AccountId: 011433970860
ContactId: ff7e9ed9-f080-4e6e-aff2-997a9871ba0d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 410660 ms
Total Talk Time (AGENT): 144600 ms
Total Talk Time (CUSTOMER): 250115 ms
Interruptions: 6
Overall Sentiment: AGENT=0.5, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/05/ff7e9ed9-f080-4e6e-aff2-997a9871ba0d_20250505T18:49_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah, hi, [PII]. This is [PII] calling from providers Of Advent Health. I'm looking for claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status, [PII]. May I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Thank you. And the member's policy number?
[CUSTOMER][NEUTRAL] OK. Uh, that is gonna be, uh it's 02462238 M as in Mary, L as in Lima, 8.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Thank you for that. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Uh, it's [PII] and the 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 and the total bill for the claim?
[CUSTOMER][NEUTRAL] It's uh [PII] and the bill charges will be $13,358.40. Yeah, no, it's 13358.40.
[AGENT][NEUTRAL] $13,358.42.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 40, OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] It has been held out of Florida.
[CUSTOMER][NEUTRAL] Capability.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Number 31.
[AGENT][NEUTRAL] Alright, so I shall received the claim on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 35.
[CUSTOMER][NEUTRAL] OK, OK, and I, uh.
[CUSTOMER][NEUTRAL] Uh, just a moment. I do have all those information. So I do have a query regarding this claim. So this claim has been underpaid actually, uh, with, so with the payer allowed is $750 even. So provided allowed is $13,345.04 which is completely underpayment. So, previously on [PII], and a bill was submitted.
[CUSTOMER][NEUTRAL] Uh, so, uh, so, can you please check the status of the of the meal?
[CUSTOMER][NEUTRAL] And the payment got
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And when was the appeal submitted?
[CUSTOMER][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, I'm not showing, so I'm not showing that the appeal was received, um.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Have
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] We received something in March from the insured, but it just says that it's miscellaneous documents. Um, however, for your for your claim, the original claim, the max was received. It's $750 per calendar day, so we can't pay more than $750.
[CUSTOMER][NEUTRAL] I then
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, and I, uh, you think that when you didn't receive any upgrade. Why don't you take the claim back for your process so that it can be processed correctly because we do have a complete underpayment, uh, which is not related amount which is very less.
[AGENT][NEUTRAL] You can submit the claim for an appeal if you like, but the maximum that this policy will pay per day is $750. So no matter what the bill total is, the max the most is $750 that this policy can pay, which is what it paid to your claim, but you can appeal at any time.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so you cannot send the claim back for a week.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, you can't send the claim back for review again.
[AGENT][NEUTRAL] I can't send the claim back for review because there was no error.
[AGENT][NEUTRAL] It was the maximum was paid to this to this claim, but you can submit an appeal if you like. We just have not received the appeal that you sent in. Did you want to go over the fax number or the mailing address?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, just a moment. So we submitted this, uh, bill on [PII], right? Or, or do we need to allow some more time to receive the apple packet?
[AGENT][NEUTRAL] No, it's already been almost 2 months, so we have not received it. You can submit it though if you'd like.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] OK. Can you please provide me the address and the time of having to submit the appeal.
[AGENT][NEUTRAL] Sure, you have 180 days from the um denial date, which was
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And our claims mailing our claims mailing address is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Check. OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII]. The zip code is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK. OK. OK, thank you so much, I know that's all for today. Have a great day. Bye-bye. Can you please provide me the call reference number?
[AGENT][NEUTRAL] So there's no call reference number, but you can use my name and today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] And like.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, [PII], thank you so much. Have a great day, bye-bye.
[AGENT][POSITIVE] You're welcome and thanks for calling APL. I hope you have a great day.