AccountId: 011433970860
ContactId: fc6aecdf-5300-49de-aa8b-0e03c00aa77b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 453029 ms
Total Talk Time (AGENT): 247323 ms
Total Talk Time (CUSTOMER): 83334 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/14/fc6aecdf-5300-49de-aa8b-0e03c00aa77b_20250314T15:55_UTC.wav
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[AGENT][NEUTRAL] Hey, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from provider's office to check on the claim status.
[AGENT][POSITIVE] [PII], I'd love to help you with claim status today and
[AGENT][NEUTRAL] Do you mind if I go ahead and get a good call back number for you please?
[CUSTOMER][NEUTRAL] Yeah, it is [PII].
[AGENT][NEUTRAL] Thank you. And what about that policy number today, [PII]?
[CUSTOMER][NEUTRAL] It is 02049395. M as in Mike, L as in Lima, number 7.
[AGENT][POSITIVE] Thank you. Give me just a moment to get everything pulled up for you today.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] do.
[AGENT][POSITIVE] Sorry, are you having a great day so far?
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hi, are you still there with me?
[CUSTOMER][NEUTRAL] Yeah, yeah. I'm there.
[AGENT][NEUTRAL] OK, perfect. And um I was just asking how your day was, but I actually was able to get that policy pulled up um if you want to verify your patient's first and last name and date of birth.
[CUSTOMER][NEUTRAL] Yeah. First name is [PII]. Last name is [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][POSITIVE] Perfect.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Do you have the date of service to look it up under? Is that what we're wanting to do, my friend?
[CUSTOMER][NEUTRAL] Yeah, uh, that is [PII].
[CUSTOMER][NEUTRAL] And the bill amount is $760.
[AGENT][NEUTRAL] OK, give me just a moment on that.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You said 760, is that correct?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][POSITIVE] OK, perfect. Hang tight with me one second. I've got 2 claims that could be under and I just need to pull them both up, OK?
[CUSTOMER][NEUTRAL] Yeah, please.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] How's your day going?
[CUSTOMER][POSITIVE] Yeah, good talk with you.
[AGENT][POSITIVE] I'm doing wonderful thank you so much for asking.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Alright.
[AGENT][NEUTRAL] Just bear with me one more second we're almost there.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] So I was able to find that claim for you. I am showing that your, oh hold on now the policy disappeared. One second, let me pull that right back up.
[AGENT][NEUTRAL] Here we go. I'm showing your claim was received on [PII], and I'm showing that we processed it the following day, [PII].
[CUSTOMER][NEUTRAL] Sure, sure.
[AGENT][NEUTRAL] I'm showing that your claim number is 3556488.
[AGENT][NEUTRAL] And I am showing that the claim denied. I have the reason stating on that claim is that benefits are only payable if your major medical insurance provides benefits. If this claim is later paid by your major medical insurance, please send the explanation of benefits showing benefits were paid.
[CUSTOMER][NEUTRAL] Oh, you're asking for primary OB, right?
[AGENT][NEUTRAL] So it looks like we did receive the primary EOB on that one, but it looks like um and I can send you or I can have like a claims adjuster give you a call but it looks like what we're seeing is that um the primary insurance.
[AGENT][NEUTRAL] Didn't
[AGENT][NEUTRAL] Apply anything for the benefits?
[AGENT][NEUTRAL] To the co-pay, co-insurance or deductible?
[AGENT][NEGATIVE] But they didn't pay anything.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. So, what is the solution for it uh? Could you please send me that?
[AGENT][NEUTRAL] Yeah, so the way this policy is designed is it helps and picks up on um anything that major medical leaves behind after their payment. So when they apply something to the insured's copay, coinsurance or co-insurance, um, the only thing that could be done is the insurance makes a payment and applies part of it to the insured's copay, co-insurance or deductible.
[AGENT][NEUTRAL] Um, so on your side, I don't think there's anything you can do, but if insurance does come back and make a payment and apply something to the deductible co-insurance or co-pay, you can go ahead and resubmit the new EOB with the claim, and we can reprocess.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. So, however, we need to submit the primary UB, right?
[AGENT][NEUTRAL] Well, so we have the primary EOB, but the, the insurance didn't pay. So if, if the primary insurance doesn't pay, we're secondary, we can't pay either.
[CUSTOMER][NEUTRAL] To process the claim.
[CUSTOMER][NEUTRAL] Oh, you're saying the primary didn't pay.
[AGENT][NEUTRAL] Yeah, yeah, when it says like the deductible, the co-assurance and copay on that primary EOB, they all say 0.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] If you have a different EOB that shows where the where the primary paid and applied something to the copay coinsurance or deductible, you can go ahead and send that to us and we can reprocess.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] May I know the appeal mailing address for sending the primary OB?
[AGENT][NEUTRAL] Oh yeah, so if you're gonna send that primary EOB, you can just send it to our claims address. It's [PII], and that's in [PII], [PII]. Our zip code is [PII].
[AGENT][NEUTRAL] And you can just send the EOB by itself or you can include the original claim um if you send the EOB by itself though you would just wanna make sure you have the policy number on it.
[CUSTOMER][NEUTRAL] OK. So how old you are the secondary, right?
[AGENT][NEUTRAL] Yes, we're, we're secondary, we're like a gap insurance.
[CUSTOMER][POSITIVE] OK, thank you. So,
[CUSTOMER][NEUTRAL] Uh, may I know the appeal timely filing limit as well as the timely filing limit?
[AGENT][NEUTRAL] We don't have a timely filing limit. You're welcome to submit that at any time.
[CUSTOMER][NEUTRAL] OK. Normal time limit, I know.
[AGENT][NEUTRAL] No timely filing limit, yep.
[CUSTOMER][NEUTRAL] OK. May I know the call reference number?
[AGENT][NEUTRAL] It's my name, [PII], first initial, last name, [PII], and today's date.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] Thank you. Have a good day.
[AGENT][POSITIVE] Hey, it's my pleasure. Thank you so much, [PII]. You take care and have a happy Friday.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Bye bye.