AccountId: 011433970860
ContactId: fa28f233-6768-42bc-a3b8-15a93c41d0ae
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 634260 ms
Total Talk Time (AGENT): 210423 ms
Total Talk Time (CUSTOMER): 214697 ms
Interruptions: 1
Overall Sentiment: AGENT=0.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/14/fa28f233-6768-42bc-a3b8-15a93c41d0ae_20250314T17:17_UTC.wav
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[AGENT][POSITIVE] Afternoon, thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Uh, hi, [PII]. Uh, this is [PII] from Cryo Autism Therapy.
[AGENT][NEUTRAL] OK, and how may I assist you today, Mr. [PII]?
[CUSTOMER][NEUTRAL] Um, yes, so I actually spoke to you last [PII] regarding a member.
[AGENT][NEUTRAL] OK, do you have the policy number?
[CUSTOMER][NEUTRAL] Uh, one moment, let me see, insurance card.
[CUSTOMER][NEUTRAL] Um, 1000.
[CUSTOMER][NEUTRAL] 614043
[AGENT][NEUTRAL] May I have a callback number just in case we get disconnected, Mr. [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] That's, um, the policy number is a little bit too long. Um, can you repeat that number one more time, Mr. [PII]?
[CUSTOMER][NEUTRAL] 1000614043.
[AGENT][NEGATIVE] That's too many numbers.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Do you have any other information that I can use, Mister?
[CUSTOMER][NEUTRAL] Um, can I give you the name?
[AGENT][NEUTRAL] That's the spelling of the last name?
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] So what's the spelling of the first name?
[CUSTOMER][NEUTRAL] Um, [PII], [PII].
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] [PII] is the first name or the last name?
[CUSTOMER][NEUTRAL] Uh, first name.
[CUSTOMER][NEUTRAL] Last name [PII].
[AGENT][NEUTRAL] What is his date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK. Thank you.
[AGENT][NEUTRAL] OK, and how may I assist you with this policy, Mr. [PII]?
[CUSTOMER][NEUTRAL] Um, yes, ma'am. Um.
[CUSTOMER][NEUTRAL] We actually send.
[CUSTOMER][NEUTRAL] Um, one moment.
[CUSTOMER][NEUTRAL] We actually submitted the request.
[CUSTOMER][NEUTRAL] Um, with the, with the cover letter.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Understanding that will likely result or receive a denial.
[CUSTOMER][NEUTRAL] Due to out of network status, so just wanna see the status of the request.
[AGENT][NEUTRAL] What is the date of service?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] It was sent last [PII].
[AGENT][NEUTRAL] OK, what is the date of birth?
[CUSTOMER][NEUTRAL] Probably that day as well.
[AGENT][NEUTRAL] The date of service, not the date it was sent but the date of service. When, when was the member on the office?
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] That day as well.
[CUSTOMER][NEUTRAL] [PII] as well.
[AGENT][NEUTRAL] [PII] is the day that he was seen and [PII] is the day that it was sent to us.
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] No, it's [PII] or [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see if I got anything pending.
[AGENT][NEUTRAL] I don't have a claim for [PII].
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] It's, it's actually not a claim it's uh uh it's uh assessment request.
[CUSTOMER][NEUTRAL] Is it the same?
[AGENT][NEUTRAL] Is it a what? I'm sorry?
[CUSTOMER][NEUTRAL] Is it, is it like it's it's like an assessment request?
[AGENT][NEUTRAL] What is an assessment request?
[CUSTOMER][NEUTRAL] Uh, for ABA services.
[AGENT][NEUTRAL] OK, um,
[CUSTOMER][NEUTRAL] Oh, it's OK. Um, so, um, is there any option or what's the fax number?
[AGENT][NEUTRAL] OK, the
[CUSTOMER][NEUTRAL] That we can.
[AGENT][NEUTRAL] Mhm. OK. Uh, for this one, this one goes to IMA before it comes to us. So it got, it goes to IMA which is the repriser, and then it comes to us, OK? Um, let me go ahead and give you the information so you can submit the claim.
[AGENT][NEUTRAL] Um, let's see, so this will go to IMA and the address is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And I have a payer ID. We don't have a fax number. Um, the payer ID is 66.
[CUSTOMER][NEUTRAL] Um, I, is it 64556?
[AGENT][NEUTRAL] Mhm, yeah.
[CUSTOMER][NEUTRAL] Um, so it's actually not the claims, it's actually a request first for assessment request for ABA services.
[AGENT][NEUTRAL] And when you say an assessment request, is it a pre-cert?
[CUSTOMER][NEUTRAL] So we faxed the document.
[CUSTOMER][NEUTRAL] Yeah, something like that.
[AGENT][NEUTRAL] We, we don't do pre-cert.
[AGENT][NEUTRAL] We don't do research on this policy.
[CUSTOMER][NEUTRAL] Let me see, would you know this fax number [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] That is for claim submissions.
[AGENT][NEUTRAL] That's our fax number for claim submission APL.
[CUSTOMER][NEUTRAL] For, for.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] We actually send that one the the the request to that fax number.
[CUSTOMER][NEUTRAL] So we're trying to see the decision.
[CUSTOMER][NEGATIVE] And we're actually expecting a denial.
[AGENT][NEUTRAL] I don't
[AGENT][NEGATIVE] I don't see anything like that being received.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] Mhm. Let me go through the notes but I didn't see anything like that and we don't do research, um.
[AGENT][NEUTRAL] OK, so you call back in on [PII] and it was for coverage and I gave you benefits and disclaimer, um.
[CUSTOMER][NEUTRAL] If you don't
[AGENT][NEGATIVE] But we did not request any research or nothing like that, and I don't see anything being received on that day.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] If you want to see.
[CUSTOMER][NEUTRAL] It actually has a cover letter stating that we are submitting this request with the understanding that will likely result in a denial due to out of network status.
[CUSTOMER][NEUTRAL] So how can we get a denial letter to.
[CUSTOMER][NEUTRAL] Proceed with alternative uh avenues.
[CUSTOMER][NEUTRAL] For, for a member I done.
[AGENT][NEUTRAL] The only way we will send you a denial is an, we need to have a claim. We only process claims, that's how we deny. We deny based on the claims. If you send us a claim after the service is rendered, we'll, we can go ahead and send a denial. We cannot send a pre-denial. Um, we don't do pre-cert and this is a limited policy. It's not a major medical.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] You can only.
[CUSTOMER][NEUTRAL] I am
[CUSTOMER][NEUTRAL] OK, we submit claims. Can we submit claims on the fax number, the [PII]?
[AGENT][NEUTRAL] For the claims, it goes to IMA.
[CUSTOMER][NEUTRAL] For this member?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] There's no other way that we can submit claims except for the address, the [PII].
[AGENT][NEUTRAL] Correct. It has to go through IMA. They need to do any repricing through multi-plan.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, we can only send a denial letter if we submit claims.
[CUSTOMER][NEUTRAL] And what, what did you mention again? Um, you don't do pre denial. I'm sorry, what was that?
[AGENT][NEUTRAL] No, we don't do pre denial. We don't do any pre-search or pre-denial. Once the service is rendered, you can submit a claim. If it's payable, it will pay. If it's not payable, we'll send a denial for the claim.
[CUSTOMER][NEUTRAL] What's the service uh and games.
[CUSTOMER][NEUTRAL] OK, got it. Do you have like a call reference number so?
[AGENT][NEUTRAL] We don't have reference numbers, you can use my name in today's date if you will.
[CUSTOMER][POSITIVE] OK, thank you so much. Uh, [PII]. Got it. Thank you so much, I appreciate that. I'm sorry about the confusion.
[AGENT][POSITIVE] No, no problem. Have a good day. Thank you.
[CUSTOMER][POSITIVE] But thank you anyway.
[CUSTOMER][POSITIVE] You too, too. Bye-bye. Have a good weekend. Bye-bye.
[AGENT][POSITIVE] You're welcome. Bye-bye. Bye bye.