AccountId: 011433970860
ContactId: fb5d24b4-5396-4f21-aeb3-c4d5efa969b7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1484910 ms
Total Talk Time (AGENT): 428714 ms
Total Talk Time (CUSTOMER): 520113 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/10/fb5d24b4-5396-4f21-aeb3-c4d5efa969b7_20250610T13:44_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, [PII]. My name is [PII] calling for the provider to check on the claim status. Please be informed that this call is being recorded and monitored for quality and training purposes. So may I know how can I help you with the patient's information or the provider's information?
[AGENT][POSITIVE] Well, I'll be more than happy to help you with the claim status, and did you say your name was [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure. It's, it's [PII]. No extension, it's a direct line.
[AGENT][NEUTRAL] Thank you. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] 4.
[AGENT][NEUTRAL] And are they all the same member or different members?
[CUSTOMER][NEUTRAL] Uh, they are, are for different members.
[AGENT][NEUTRAL] OK, and will you need a copy of the explanation of benefits for each?
[CUSTOMER][NEUTRAL] Uh, it depends upon the status of the claim.
[AGENT][NEUTRAL] OK, may I have the first member's policy number?
[CUSTOMER][NEUTRAL] Yeah, the first name will be
[CUSTOMER][NEUTRAL] Policy will be, uh, OK, the first policy number will be 01719419.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] So, the member's first name is [PII] and the last name is [PII]. The date of birth will be [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 and the total bill for the claim?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] The date of service is [PII].
[CUSTOMER][NEUTRAL] And the total bill amount will be $2,222,750 even.
[AGENT][NEUTRAL] OK, thank you, hold on one moment.
[CUSTOMER][NEUTRAL] you
[AGENT][NEUTRAL] And do you mind if I place you on a brief hold while I locate the claim?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, what now?
[AGENT][NEUTRAL] I wish it was a way we can make these longer.
[AGENT][NEUTRAL] 22,000.
[AGENT][NEUTRAL] 8000
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] I want to do 674 1st and see what that total is.
[AGENT][NEUTRAL] There you go. Well, let's check the other ones just to make sure cause sometimes multiples come in with the same amount. 322.
[AGENT][NEUTRAL] OK, that's different.
[AGENT][NEUTRAL] 218 was the next big balance. So.
[AGENT][NEUTRAL] Yeah, OK.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Uh yeah.
[AGENT][POSITIVE] Thank you so much for holding. I apologize for the wait. Um, and can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Uh yeah, it's Northeast Orthopedic Alliance.
[AGENT][NEUTRAL] Thank you. And we received the claim on [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] The claim number is 359.
[AGENT][NEUTRAL] 1674.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because benefits are only payable if the major medical provides benefits.
[AGENT][NEUTRAL] If this claim is later paid by major medical insurance, please present the explanation of benefits showing they were paid.
[AGENT][NEUTRAL] And we can reprocess this claim.
[CUSTOMER][NEUTRAL] OK. Uh, so the benefits will not come under the member's plan?
[AGENT][NEUTRAL] No, that's not what that says. So, that's saying we we're second to their major medical. So if you have an explanation of benefits showing that the major medical insurance did pay towards this claim, present the explanation of benefits showing that they paid, and we can reprocess our claim.
[AGENT][NEUTRAL] We cannot
[CUSTOMER][NEUTRAL] OK, just a second, give me.
[CUSTOMER][NEUTRAL] OK, so you want the prime, your explanation of benefits for the primary, uh, for the primary of the primary insurance.
[AGENT][NEUTRAL] We've already received the explanation of benefits. If you have an explanation of benefits showing that their primary insurance did pay towards this claim.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Then present that explanation of benefits showing the payment from primary insurance, then we can know that primary applies, so secondary can apply and we can reprocess the claim for a new decision.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, uh, [PII], as if I can see over here, the primary insurance has not paid anything, so, so you're not going to pay as well?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] Right, we're secondary, so if the first did not apply, the second cannot, which is what that denial reason is saying.
[CUSTOMER][NEUTRAL] Because your phone is right
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, OK.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] OK, and do you follow the Medicare guidelines, right?
[AGENT][NEUTRAL] I'm sorry, can you repeat that slowly, please?
[CUSTOMER][NEUTRAL] You follow the Medicare guidelines, am I right?
[AGENT][NEUTRAL] No, we're not affiliated with Medicare and Medicaid.
[CUSTOMER][NEUTRAL] I mean
[CUSTOMER][NEUTRAL] OK. What will be the timely filing limit to submit the corrected claim?
[AGENT][NEUTRAL] Um, if you have an explanation of benefits showing that the primary did pay something, um, there's no timely filing, you can submit that explanation of benefits at any time.
[CUSTOMER][NEUTRAL] OK, and what will be the mailing address?
[AGENT][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] OK, and
[CUSTOMER][NEUTRAL] What will be the timely filing limit to submit an appeal as well?
[AGENT][NEUTRAL] For an appeal, it's 180 days from the denial date.
[CUSTOMER][NEUTRAL] And the mailing address will remain the same, am I right?
[AGENT][NEUTRAL] Yes, but you'll put APL appeals.
[CUSTOMER][NEUTRAL] OK. Is there any specific form for an appeal?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, and in is required for submitting an appeal, uh, and or the claim.
[AGENT][NEUTRAL] Wait, can you say that slowly, please? I'm sorry.
[CUSTOMER][NEUTRAL] Denied EUB is required, am I right? you stated that you need the primary EOB.
[AGENT][NEUTRAL] This is two different things.
[CUSTOMER][NEUTRAL] So
[AGENT][NEGATIVE] The primary EOB that we're asking for, like you said, you have an EOB, but it shows that primary did not pay anything.
[AGENT][NEGATIVE] The only way this can be approved is if you have something that shows primary did pay something. So that's the EOB I'm referring to. The denied EOB from us.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, but I
[CUSTOMER][NEUTRAL] It's not required.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Is it, OK. And you just need the primary EOB which means they have paid something like that.
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] Correct, the primary EOB showing, the EOB from primary showing that they did provide something to this claim.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] But now as if I can see primary has not paid anything.
[AGENT][NEUTRAL] Right, which is why there's no need for an appeal, but you have a right to appeal, if you'd like.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Just a second. Give me a second, [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And you stated attention to APL, am I right?
[AGENT][NEUTRAL] If you're sending something like corrected information, it will be APL claims department. If you're filing an appeal, it'll be APL appeals department, but it's the same address.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a sec. And what will be, OK, you give me the claim number. The claim number is 3591674. Am I right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a second.
[CUSTOMER][NEUTRAL] OK, shall we move to the next one? And the call reference number will be your name and today's date.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Yes, for the entire call.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, just a second, it's loading in now.
[AGENT][POSITIVE] Sure, take your time.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The next member ID is 02 OK, sorry for that. OK, it's 02201631 M as in Mike, L as in Lima, 78.
[CUSTOMER][NEUTRAL] The
[AGENT][NEUTRAL] Thank you. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So the member's first name is [PII] and the last name is [PII]. The date of birth will be [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service and total bill?
[CUSTOMER][NEUTRAL] The service will be [PII] and the total bill amount will be $277.40. OK, it's $277.40. And do you want the tax ID as well because the tax ID is different for this.
[AGENT][NEUTRAL] Uh, hold on, let me pull up the claim.
[CUSTOMER][POSITIVE] Yeah, yeah, sure. Take your time.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, what's the name of the provider on this claim?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] It's.
[CUSTOMER][NEUTRAL] Florida Women Care.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So I'm showing that we received this claim on [PII].
[AGENT][NEUTRAL] The claim number is 359.
[AGENT][NEUTRAL] 468 5.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Right
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because office visits are not covered on this policy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Office visits.
[CUSTOMER][NEUTRAL] Bear with me, bear with me.
[CUSTOMER][NEUTRAL] OK, and there is only one CPD code, 99213, and that's not covered under the member's plan. Am I right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] 99213. Perfect.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] The further details will remain the same. That means the timely filing and the mailing address.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Shall we move to the next one?
[AGENT][NEUTRAL] Um, hold on one moment, I'm almost finished with these notes.
[CUSTOMER][POSITIVE] Yeah, sure, tell me just once we are ready.
[AGENT][NEUTRAL] Alright, and then
[AGENT][NEUTRAL] And the next member's policy number whenever you're ready.
[CUSTOMER][NEUTRAL] The next member ID is 02421775.
[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] Sure. The member's first name is [PII] and the last name is [PII]. The date of birth will be [PII].
[AGENT][NEUTRAL] Thank you for that. And again, just for the call, all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and total bills?
[CUSTOMER][NEUTRAL] Sure, the data service is.
[CUSTOMER][NEUTRAL] [PII]. total bill amount will be $239 even.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] Alright, so I'm not showing a claim on file, well, any claims on file. We haven't processed any claims for her, um, but there's no claim on file with your data service or total bills.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, just a second.
[CUSTOMER][NEUTRAL] OK, you don't have a claim on file.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] For the, just a second, let me check the claim for months.
[CUSTOMER][NEUTRAL] Sierra Sierra.
[CUSTOMER][NEUTRAL] Smith
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 2:39.
[CUSTOMER][NEUTRAL] 239.
[CUSTOMER][NEUTRAL] OK. I do have one claim number with me and uh could you please uh verify that claim number me once?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] It's 378472-0100.
[AGENT][NEUTRAL] Yeah, that's not an APL policy. I'm sorry, claim number, but there, like I said, we haven't processed any claims like it's blank. We've never processed anything for her.
[CUSTOMER][NEUTRAL] OK, got it, got it. Just a second, let me just check when we have submitted any claim.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, so do you have, uh, members effective date and the term date?
[CUSTOMER][NEUTRAL] Are you there?
[AGENT][NEUTRAL] The policy was
[AGENT][NEUTRAL] Yes, just give me a second to answer. The policy was effective from [PII].
[CUSTOMER][NEUTRAL] Oh yeah
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]. So the member, yeah, so the member was active on the date of birth, OK. And your primary, am I right?
[AGENT][NEUTRAL] Um, this is a hospital indemnity policy, so the patient could have another policy. We just don't have it on record. You would have to check with the patient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. And do you have any information regarding when was the last coordination of benefits were updated?
[AGENT][NEUTRAL] This is the only policy we have for the patient.
[CUSTOMER][NEUTRAL] So it was never updated, am I right?
[AGENT][NEGATIVE] There was, there was no coordination of benefits ever, so.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Like I said, if they have other policies, we're unaware of it.
[CUSTOMER][NEUTRAL] OK. So, what will be the?
[CUSTOMER][NEUTRAL] OK, so what will be the claim submission timely filing limit?
[AGENT][NEUTRAL] There's no timely filing as long as the policy was active on the data service, you can file the claim at any time.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] What will be the claim submission mailing address it will be the same.
[AGENT][NEUTRAL] No, for this policy, it's [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] [PII], the abbreviation is M like Mary, N like [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] What will be the pay ID?
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] 64556.
[CUSTOMER][NEUTRAL] 645-556.
[CUSTOMER][NEUTRAL] And you accept both paper as well as electronic submission, am I right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Shall we move to the last claim?
[AGENT][NEUTRAL] Um, hold on one moment, let me note this policy.
[CUSTOMER][NEUTRAL] it's
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, and the next member's policy number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 01841102.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, the member's first name is [PII] and the last name is [PII]. The date of birth will be [PII].
[AGENT][NEUTRAL] Thank you. And may I have the total bills and the date of service for the claim?
[CUSTOMER][NEUTRAL] The total bill amount, OK, the date of service is [PII] and total bill amount will be $256 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Is $256 the only total bill that this claim can have?
[CUSTOMER][NEUTRAL] 256. Yes, just a second, let me double check it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Do you have the claim on file for $230?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is that the same claim?
[CUSTOMER][POSITIVE] Yes yes.
[AGENT][NEUTRAL] OK, so we received the claim on [PII].
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] The claim number is 359.
[AGENT][NEUTRAL] 3744.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because office visits are not covered by this policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Patient active just a second.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Office visits.
[CUSTOMER][NEUTRAL] And what is the particular CPD code which is not covered?
[AGENT][NEUTRAL] 99213.
[AGENT][NEUTRAL] Do you want me to give you the denial for each code?
[CUSTOMER][NEUTRAL] Mm no. No, only just one CPT code is not covered. Am I right?
[CUSTOMER][NEUTRAL] Uh, there are multiple CPT codes.
[AGENT][NEUTRAL] No, the whole
[AGENT][NEUTRAL] So there's multiple, there's multiple CPT codes with multiple denial reasons, but the main reason for this, the first line.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It's the 99213 and the office visits are not covered. Did you want me to go over the other codes with you?
[CUSTOMER][NEUTRAL] No, the one that is.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, perfect. 99213 is not covered. OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Uh, so, and then the further details will remain the same, the time the filing and the mailing address. Am I right?
[AGENT][NEUTRAL] Correct. For this one it's the [PII], not the [PII].
[CUSTOMER][NEUTRAL] Uh yeah, I got it.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Social, OK. So, and the call reference number will be your name and today's date.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][POSITIVE] OK, perfect. Thanks for your assistance, [PII]. I hope you have a wonderful day.
[AGENT][POSITIVE] You're welcome.
[AGENT][POSITIVE] You also, was there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] You
[CUSTOMER][POSITIVE] Uh, no, ma'am. Thanks for your assistance.
[AGENT][POSITIVE] Alright, thanks for calling APO have a great day.