AccountId: 011433970860
ContactId: 0379ab76-1356-45ad-a693-6d787e90d70e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 625789 ms
Total Talk Time (AGENT): 228504 ms
Total Talk Time (CUSTOMER): 126644 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/28/0379ab76-1356-45ad-a693-6d787e90d70e_20250428T13:03_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] Yes, hi, this is [PII] and I'm calling for provider's office to check my additional information about the claim that has been denied. Please note this call will be monitored recorded for quality and training purposes. How are you today, [PII]?
[AGENT][POSITIVE] I'm doing well, [PII] How are you?
[CUSTOMER][POSITIVE] Yes, I'm also doing good. Thank you so much for asking.
[AGENT][POSITIVE] That's good. Well, I'll be more than happy to help you with your denial clarity. May I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure, it's [PII].
[CUSTOMER][NEUTRAL] [PII] and that is direct line?
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the policy number whenever you're ready.
[CUSTOMER][NEUTRAL] That's D as in Delta, 448-04146.
[AGENT][NEUTRAL] OK, and do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And on the ID card, do you see anywhere that says in hospital or outpatient policy cert number?
[AGENT][NEUTRAL] It should start with a 01 or 02.
[CUSTOMER][NEUTRAL] Uh yes, I have one more ID uh which is uh 02580825.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] That's [PII]. Date of birth, uh [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 claim number for the denial you'd like to go over?
[CUSTOMER][NEUTRAL] Uh, yes, one moment.
[CUSTOMER][NEUTRAL] It's loading here. One moment.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah, the number here, it shows 358-512-3.
[AGENT][NEUTRAL] OK. And do you mind if I place you on just a brief hold while I locate the claim and see the denial?
[CUSTOMER][POSITIVE] Sure, no problem.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] But
[AGENT][NEGATIVE] Oh, it was all too far.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Uh
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello, [PII]
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you so much for holding. I do apologize for that wait. Um, so the claim number that you gave 358-512-3 was denied as a duplicate of the original claim, which is claim number 3,566,650, which was denied because the um maximum for the data service has been met.
[CUSTOMER][NEUTRAL] Maximum has been met. And may I know, is it regarding the number of visits or according to the dollar amount?
[AGENT][NEUTRAL] Both, um, the benefit is $100.04 times a calendar year, and the $100 was applied to code 99214, um, which is another claim, but it was still the same date of service, um, as yours.
[CUSTOMER][NEUTRAL] OK. $100 for 4 visits, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. May I know when was the member has utilized the, is it the same date of service?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. It's for the same, uh, I mean, same provider?
[CUSTOMER][NEUTRAL] A different provider.
[AGENT][NEUTRAL] No, it's, I'm checking that now, but it's the same provider. I'm just seeing if it's a different tax ID. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah, it's the same tax ID. So it's the same provider. So you have a claim that was submitted claim number 3,566,650 and we paid $100 to that claim.
[CUSTOMER][NEUTRAL] One moment. Let me check if I have the UOB or not.
[AGENT][NEUTRAL] Hold on, I said that wrong. Wait a minute. So you, you also submitted this claim three times. The first time you submitted it was [PII], well, we received it on [PII], which is claim number 3566646.
[AGENT][NEUTRAL] On that claim, we paid $100 to code 99214.
[AGENT][NEGATIVE] You then submitted the claim again, which is 356-6650, which was um denied because the max had been met, we paid the $100 on the first claim and then you sent it in again and it was denied as a duplicate of the second claim because the max has been met.
[CUSTOMER][NEUTRAL] Yes, uh, but according to the
[CUSTOMER][NEUTRAL] There is, uh, not that, uh, it's not 99214. There are three different codes built on this claim.
[AGENT][NEUTRAL] As I stated, the 99214 is on a different claim. That claim number is 3566646.
[AGENT][NEUTRAL] It's patient account number 721.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 01
[AGENT][NEUTRAL] 83 V like Victor, 8042.
[CUSTOMER][NEUTRAL] Yes, but there are some uh different CPT codes, right? Uh, not the same services, right?
[AGENT][NEUTRAL] So there's one benefit. The benefit is $100.04 times a year per visit. These are different CPT codes, but they are all for date of service, [PII]. That's one day we applied the $100 to the first claim that came in.
[AGENT][NEUTRAL] That is the max for that benefit.
[CUSTOMER][POSITIVE] OK, yeah, I got it.
[CUSTOMER][NEUTRAL] Uh yes. Could you please repeat the uh patient account number one more time for my documentation.
[AGENT][NEUTRAL] For the paid claim?
[CUSTOMER][NEUTRAL] The paid one.
[AGENT][NEUTRAL] It's 721.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] 01
[AGENT][NEUTRAL] 830.
[AGENT][NEUTRAL] V like Victor.
[AGENT][NEUTRAL] 8042.
[CUSTOMER][POSITIVE] Thank you so much for that information. And yes, the, is there any, uh, the appeal mailing address?
[AGENT][NEUTRAL] The appeals mailing address. Hold on, let me see which one this goes to. Hold on one second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII] is the zip code.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the finding limit would be?
[AGENT][NEUTRAL] Um, 180 days after the denial date.
[CUSTOMER][POSITIVE] Thank you so much. And is there any call reference number?
[AGENT][NEUTRAL] So there's no call reference number, um, but you can use my name in today's date and again that's [PII], first initial and my last name is [PII].
[CUSTOMER][POSITIVE] Got it. Thank you so much uh for that information, [PII] and really have a great day. Bye.
[AGENT][POSITIVE] Thank you, [PII] You also, was there anything else I can assist with?
[CUSTOMER][NEUTRAL] No, this bill. Thank you.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL bye bye.