AccountId: 011433970860
ContactId: f7f0ea67-02ce-4999-85cd-309744917fc4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1398459 ms
Total Talk Time (AGENT): 567554 ms
Total Talk Time (CUSTOMER): 254993 ms
Interruptions: 0
Overall Sentiment: AGENT=0.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/30/f7f0ea67-02ce-4999-85cd-309744917fc4_20250130T14:36_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII] speaking. How may I help you?
[CUSTOMER][NEUTRAL] Yeah, hi, this is [PII]. I'm calling from provider's office to check on claim status. Please note this call will be monitored and recorded for quality and training purposes. How are you doing today?
[AGENT][NEUTRAL] Uh, hi [PII], thank you for, uh, for that. Um, yes, uh, I can help you with the claims status. May I have your, uh, callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and may I have the name of the provider or facility you're calling from, [PII]?
[CUSTOMER][NEUTRAL] Provider's name is
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and what is the policy certificate or member ID please?
[CUSTOMER][NEUTRAL] Member ID is D as in Delta 434103777.
[AGENT][NEUTRAL] OK, thank you for that [PII]. Now I can't search with that um ID number in my system. Is there a policy certificate number listed? Do you have a copy of the ID card?
[AGENT][NEUTRAL] If not we can search with a name or social security number.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I don't have, uh, I'll, do you know the member's name?
[AGENT][NEUTRAL] Yeah, go ahead and spell the last name please.
[CUSTOMER][NEUTRAL] Yes,
[CUSTOMER][NEUTRAL] Member's last name is [PII]
[AGENT][NEUTRAL] OK, and the first name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And date of birth?
[CUSTOMER][NEUTRAL] Date of birth for this number is uh [PII].
[AGENT][NEUTRAL] And can you tell me, uh, [PII], what city and state they live in?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] The patients.
[CUSTOMER][NEUTRAL] City name is?
[CUSTOMER][NEUTRAL] One second.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And um can I, can I have you spell that last name one more time? [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And just give me one moment to search please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I believe I have located that policy information, um, and you needed a claim status, [PII], can you tell me the date of service and the amount on the claim for [PII], please?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Date of service is [PII]. And the charge amount for this claim is $63 even.
[AGENT][NEUTRAL] $63 for [PII], is that right?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you, just give me one moment please.
[CUSTOMER][NEUTRAL] OK. I have a specific question for this claim. Uh, when you're ready, I'll ask you.
[AGENT][NEUTRAL] Certainly.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I believe I located the claim here and what's your specific, uh, you said you had a question about it.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] Uh, for this one, we have submitted an appeal on [PII]. And we have a note that the appeal is still in process. We got that note on [PII]. Could you please check that the appeal is still in process or it is upheld? Could you please check that, please?
[AGENT][NEUTRAL] Certainly, so we're looking for an appeal, appeal that was filed for this claim and you said on what day? July?
[CUSTOMER][POSITIVE] Yes. Yes, yes.
[CUSTOMER][NEUTRAL] Um, first, the appeal is, uh, submitted on [PII]. But we got the notes that appeal is still in process in on uh [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me just take a look and see if I have.
[AGENT][NEUTRAL] And was the um can you tell me was the claim marked as an appeal?
[AGENT][NEUTRAL] Was it marked as an appeal or?
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] It the claim was marked as an appeal.
[CUSTOMER][NEGATIVE] No, no, no, no.
[AGENT][NEUTRAL] The that where that they're where they're supporting documentation for the appeal.
[CUSTOMER][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So just give me a moment please.
[AGENT][NEUTRAL] I'm gonna look at some information.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Two times connector.
[AGENT][NEUTRAL] OK, I show uh um.
[AGENT][NEUTRAL] A claim um are you there [PII]?
[CUSTOMER][NEUTRAL] Yeah, I'm here.
[AGENT][NEUTRAL] OK, and so, um, this particular claim that you're inquiring about for $63 there were two procedure codes listed on that claim, is that right? 84156 and 82,570?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, alright, so I don't find a um an appeal. What I do find, um, we did receive a a request for reconsideration for this claim, but I don't show appeal documents. I don't show anything that came in as an appeal, and you said it, it was mailed on [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, just give me one moment I'm gonna look at one more piece of uh.
[AGENT][NEUTRAL] Information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, so it looks like the request that was sent in July, um, the first time, let's see.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] For the 60 for this particular claim for the um uh it looks like it was a combined um visit for that day we had a couple different claims that came in for uh.
[AGENT][NEUTRAL] The [PII] date.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, and what this policy is a limited hospital indemnity plan, so that maximum benefit for that data service was paid on the um office visit portion of the claim.
[AGENT][NEUTRAL] Um, and it, it was from the same provider, um, the Heartland, uh, Women's Healthcare, but it was a different amount. So the benefit was paid on that claim. And so when your claim came in, the maximum it was denied as maximum benefit met for the data service. So that's the maximum benefit that can be paid for this service.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So when we received the uh claim reconsideration it was denied as a duplicate because it was the same information received on the claim even though it had additional information attached to it, it was still viewed as a claim reconsideration and not an appeal. If you want to appeal, it must be marked as an appeal and you have to um include supporting documentation that's an appeal and why you're appealing the decision.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] So that it can be uh reexamined. However, there, there is unfortunately there's nothing to appeal for this particular data service because we did pay the benefit we just did not pay the $63 claim because it was already that benefit was already used up it was already maxed out for that [PII] data service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] May I know the, the appeal is denied on which date?
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Just one moment.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, let me go back to that claim. It'll just be one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So we had the original denial.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, I'm just reviewing the claims. It looks like there's a lot for that data service, so just bear with me for one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We received that multiple times so I'm just trying to make sure that I give you the correct uh the correct information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You don't
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] 350 6514 OK.
[AGENT][NEUTRAL] And you want that claim details, is that right?
[CUSTOMER][NEUTRAL] Yes, and also that the uh reconsideration is upheld on which date, please?
[AGENT][NEUTRAL] OK, so we received that request for reconsideration. I have it on [PII]. This is the one where the documents are attached asking for the request for reconsideration, so we process that uh information. Receipt date is [PII]. It was processed on [PII].
[AGENT][NEUTRAL] The claim number attached 35.
[AGENT][NEUTRAL] 06514.
[AGENT][NEUTRAL] And that claim again the decision was that the maximum benefit was meant for that data service so that particular claim we didn't deny it is duplicate because there was additional information for the claim. however, like I said, it wasn't marked as an appeal, it was just a claim reconsideration, so we again gave that same denial that was on the first claim that was received that the maximum benefit is met for that data service.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. May I know the mailing address?
[AGENT][NEUTRAL] Uh, yes, the appeal address you have to send it to the claims address. It must be marked as an appeal and includes supporting documentation. The information needs to go to IMA.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] 04
[AGENT][NEUTRAL] And that's [PII].
[AGENT][NEUTRAL] 55121.
[CUSTOMER][NEUTRAL] May I know the turnaround time?
[AGENT][NEUTRAL] Pardon me?
[AGENT][POSITIVE] So I'm sorry?
[CUSTOMER][NEUTRAL] I'm asking that how mm may I know the timely file need to submit an appeal.
[AGENT][NEUTRAL] Um, I believe it's 6 months from the decision on this particular policy.
[AGENT][NEUTRAL] Just give me one moment, I can double check that.
[CUSTOMER][NEUTRAL] 6 weeks
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] And again that um decision was made on [PII] the original claim denial um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, that original claim denial was uh.
[AGENT][NEUTRAL] 5:24.
[AGENT][NEUTRAL] 2024.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. I have another one claim. Could you help me with that claim?
[AGENT][NEUTRAL] You have another claim for the same member?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] No, different one.
[AGENT][NEUTRAL] OK then um give me just one moment.
[CUSTOMER][NEUTRAL] Give me just one moment also 1 2nd.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Under the same member only.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] It's the same number?
[CUSTOMER][NEUTRAL] Yes, ma'am, same number, same provider.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Same provider, what's the data service on that claim?
[CUSTOMER][NEUTRAL] D of service for this number is um [PII].
[AGENT][NEUTRAL] And what's the claim amount?
[AGENT][NEUTRAL] Please.
[CUSTOMER][NEUTRAL] Uh yes. Uh, one second, I'm checking that one only.
[CUSTOMER][NEUTRAL] That is uh $309 even.
[AGENT][NEUTRAL] OK and uh OK and I have that claim information as well.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so that claim, uh, received in our office on [PII]?
[AGENT][NEUTRAL] Process on [PII].
[AGENT][NEUTRAL] The claim number 348.
[AGENT][NEUTRAL] 1454.
[AGENT][NEUTRAL] Uh, we paid the benefit on that claim of $75.
[AGENT][NEUTRAL] Do you want the check information, [PII]?
[CUSTOMER][NEUTRAL] Uh, yes, sir. May I know the, the whole claim is paid, right?
[AGENT][NEUTRAL] Well we paid the maximum benefit allowed for this particular service which was $75 on the office visit line we paid the $75 that some maximum benefit allowed for this plan. Again, it is limited medical hospital indemnity, so it's not a major medical plan.
[AGENT][NEUTRAL] It is uh
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Limited medical plans.
[CUSTOMER][NEUTRAL] OK. I have one doubt. I said the line 96127 is denied for $50. What is the reason? May I know the denied reason?
[AGENT][NEGATIVE] Well, it was denied because that's the maximum meant for the data service was the $75. That's the maximum benefit allowed, so there was no payment for 961-27 CPT code for $50. It was denied as uh max maximum benefit meant for the data service.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Which is why the additional claim that was filed for the $63 was also denied as max benefit. We paid the maximum benefit allowed under the plan, which was $75.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, for this one,
[CUSTOMER][NEUTRAL] May I know you paid it through?
[CUSTOMER][NEUTRAL] How much, uh, you paid a low amount and paid amount is same.
[AGENT][NEUTRAL] Allowed a $75 paid amount was $75 on this claim 3481454 for data service [PII]. We pay the maximum benefit allowed under the plan of $75.
[CUSTOMER][NEUTRAL] OK, it's paid through check or EFT?
[AGENT][NEUTRAL] Checking check.
[CUSTOMER][NEUTRAL] Check number, please.
[AGENT][NEUTRAL] 1863.
[AGENT][NEUTRAL] 039.
[CUSTOMER][NEUTRAL] Paid through single amount of check uh bulk amount.
[AGENT][NEUTRAL] It was a single check for $75.
[AGENT][NEUTRAL] The payee was Heartland Women's Healthcare.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It went to [PII].
[AGENT][NEUTRAL] Issue date is [PII].
[AGENT][NEUTRAL] And I do show it's cleared, it's been cashed and that status date shows [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you have any other questions?
[CUSTOMER][NEUTRAL] Could you please um, could you please tell me that, uh, patient account number?
[AGENT][NEUTRAL] The patient account number on the claim.
[CUSTOMER][NEUTRAL] Mhm. Yes.
[AGENT][NEUTRAL] 74.
[AGENT][NEUTRAL] 728.
[AGENT][NEUTRAL] 7 V like Victor.
[AGENT][NEUTRAL] 21608.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm, one second.
[CUSTOMER][POSITIVE] OK, thank you so much. Um, may I know your name, please? Could you please spell it?
[AGENT][NEUTRAL] Certainly [PII], and this will be your call reference number as well. My first name is [PII]
[AGENT][NEUTRAL] Last initial [PII] and today's date is your call reference number.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] You're welcome. Did you have any other questions?
[CUSTOMER][POSITIVE] Thank you for your assistance. Have a great day. Nothing. Thank you for your assistance. Have a great day.
[AGENT][POSITIVE] You too, [PII], thank you for calling APL. Hope you have a great rest of your day.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.