AccountId: 011433970860
ContactId: fabe93a4-1ad2-49fc-a546-5891fb4f25a7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 2462439 ms
Total Talk Time (AGENT): 794989 ms
Total Talk Time (CUSTOMER): 676147 ms
Interruptions: 24
Overall Sentiment: AGENT=-0.1, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/fabe93a4-1ad2-49fc-a546-5891fb4f25a7_20250121T16:50_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi
[CUSTOMER][NEUTRAL] How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII] calling from private office to for uh checking claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to assist you with the claim status. And [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And how many claims do you have in total today, [PII]?
[CUSTOMER][NEUTRAL] 4 claims.
[AGENT][NEUTRAL] And may I have the first member's policy number?
[CUSTOMER][NEUTRAL] Yep.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK. The policy number is 02451392.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Hm
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Sure. My first name is uh [PII] and last name is [PII]. And date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim?
[CUSTOMER][NEUTRAL] Yeah, date of service is [PII] and uh total charge is $842 even.
[AGENT][NEUTRAL] OK. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the provider's office on the claim?
[CUSTOMER][NEUTRAL] Can you verify
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Can you give the provider's name for the claim?
[CUSTOMER][NEUTRAL] Is the provider's name for the claim? Yes.
[CUSTOMER][NEUTRAL] And the provider
[CUSTOMER][NEUTRAL] Her name is uh [PII].
[AGENT][NEUTRAL] What's the tax ID?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, we have a claim on file for
[AGENT][NEUTRAL] Let me see if I can. The total charges are different though. Is there any other total bill that it could be?
[CUSTOMER][NEUTRAL] The total charges are different though. Is there any other total that they could be?
[CUSTOMER][NEUTRAL] No, it's uh
[CUSTOMER][NEUTRAL] It's only $840 even only.
[AGENT][NEUTRAL] OK, can you give like 3 of the codes that are on your claim? I'm just trying to see if this is the correct claim because the total bill is different.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] Yes. Yes, it's uh
[CUSTOMER][NEUTRAL] D. 0120.
[CUSTOMER][NEUTRAL] D. 0274.
[CUSTOMER][NEUTRAL] D. 0220.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] D 2393 and D2392 and
[CUSTOMER][NEUTRAL] D. 0230. And last one is uh D 0603.
[AGENT][NEUTRAL] OK, this is the same um claim, but it has a different total bill. Do you want me to give you that um this claim status it is from your provider, but the total bill on this claim is $548.
[CUSTOMER][NEUTRAL] How many did you see?
[CUSTOMER][NEUTRAL] It's same of CVD codes of 7.
[AGENT][NEUTRAL] Oh, you know what, hold on one moment. Total this claim 84. OK, now this is your claim. So this claim was received on [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 349.
[CUSTOMER][NEUTRAL] Claim number is 3498.
[AGENT][NEUTRAL] 4456.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], we process the claim.
[CUSTOMER][NEUTRAL] And on [PII] we process the claim.
[AGENT][NEUTRAL] And paid out to the provider a total of $500.
[CUSTOMER][NEUTRAL] Paid out to the provider a total of $500.
[CUSTOMER][NEUTRAL] Exactly $500.
[AGENT][NEUTRAL] Yes, $500 even.
[CUSTOMER][NEUTRAL] OK, this claim have any personal responsibilities?
[AGENT][NEUTRAL] Um, hold on one moment, let me look at the EOB.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Oh. OK.
[AGENT][NEUTRAL] I'm just waiting for the documents to populate here.
[CUSTOMER][NEUTRAL] For the documents to populate here.
[CUSTOMER][NEUTRAL] Take your time, and.
[AGENT][NEUTRAL] Let me see if it's on the patient.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] Do you mind if I place you on just a brief hold?
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEUTRAL] OK hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] So why not at the end of the column show what the total.
[AGENT][NEUTRAL] Patient responsibility is. What, what are we doing?
[AGENT][NEUTRAL] Because we're not in claims, so we don't know how to read this EOB.
[AGENT][NEUTRAL] Patients, are you saying that they owe this? I mean, I'm gonna just go off for the last call and that's how it was. They want us to do claims.
[AGENT][NEUTRAL] It is what it is. I gave the disclaimer.
[AGENT][NEUTRAL] And I'm going about my business. 21268046.
[AGENT][NEUTRAL] 3629.
[AGENT][NEUTRAL] So it looks like patient responsibility, OK, 842 total.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I pay 342 PR.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh I forgot he got 504. Hello [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for that wait. So with the total bill being $842 and we paid $500 the remaining balance of $342 is patient responsibility.
[CUSTOMER][POSITIVE] Thank you so much for
[CUSTOMER][NEUTRAL] So that way, so with the total bill being $842 and we pay $500 the remaining balance of $342 is patient responsibility.
[CUSTOMER][NEUTRAL] OK, so remaining up, what is the, uh, what is the name of the person responsibility, a deductible or co-pay or coins insurance or anything?
[AGENT][NEUTRAL] From the total bill that you billed and what we pay, the patient responsibility is the different.
[CUSTOMER][NEUTRAL] the
[CUSTOMER][NEUTRAL] Yes, you are paid 500 and the balance of 342 is what you are saying is a patient responsibility, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And what is the amount of 342? It's denied or uh anything of applied deductible or a copay for two patients?
[AGENT][NEUTRAL] With the $500 that was the max that we could pay for their policy. So the remaining balance, the outstanding balance of $342 is patient responsibility unless there's other insurance.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, that's not a problem. um, so what is the payment method used for this claim?
[AGENT][NEUTRAL] So this was a check. Hold on one moment, let me get that information for you.
[CUSTOMER][NEUTRAL] This is a check. Hold on one moment, let me get that information for you. Mhm.
[AGENT][NEUTRAL] So it's a single check number 1868713.
[CUSTOMER][NEUTRAL] So the simple check number 186-8713.
[CUSTOMER][NEUTRAL] Issued on
[AGENT][NEUTRAL] It was issued
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] It was issued on [PII].
[CUSTOMER][NEUTRAL] It was issued on [PII].
[AGENT][NEUTRAL] And it was mailed to [PII].
[CUSTOMER][NEUTRAL] to [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] In [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] But I am showing that it's still outstanding. So if you'd like, I can send this over to our representative to check on the check and reissue it if needed.
[CUSTOMER][NEUTRAL] Showing that it's still outstanding so if you'd like I can send this over to our representative to check on the check and reissue it if needed. Yes, can you please reissue the check again?
[AGENT][NEUTRAL] OK, I'll go ahead and send that request over and they'll check on the check and then um if we need to reissue it, we can, or if it's been, um, if it has been cleared, we'll provide a copy of the clear check.
[CUSTOMER][NEUTRAL] So the issue we
[CUSTOMER][NEUTRAL] Um, if it has been cleared, we'll provide a copy of the clear check. OK.
[AGENT][NEUTRAL] All right, and the next member's policy number?
[CUSTOMER][NEUTRAL] And the next member's policy number.
[CUSTOMER][NEUTRAL] Hey
[CUSTOMER][NEUTRAL] I can
[CUSTOMER][NEUTRAL] So, did you send a uh check to the issue?
[AGENT][NEUTRAL] Yes, I'm, I have sent that for you, but it's not gonna happen right now. It's sent to a representative, so we can move to the next time.
[CUSTOMER][NEUTRAL] And uh it yes if you have any of the time or and time to reach you.
[AGENT][NEUTRAL] So we give that the same turnaround as a claim, so 7 to 10 business days.
[CUSTOMER][NEUTRAL] So we get that the same 7 to 10 business days. 7 to 10 business days.
[CUSTOMER][NEUTRAL] OK. Uh, can I get the call reference number for this patient?
[AGENT][NEUTRAL] So the call reference number for the entire call will be my name and today's date?
[CUSTOMER][NEUTRAL] Your name is [PII]?
[AGENT][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, let me move for the next patient.
[CUSTOMER][NEUTRAL] OK. Uh, it's the next number, it's a different provider and same tax ID.
[AGENT][NEUTRAL] Different provider in the same tax ID?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Oh, you mean like a different, the actual, OK.
[CUSTOMER][NEUTRAL] So let me give the member ID.
[AGENT][POSITIVE] OK, I'm ready when you are.
[CUSTOMER][NEUTRAL] Yes, Member ID is 2466.
[CUSTOMER][NEUTRAL] 963
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Did you able to send the UOB to my fax?
[AGENT][NEUTRAL] And can
[AGENT][NEUTRAL] Sure, what's a good fax number for you?
[CUSTOMER][NEUTRAL] Yes. Uh, fax number is [PII].
[CUSTOMER][NEUTRAL] [PII] and attention is [PII]. And uh I need a copy of PUB for a previous claim.
[AGENT][NEUTRAL] Would you need a copy of the EOB?
[CUSTOMER][NEUTRAL] And for uh upcoming clients also.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. And the patient first name is uh
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] And last name is [PII], and date of birth is uh [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service for the claim?
[CUSTOMER][NEUTRAL] Yep
[CUSTOMER][NEUTRAL] And date of service is [PII].
[CUSTOMER][NEUTRAL] Please
[AGENT][NEUTRAL] And the total bill amount?
[CUSTOMER][NEUTRAL] And uh total bill amount is uh.
[CUSTOMER][NEUTRAL] $786 even.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And what is the name of the provider on this claim?
[CUSTOMER][NEUTRAL] And what is the name of the provider on this claim?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And you provided is uh
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Alright, so I'm showing we received the claim on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That claim number is 349.
[AGENT][NEUTRAL] 7659.
[AGENT][NEUTRAL] And on [PII],
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Just one moment please.
[CUSTOMER][NEUTRAL] OK, you continue. Sorry for the hold.
[AGENT][NEUTRAL] The claim number is 349.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 7659.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because the policy does not provide benefits for any procedure.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Be any procedure or service not listed in the covered dental service procedure.
[AGENT][NEUTRAL] Or service not listed in the covered dental services and procedures.
[CUSTOMER][NEUTRAL] Uh, did you mean policy did not provide any procedure and the service is not listed in patient benefit plan?
[AGENT][NEUTRAL] It's not a covered service or procedure for the patient's policy.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh but uh you paid it partially for this claim, right?
[AGENT][NEUTRAL] Um, no, there was no, uh, payment on this claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Just one moment.
[CUSTOMER][NEUTRAL] So, you do need a CDT only for 1351 and 1206, right?
[AGENT][NEUTRAL] Um, the only claim, uh, the only code on this claim is 01351.
[CUSTOMER][NEUTRAL] What about 1206?
[AGENT][NEUTRAL] Hold on one moment. Oh wait, there's several codes on here. Oh, so 01351 was built, oh, there's different parts to it and then 01206.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[AGENT][NEGATIVE] Um, yeah, so it was denied, they were all denied.
[CUSTOMER][NEUTRAL] Yeah, so it was not they were all deny it.
[AGENT][NEGATIVE] The entire claim was denied.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What is the reason?
[AGENT][NEUTRAL] They're not covered services on the member's policy, but the explanation on the explanation of benefits says this policy.
[CUSTOMER][NEUTRAL] They're not covered services.
[CUSTOMER][NEUTRAL] The member's policy.
[CUSTOMER][NEUTRAL] But the explanation on the explanation of benefits of this policy.
[AGENT][NEGATIVE] Does not provide benefits.
[CUSTOMER][NEGATIVE] Does not provide benefits.
[AGENT][NEUTRAL] For any procedure or service.
[CUSTOMER][NEUTRAL] For any procedure or service.
[AGENT][NEGATIVE] Not listed in the schedule of covered dental services and procedures. It's not covered.
[CUSTOMER][NEGATIVE] Not listed in the schedule of covered dental services and procedures. It's not covered.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, you know.
[CUSTOMER][NEUTRAL] So, actually, this is not covered by a molas, right?
[AGENT][NEGATIVE] It's not covered by the member's policy.
[CUSTOMER][NEUTRAL] So, no, but I'm seeing in the member policies, so 1351 is covered once in 36 months.
[AGENT][NEUTRAL] OK, hold on one moment. Let me pull up the.
[CUSTOMER][NEUTRAL] And also, it's a 1351 is covered once in 36 months. And also 1206 is also uh covered in once in 12 months.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Hey
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] It's a waste of
[AGENT][NEGATIVE] This is not basic. this is extensive, this is not call center.
[AGENT][NEGATIVE] This is annoying.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] What you think? I can't even think.
[AGENT][NEUTRAL] How am I doing?
[AGENT][NEUTRAL] The codes.
[AGENT][NEGATIVE] Oh, it's wrong, then they don't want us to be off the phone and then you're gonna get mixed.
[AGENT][NEUTRAL] sh
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] And then I'm gonna have to pull up the tag on thing so this is ridiculous.
[AGENT][NEUTRAL] Every time I try to chill, something else happens. 1351. And what's the next one?
[AGENT][NEUTRAL] 1206 is not covered.
[AGENT][NEUTRAL] 1351.
[AGENT][NEUTRAL] It so they do 20510351.
[AGENT][NEUTRAL] V
[AGENT][NEGATIVE] This is ridiculous.
[AGENT][NEUTRAL] One for 36 months, 1 per 36 months. So that's over a year and the last.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Well, wouldn't this bring up all the claims that was processed with that code. So if there was another
[AGENT][NEUTRAL] Claim with this code, it will populate, correct?
[AGENT][POSITIVE] It is right here.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] Well, wait a minute, that's a different claim number.
[AGENT][NEUTRAL] 346-6503.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 8 0604.
[AGENT][NEUTRAL] Is this the same?
[AGENT][NEGATIVE] I should not have, this is research.
[AGENT][NEUTRAL] OK. So it didn't cover it on that one because it was included.
[AGENT][NEUTRAL] In the first one, it looked like this, no, this, it was included in the first one.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Oh wait, but I was looking to see if it was the same provider.
[AGENT][NEUTRAL] Different provider. Hello, [PII].
[CUSTOMER][NEUTRAL] Yes, [PII], tell me.
[AGENT][NEUTRAL] Thank you so much for holding. I apologize for that wait. So code 1206 is not a covered code on this fax back. If you look at the fax back, it only has codes 1203 to 1205. So 1206 is not a covered code on the policy.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] If you look at the fax bag, it only has codes 1203 to 12:05, so 1206 is not a cover code on the policy.
[AGENT][NEUTRAL] As for 1351.
[CUSTOMER][NEUTRAL] No, yes, yes, tell me.
[AGENT][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] As for 1351, there was a claim that was received from your provider's a different, um, it came in as JDC Healthcare, but it's the same tax ID.
[CUSTOMER][NEUTRAL] Um, it came in as JBC Healthcare, but it's the same tax ID.
[AGENT][NEUTRAL] And it came in on [PII].
[CUSTOMER][NEUTRAL] And it came in on [PII].
[AGENT][NEUTRAL] That's claim number 3466503.
[CUSTOMER][NEUTRAL] That's claim number 3466503.
[AGENT][NEUTRAL] All of the codes from the
[CUSTOMER][NEUTRAL] All of the clothes
[AGENT][NEUTRAL] claim that was received in August that we first went over were included in this first. I'm sorry, this first claim.
[CUSTOMER][NEUTRAL] Claim that was received in August that we first went over were included in this first move.
[CUSTOMER][NEUTRAL] I'm sorry, this first client.
[AGENT][NEUTRAL] So that's why the second one is giving you a denial of it's not um
[CUSTOMER][NEUTRAL] So that's why the second one is giving you a denial of it's not uh.
[AGENT][NEUTRAL] Covered by the policy because you already filed for it within the year, it's 36 months apart.
[CUSTOMER][NEUTRAL] Covered by the policy because you already filed for it within the year and it's 36 months apart.
[CUSTOMER][NEUTRAL] OK, but the patient does not having any service within 36 months for a 1351. Do you have any uh history update?
[AGENT][NEUTRAL] So, I'm gonna explain it again. So the 1351, you filed it, you filed a claim for [PII], you filed it twice.
[CUSTOMER][NEUTRAL] So I'm gonna
[AGENT][NEUTRAL] So, on the first claim, we paid out and we gave the denial that it applies to the molar teeth only. So then when you filed it again the second time, it received the denial that is not covered by the policy because you've already filed it once within this year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Then when you filed it again the second time it receives the denial that is not covered by the policy because you've already filed these points within this year.
[CUSTOMER][NEUTRAL] But you didn't pay for 1351, right?
[AGENT][NEGATIVE] Right, it originally was denied because applications are made to permanent molar teeth only.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] On the first time you filed for it.
[CUSTOMER][NEUTRAL] OK. You can, you can, you can pay only for a permanent tooth only for a child's, right?
[AGENT][NEUTRAL] Right, it's only for permanent molar teeth.
[CUSTOMER][NEUTRAL] OK, one moment.
[CUSTOMER][POSITIVE] OK, and uh thank you so much for uh understanding for the denial.
[AGENT][NEUTRAL] You're very welcome. Was there anything else I can assist you with today? Oh, wait, we have other claims.
[CUSTOMER][NEUTRAL] I can, I can, yes, we have another claim.
[AGENT][NEUTRAL] OK, you needed me to fax this um explanation of benefits over as well?
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] No need for this claim. I have already have that this claim only for UB.
[AGENT][NEUTRAL] OK, and what's the next member's policy number?
[CUSTOMER][NEUTRAL] Just one moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you so much. So let me go for the next patient ID.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The expiration ID is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yup, sure. And uh my first name is uh
[CUSTOMER][NEUTRAL] [PII]. And last name is uh [PII].
[CUSTOMER][NEUTRAL] And date of birth is uh [PII].
[AGENT][NEUTRAL] OK, hold on one moment. That member is not on this policy. Let me see if they have another one. OK, now, so this policy.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] That member is not included on this policy. This is the policyholder and the spouse.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so patient is.
[AGENT][NEUTRAL] Can you spell the first name for me just so I can
[CUSTOMER][NEGATIVE] No dental coverage.
[AGENT][NEUTRAL] I'm sorry.
[AGENT][NEUTRAL] Can you spell your patient's first name for me?
[CUSTOMER][NEUTRAL] Yes, I need to spell the first name?
[CUSTOMER][NEUTRAL] Yep.
[CUSTOMER][NEUTRAL] First name is [PII].
[AGENT][NEUTRAL] OK, yes, that member is not on this policy.
[CUSTOMER][NEUTRAL] Yeah, that
[CUSTOMER][NEUTRAL] And the new claim?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Can you see the date of service?
[AGENT][NEUTRAL] The member is not on this policy. It is the spouse and the policyholder. There's no um coverage for a member that's not on the policy.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] So you cannot be able to check the claim in receipt or not.
[AGENT][NEUTRAL] Is it for the policyholder or his spouse?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Right, so the, so we can't check for a claim if the member, like there's literally only 2 people on the policy, so I can't search for anyone else that's not on the policy.
[CUSTOMER][NEUTRAL] Can you able to find uh find a claim with return uh policy number?
[AGENT][NEUTRAL] Sir,
[AGENT][NEUTRAL] The member that you're looking for is not included on this policy. So you'll have to reach out to the member and let them know it's not, there's no child on this policy. There's only the policyholder and the spouse.
[AGENT][NEUTRAL] So there's no coverage for someone that's not on the policy.
[CUSTOMER][NEUTRAL] So this claim is that the patient is uh spouse for the policy number, right?
[AGENT][NEUTRAL] That is the policyholder and the spouse, that's the only people that were covered on the policy.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Policy holder and the spouse, so.
[CUSTOMER][NEUTRAL] The patient is not eligible for this claim, right?
[AGENT][NEUTRAL] Patient is not on the policy. They're not eligible, no.
[CUSTOMER][NEUTRAL] Let me see
[CUSTOMER][NEUTRAL] Can you please repeat the word policyholder in the spouse and what is the sentence and you note that.
[AGENT][NEUTRAL] Policy only covered policyholder and spouse, no dependent coverage.
[CUSTOMER][NEUTRAL] What is the last one? No?
[AGENT][NEUTRAL] No dependent coverage.
[CUSTOMER][NEGATIVE] No deparent coverage.
[CUSTOMER][NEUTRAL] So you did not, uh, uh, we need, we don't.
[CUSTOMER][NEUTRAL] We did not file the claim with uh this patient name for it because the patient does not have a coverage in uh American public life, right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] What is the reason that we need to reach for reach out for the patient?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] What is the reason that we need to reach out for a patient?
[AGENT][NEUTRAL] To see who
[CUSTOMER][NEUTRAL] We need to ask any of the patient have any.
[AGENT][NEUTRAL] You need to be asking the patient who, what insurance the child has.
[AGENT][NEUTRAL] So that you can file the claim with the correct insurance company.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, let me move for the next last one patient.
[AGENT][NEUTRAL] Um, hold on one moment for me.
[AGENT][NEUTRAL] OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] OK, the next member's policy number.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Next member policy ID is 914813.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] And can you
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Remember, first name is uh [PII], and last name is [PII], and date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information again provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And it of services, uh.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you and the total bill amount?
[CUSTOMER][NEUTRAL] Sorry? Yes, total amount is uh.
[CUSTOMER][NEUTRAL] Total amount is $163 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK. So we received this a few times as well. Hold on one moment.
[CUSTOMER][NEUTRAL] OK, so we've received this a few times as well. Hold on one moment.
[AGENT][NEUTRAL] And what is the name of the provider's office on your claim?
[CUSTOMER][NEUTRAL] And what is the name of the provider's office on your claim?
[CUSTOMER][NEUTRAL] JDC
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] OK, that's a duplicate. What's the original?
[AGENT][NEUTRAL] Alright, so we originally received the claim on [PII].
[CUSTOMER][NEUTRAL] OK, so we originally received the claim on [PII].
[AGENT][NEUTRAL] The claim number is 351.
[CUSTOMER][NEUTRAL] The flight number 351.
[AGENT][NEUTRAL] 268. I'm sorry.
[CUSTOMER][NEUTRAL] OK. 7268.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim $220.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let me get that information for you.
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] So it was a single check as well?
[CUSTOMER][NEUTRAL] That was a single check as well.
[AGENT][NEUTRAL] Um, check number 20.
[CUSTOMER][NEUTRAL] So, uh, OK, what about the CDD 0330?
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] 00330 was denied because the policy is limited to one X-ray procedure per five-year period.
[CUSTOMER][NEUTRAL] Frequency limit exceeded and is uh only approved for.
[CUSTOMER][NEUTRAL] 5 years once, right?
[AGENT][NEUTRAL] 1 X-ray per 5 years.
[CUSTOMER][NEUTRAL] In 5 years and uh
[CUSTOMER][NEUTRAL] Can I have his history date of this one?
[AGENT][NEUTRAL] The last date that this um code was processed was [PII].
[AGENT][NEUTRAL] So [PII], uh, they'll be eligible.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, what is the code paid for [PII]?
[AGENT][NEUTRAL] 00330.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] 0330, right? D 0330.
[AGENT][NEUTRAL] Yes, that's the code you were asking me for, yes.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] The last time that it was used was [PII], which is not 5 years. Five years will be [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So this about claim number, so can you please send the UB to me fax?
[AGENT][NEUTRAL] Yes, I'll be sending you an EOB for all of them except the two you said don't send.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And was there anything else I could assist you with today, [PII]?
[CUSTOMER][NEUTRAL] Uh, no, no, uh, I'm waiting for, uh, your EOB, so how much take time to say I, I will receive that.
[AGENT][NEUTRAL] You would like me to send them over the phone?
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] So I'm faxing the explanation of benefits to you, so you'll have to give it at least an hour, it's being sent by fax.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] If you have not received them by the end of day today, you definitely can give us a call back and we'll be more than happy to send it again for you.
[CUSTOMER][POSITIVE] OK, thank you so much, [PII].
[AGENT][POSITIVE] You're very welcome. Was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] OK. No, [PII], thank you so much for uh providing assistance for this, uh, both of claims and all. Have a nice day to you, [PII].
[AGENT][POSITIVE] You also, and thanks for calling APL.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Yeah bye.