to know one more thing. The insurance is a secondary to the
[AGENT][NEUTRAL] That is primary major medical insurance.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] So if the UHC covers then while processing that a second rate, it should not be get denied.
[AGENT][NEUTRAL] This is a, this is a separate policy, and the supplemental policy does not provide benefits for office visits.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] So you're saying this was the supplement policy and this does not cover the
[CUSTOMER][NEUTRAL] Office visits?
[AGENT][POSITIVE] That is what I said, that is correct.
[CUSTOMER][NEUTRAL] OK, just one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Thank you so much for your patience. Uh, so may I know is this insurance, like this particular policy follows the insurance separate guidelines or the Medicare guidelines?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] No, this would not follow Medicare guidelines. This has its, this is not major medical insurance. It is a supplemental policy that's designed to help with co-pays, deductibles, and co-insurance amounts of covered services. And under this supplemental policy, office visits are not a covered service.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][POSITIVE] Thank you so much for that information. So we just have to bill it to the patient.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And we do not determine patients. Yes, but we do not determine patient responsibility here at APL. That would be up to the provider for the reference number you will use my name along with today's date, [PII]. And lastly, if you need a copy of the explanation of benefits that has the denial remark on there about that I read to you, you can print that by going to our portal at [PII].
[CUSTOMER][NEUTRAL] Mm, can I get the call reference?
[CUSTOMER][NEGATIVE] Oh sorry.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, so you're saying that this amount is not the patient's responsibility.
[AGENT][NEUTRAL] We do not determine patient responsibility, that would be up to the provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, then provide me the mailing address because uh the UB which we have, it has the copay amount.
[AGENT][NEUTRAL] The appeal would
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] You should have an explanation of benefits from American Public Life with that claim number and the member's policy number for APO and on page 2 it does state on there that office visits are not covered.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] If you wish to file an appeal, you would send it to our appeals department at the same mailing address as claims, and it must be filed within 180 days from the date of the decision.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] And again it must be sent to attention appeals department.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thanks so much for that information.
[AGENT][POSITIVE] Well, you're welcome. And again, is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No, that's the only claim I have.
[AGENT][POSITIVE] OK, [PII]. Well, thank you again for calling [PII]. I hope you have a nice day.
[CUSTOMER][NEUTRAL] Mhm you too. Bye.
[AGENT][POSITIVE] Thank you. Bye-bye.