AccountId: 011433970860
ContactId: 03861e5e-5cc3-475e-a778-2996ed9a4f2b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 303480 ms
Total Talk Time (AGENT): 119584 ms
Total Talk Time (CUSTOMER): 112766 ms
Interruptions: 2
Overall Sentiment: AGENT=0.8, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/23/03861e5e-5cc3-475e-a778-2996ed9a4f2b_20250423T21:12_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] Hi, [PII]. My name is [PII]. I'm calling from South Medical Foundation, checking on the claim status.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claim status and how many claims do you have in total today, [PII]?
[CUSTOMER][NEUTRAL] One claim.
[AGENT][NEUTRAL] OK, may I have the, well, a good contact number in case we're disconnected and then the policy number.
[CUSTOMER][NEUTRAL] Yes, uh, contact number is [PII] [PII] and the ID is [PII].
[AGENT][NEUTRAL] And that was 02550829?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah, member's name [PII], and 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] Oh.
[CUSTOMER][NEUTRAL] [PII] and the amount is $2,272 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And what is the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Setter Guard Medical Foundation.
[AGENT][NEUTRAL] Alright, so I'm showing the claim was received on [PII].
[CUSTOMER][NEUTRAL] 5
[AGENT][NEUTRAL] The claim number is 358.
[CUSTOMER][NEUTRAL] Yeah, for this one, I do have a specific question.
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] Yeah, one moment, please. Yeah, for this one, I do see that uh CPT 70553 has been paid of $500 and there are two other CPTs A 9585 CPTs uh were not paid like uh we did not receive any payments for that CPT. So can you please help me with that information?
[AGENT][NEUTRAL] Yes, both claims uh both lines were denied because there's a per occurrence maximum for treatment. So the $500 was the max for this occurrence. Occurrence is anything with the same or related condition. So those were denied because the max was paid to 70553.
[CUSTOMER][NEUTRAL] OK, the, the, the CPT allowable amount is 500 only for that CPT.
[AGENT][NEUTRAL] The benefit, not CPT, the benefit used is the outpatient um benefit. Hold on one moment, let me go to that screen.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] It's um outpatient per occurrence.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Some of them are per day, some of them are per calendar year. This policy is per occurrence. So anything with the same or related condition is an occurrence. So everything on this claim was the same date of service and for the same issue, that's the same occurrence. So $500 was applied to the first code.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can you please uh go ahead and, uh, fax the UB.
[AGENT][NEUTRAL] What's a good fax number for you?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And should I put attention, [PII]?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh yes. [PII]
[AGENT][NEUTRAL] And that was not
[AGENT][NEUTRAL] And that was 916-732-88887?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so I'll go ahead and send this over to you now. Was there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And nothing else. Help me with your name and the call reference number.
[AGENT][NEUTRAL] Sure, my name is [PII] There is, well, the first initials of my last name is [PII]. There's no call reference number, but you can use my name and today's date.
[CUSTOMER][POSITIVE] OK, [PII], thank you. That's it for now.
[AGENT][POSITIVE] You're welcome, [PII]. Thanks for calling APL. I hope you have a great day.
[CUSTOMER][POSITIVE] Thank you same to you bye bye.
[AGENT][NEUTRAL] Bye bye.