AccountId: 011433970860
ContactId: 036dd38c-71ab-4869-b229-e743257f25c1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 452940 ms
Total Talk Time (AGENT): 169910 ms
Total Talk Time (CUSTOMER): 214360 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/036dd38c-71ab-4869-b229-e743257f25c1_20250429T12:46_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], and I'm calling on behalf of Calcau Urgent Care, and I need to do a follow up regarding claim status.
[AGENT][NEUTRAL] OK, well I can definitely help you with the claim status, and [PII], may I have a good contact number in case we're disconnected and then the policy number?
[CUSTOMER][NEUTRAL] Yes. My direct, um, the contact is gonna be.
[CUSTOMER][NEUTRAL] Hold on one moment because we just switched our phone systems. [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Oh, take your time.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][POSITIVE] Thank you for that, and then the member's policy number whenever you're ready.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yes, it is 02519757.
[AGENT][NEUTRAL] 02519757
[CUSTOMER][NEUTRAL] Yes, 02519757. Correct.
[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] This is for [PII]. His 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 bills for the claim?
[CUSTOMER][NEUTRAL] Yes, for this patient, I actually have, um, he has 1234 dates of service.
[AGENT][NEUTRAL] OK, you can give them all to me in the total bill.
[CUSTOMER][NEUTRAL] OK, the first one I have is gonna start with is 23, hold on, I'm sorry. This one is $288. The data service is 32025.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] You want to do them one by one or all together?
[CUSTOMER][NEUTRAL] Um, let's
[CUSTOMER][NEUTRAL] We can do them all. Um, the next one is gonna be.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well, let me get the total bill amount. One moment. So that's OK, 32025 that one is for 288.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The next one
[CUSTOMER][NEGATIVE] I wish it, I wish I could see them all at one time, but it ain't giving me that privilege.
[AGENT][POSITIVE] Well, take your time, it's OK.
[CUSTOMER][NEUTRAL] Um, the next one is, um.
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] Come on.
[CUSTOMER][POSITIVE] Just now I wanna move slow. I'm sorry.
[AGENT][NEUTRAL] You are fine.
[CUSTOMER][NEUTRAL] OK, the next one is 324 25 for $348.02.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Before we go further, well, let me just show you, even with these two claims, we did receive a payment, but I guess some of the charges are not being paid. So I guess I'm trying to verify, are they basically only paying certain line items because we build it with a modifier.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, let me look at the first.
[CUSTOMER][NEUTRAL] Or is there a max a benefit max?
[AGENT][NEUTRAL] 358, hold on one moment, 3583.
[AGENT][NEUTRAL] OK, so that's the 2nd co. Let me see the 1st 1. OK, hold on one second, I'm just getting them together.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I know you're fine.
[AGENT][NEUTRAL] OK, so it's a little bit of both. So, let me pull up the full policy so I can see the whole benefit. Hold on one second.
[CUSTOMER][NEUTRAL] OK, cause yeah, it looks like they're paying the office visit, but then when we're in, we're billing it with a 25 modifier cause it looks like the other charges like the X-ray.
[CUSTOMER][NEGATIVE] And any other services, they're not paying them.
[AGENT][NEUTRAL] So basically, the insurer has a hospital indemnity policy, so it's a limited medical policy. So there's a benefit, so that's the part of why the other lines aren't being paid because the benefit is um for outpatient sickness, the policy will pay up to $25 per visit with a max of 5 visits per calendar day. So it's applying that $25 to the like 99213.
[CUSTOMER][NEUTRAL] That's what it is.
[AGENT][NEGATIVE] The the place of service code and then the other ones are denied because that 25 is the max.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so they have a $25 max that they allowed it for 5 visits.
[AGENT][NEUTRAL] Yes, per year, per calendar year. Now they do have like, um, let me go down to that because I thought I saw wellness. Hold on one moment.
[CUSTOMER][NEGATIVE] Well, we're an urgent care facility, so that wouldn't even apply.
[AGENT][NEUTRAL] But the wellness and you said X-rays and stuff, right, because the diagnostic testing is with that, but uh some policies.
[AGENT][NEUTRAL] Let me see if this species. There was imaging done, right? You said, I thought, did you mention that?
[CUSTOMER][NEUTRAL] He, yeah, he had a he had an X-ray of his toes. So I'm assuming he had an injury.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Yeah, based on his um.
[CUSTOMER][NEUTRAL] Let's see something.
[AGENT][NEUTRAL] Oh yeah, the policy specifies. So I was thinking for the, for the imaging, maybe we could count some of that because they have an imaging or a diagnostic testing benefit, but it's only for MRIs, CT scans, and colonoscopies.
[CUSTOMER][NEUTRAL] OK. That, so this answers my question about this policy cause it kept going in a circle cause it looks like people have been working it but nobody came to figure out why the other charges are not being paid and I yeah, I'm like, why I, I haven't nobody called on this to find out the depth of the polic[PII]
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Why?
[CUSTOMER][NEUTRAL] But that's what it is. OK. So, he has a hospital, hospital indemnity policy. So he only, it only covers $25 max for 5 visits per calendar year.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes, mhm.
[CUSTOMER][NEUTRAL] So the rest is his is patient responsibility.
[AGENT][NEUTRAL] Now, we don't determine patient responsibility because we're not a major medical, but if he doesn't have any other insurance, then it would just be up to, you know, you all, whatever your procedures are for outstanding balances. Mhm.
[CUSTOMER][NEUTRAL] Yeah, he don't, yeah, he didn't provide any other insurance, so that's what it is. I just want to make sure. OK. That makes sense. OK. And again, I'm sorry, what's your name again?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] My name is [PII] and the first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] And [PII], can I get a reference number?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name and today's date.
[CUSTOMER][POSITIVE] Got it. Thank you so much for all your help. I really appreciate it.
[AGENT][NEUTRAL] You're welcome, [PII]. Was there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, that's it. Thank you.
[AGENT][POSITIVE] Alright, well, I hope you have a great day. You're welcome.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] You too. Bye-bye.