AccountId: 011433970860
ContactId: 0481922f-309e-4455-8499-2bd3e6831902
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 752219 ms
Total Talk Time (AGENT): 221724 ms
Total Talk Time (CUSTOMER): 205063 ms
Interruptions: 2
Overall Sentiment: AGENT=-0.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/02/0481922f-309e-4455-8499-2bd3e6831902_20250502T18:29_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello, my name is [PII] calling from the provider's office.
[AGENT][NEUTRAL] Uh, your name was, you said, uh, Siri?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, uh, so, can I get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you and then what can we help you with today?
[CUSTOMER][NEUTRAL] Um, please.
[AGENT][NEUTRAL] OK, I could check on a claim for you. Uh, Siri, can I get uh that policy number, please?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 0194 0423.
[AGENT][NEUTRAL] OK, and what was the name and date of birth for this number?
[CUSTOMER][NEUTRAL] [PII]. And the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for verifying that. And what was the date of service for this claim?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] Yeah, that was [PII].
[CUSTOMER][NEUTRAL] Yeah, the total charges of $8,193.63.
[AGENT][NEUTRAL] OK, um, one moment please.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, so we did receive this claim, uh, we were unable to pay a benefit as under this policy, the outpatient benefit pays per occurrence and the maximum amount payable for this occurrence had been met.
[CUSTOMER][NEUTRAL] So, you mean the primary paid more than to be allowed?
[AGENT][NEUTRAL] No, um, so under this policy, their outpatient benefit pays on a per occurrence basis. So it had reached its maximum amount payable for this occurrence.
[AGENT][NEUTRAL] I can send you this EOB if you'd like Siri.
[CUSTOMER][NEUTRAL] We actually send uh.
[CUSTOMER][NEUTRAL] Just a, ma'am.
[CUSTOMER][NEUTRAL] It's actually my 2nd time calling for this claim, and when we call the it was denied as charges, uh, fee excluded marks LOL so.
[AGENT][NEGATIVE] Yes, the benefit amount had met its maximum. We were unable to pay anything additional for this occurrence.
[CUSTOMER][NEUTRAL] OK. Uh, which code is, I mean, the code 741676 can be billed within 90 days?
[AGENT][NEUTRAL] Um, build, what do you mean?
[CUSTOMER][NEUTRAL] I mean,
[CUSTOMER][NEUTRAL] Uh, which code is denied?
[AGENT][NEGATIVE] It's the entire uh claim. We were unable to make a pay a benefit on it as we had already paid the maximum amount for this occurrence.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, may I know when we have built the same, uh, code previously?
[AGENT][NEUTRAL] When we had received this claim?
[CUSTOMER][NEUTRAL] Can you provide me the key?
[CUSTOMER][NEUTRAL] I mean, no. You said uh the maximum allowed amount allowed.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] But when it had maximum you mean?
[CUSTOMER][NEUTRAL] So when we build the claim previously, like when the code, when the code.
[CUSTOMER][NEUTRAL] Has built previously.
[AGENT][NEUTRAL] For this occurrence, yes, so for this occurrence we paid the benefit maximum on [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] And they continued receiving treatment after, but we were unable to pay anything additional as it was for the same occurrence.
[CUSTOMER][NEUTRAL] Can you provide me the claim number?
[AGENT][NEUTRAL] 356-557-0.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you already paid uh to this to for another date of service, right? May I know the account number as well?
[AGENT][POSITIVE] Correct. And
[AGENT][NEGATIVE] No, as that was from a different provider and I'm, I'm unable to give that information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, what do you suggest me to do?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Um, what's the next step we have to do for this claim?
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Um, I mean there's nothing that we're able to do. They had exceeded their benefit. They had met their benefit amount, so there's nothing for us to be able to pay.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, was there anything else I can help you with Siri?
[CUSTOMER][NEUTRAL] Yeah, just a minute. Can you, in the meantime, can you spell your name?
[AGENT][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] And the call reference number?
[AGENT][NEUTRAL] Reference number would just be my first name, last initial, and today's date so my last initial is A.
[CUSTOMER][NEUTRAL] Just a minute, let me discuss with my supervisor please OK?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, and may I know the data service which we built recently for that uh so code again?
[AGENT][NEUTRAL] The date of service you gave me was for uh [PII]. Do you mean when we received this claim?
[CUSTOMER][NEUTRAL] No, you said
[CUSTOMER][NEUTRAL] We already paid, right?
[CUSTOMER][NEUTRAL] Sorry, sorry.
[CUSTOMER][NEUTRAL] Actually,
[CUSTOMER][NEUTRAL] The claim number you mentioned is belongs to which uh data service?
[AGENT][NEUTRAL] That was [PII] for $8,193.63.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Would you like me to send you this EOB series that has all of this information?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. Uh, in our claim, the 74176. So may I know how many times we can build this code to the?
[AGENT][NEUTRAL] What was that? I'm sorry?
[CUSTOMER][NEUTRAL] The code which is 74176 in the claim form.
[AGENT][NEUTRAL] OK, we, it doesn't matter which code it is Siri as it was all a part of the same occurrence for this member. So for this particular occurrence there's nothing additional we can pay regardless of the procedure code.
[CUSTOMER][NEUTRAL] Yeah, so how many times uh we can build the same code?
[CUSTOMER][NEUTRAL] Within which time period, like 90 days or?
[AGENT][NEUTRAL] For this same occurrence, we're not able to pay anything additional.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Twice we can bill twice. Zip code.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Uh, actually, I'm asking you.
[CUSTOMER][NEUTRAL] There is the code in our claim form like the CPT code.
[CUSTOMER][NEUTRAL] 74176. May I know how many times this code can be paid? Like in the time period of 90 days or 30 days.
[AGENT][NEUTRAL] That's not how this policy works. Again, it goes based off of occurrence, not specific procedure codes.
[AGENT][NEGATIVE] So for this particular occurrence, regardless of procedure codes, we're unable to pay anything additional.
[CUSTOMER][NEUTRAL] Like
[AGENT][NEUTRAL] So it's not a matter of how many times that can be sent to us.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So do we need to build the balance of 300 to the patient?
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] We don't say what is patient responsibility, that would be up to the provider.
[CUSTOMER][NEUTRAL] OK. Is it uh our
[CUSTOMER][NEUTRAL] Responsibility to pay?
[AGENT][NEUTRAL] We do not say what is patient responsibility, that would be up to the provider. We don't say either way.
[CUSTOMER][NEUTRAL] It just
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can we appeal for this scenario?
[AGENT][NEUTRAL] You're more than welcome to, so this original, it's um let's see, let me see when this original process date was.
[CUSTOMER][POSITIVE] We actually appealed this uh
[AGENT][NEUTRAL] So this claim was processed.
[CUSTOMER][NEUTRAL] Uh, we actually sent the appeal on [PII].
[AGENT][NEUTRAL] This disclaimer
[AGENT][NEUTRAL] If you have submitted an appeal, we have not yet received it. I'm not showing we have any appeals for this.
[AGENT][NEUTRAL] So it does have to be within 180 days of the process date, which was [PII], and along with the information, it does have to include a letter stating that it is indeed for an appeal.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank you. Have a great day.
[AGENT][POSITIVE] All right, thank you. You too. Bye-bye.