AccountId: 011433970860
ContactId: 077252a1-d3a5-41a7-8f0f-15a35b0fe2c7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 742099 ms
Total Talk Time (AGENT): 206795 ms
Total Talk Time (CUSTOMER): 201573 ms
Interruptions: 4
Overall Sentiment: AGENT=0, CUSTOMER=-0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/13/077252a1-d3a5-41a7-8f0f-15a35b0fe2c7_20250513T13:51_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. I need to check on the claim. Can you please help me on this?
[AGENT][NEUTRAL] Sure, [PII], I can assist you with claim status. Um, first, I'll need a good callback number just in case we're disconnected.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. Now, I need the policy number, please.
[CUSTOMER][NEUTRAL] Uh-huh. The policy number is 02521722.
[AGENT][NEUTRAL] Please verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK, thank you. Now I need the date of service and bill charges for the client.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, so I need the date of service and bill charges for the claim.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes, the date of service and bill charges for the claim, please.
[CUSTOMER][NEUTRAL] Please.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Total bill amount, $1,628 even.
[AGENT][NEUTRAL] OK, one moment, please.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Do you need the claim number?
[AGENT][NEUTRAL] Yes, what's the claim number?
[CUSTOMER][NEUTRAL] Hold on, I do have the claim number.
[CUSTOMER][NEUTRAL] 3583276.
[AGENT][NEUTRAL] OK. Yes, sir. We received that claim on [PII].
[AGENT][NEUTRAL] The claim processed on [PII].
[AGENT][NEUTRAL] And the claim denied because under this policy, we cover up to $200 per day.
[AGENT][NEUTRAL] And that maximum was met on a previous client.
[AGENT][NEUTRAL] So the claim denied because benefit maximum was reached on a previous claim.
[CUSTOMER][NEUTRAL] Uh, sir, it's a $1.
[AGENT][NEUTRAL] Please repeat the question.
[CUSTOMER][NEUTRAL] Uh, the maximum benefit existed for the dollar amount or for visits?
[AGENT][NEUTRAL] Um, for the dollar amount.
[CUSTOMER][NEUTRAL] What is, uh, uh,
[CUSTOMER][NEUTRAL] The CPT code that is billed is 00400 QKQP3.
[CUSTOMER][NEUTRAL] But this is a particular code that has been denied, right?
[AGENT][NEUTRAL] Yes, they denied because of the dollar amount. The benefit maximum was reached on a previous claim.
[CUSTOMER][NEUTRAL] OK. Can you please help me what is the previous uh claim number that has been uh
[AGENT][NEUTRAL] The claim number is 3563095.
[CUSTOMER][NEUTRAL] OK. And your name, please?
[AGENT][NEUTRAL] My name is [PII]. Um, it's spelled [PII] My last initial is [PII]. Um, is there anything else I can assist you with?
[CUSTOMER][NEUTRAL] Yes, and uh I have a small concern. We have uh just for courtesy, we have received a response from our uh coding department stating that, that the previous claim number I have checked, there is no modified on that. This is differently different CPT code. As for NCC Medicare guidelines, uh, the previous that has been paid for totally for different CPT code and for also for the
[CUSTOMER][NEUTRAL] Previous different services. For one time, you can send the claim back for reprocessing. If the claim gets the same denied, then we can go ahead and appeal as for our uh coding the billing department. Thank you.
[AGENT][NEUTRAL] OK. Is there anything else I can assist you with, [PII]?
[CUSTOMER][NEUTRAL] OK. How long it will take now to get the reprocess?
[AGENT][NEUTRAL] Once we receive the claim, please allow 7 to 10 days for the claim to be processed.
[CUSTOMER][NEUTRAL] 7 to 10 business days or calendar days.
[AGENT][NEUTRAL] Business days.
[CUSTOMER][NEUTRAL] OK. You can send the claim back. And what is the uh
[AGENT][NEUTRAL] Well, you would have to resubmit the claim. You would have to resubmit the claim. I can't send the claim back. You would have to resubmit it.
[CUSTOMER][NEUTRAL] Previous uh
[CUSTOMER][NEUTRAL] If
[CUSTOMER][NEUTRAL] No, no, no, no. We can't be able to resubmit the claim since already we have submitted the claim for more than 1 2nd. 1234 times. Since we get the same, that's why I stated you, please send claim back for once time. And then if we get the same dinner, then we can go ahead and appeal for the consult.
[AGENT][NEUTRAL] No, sir. We don't, we don't send, we don't, we don't send the claim back. Is there anything else I can assist you with? I can't assist you with sending the claim back. We don't do that. You would have to resubmit it. If you don't want to resubmit it.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Is there anything else I can assist you with, [PII]?
[CUSTOMER][NEUTRAL] Can you please transfer the call to the supervisor?
[AGENT][NEUTRAL] No, I can't, not at this time.
[AGENT][NEUTRAL] You can give her a call back. Would you like her number?
[CUSTOMER][NEUTRAL] Yeah, that's fine for one-time courtesy.
[CUSTOMER][NEUTRAL] No, no, no, no. For one time you can send the claim back, uh.
[AGENT][NEUTRAL] No, sir. We don't do that. We don't send claims back.
[CUSTOMER][NEUTRAL] Ma'am, uh, one second. Already we have submitted the claim 6 times.
[AGENT][NEUTRAL] Well, the claim is the, the claim is the 9. The claim is the 9, sir. We cover up to $200 per calendar day, and that benefit maximum was reached on a previous claim. The benefit maximum has already been reached for that day. That's why the claim continues to deny.
[CUSTOMER][NEUTRAL] Previous stat is stated they have one second.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] Yeah, no, no, no. That's why we
[CUSTOMER][NEUTRAL] No, that's why we have received from the NCC Medicare guidelines that the previous uh CPD and the claim number is for totally different services. That's why I suggest a previous process, you send the claim back, but it was incomplete. They have not sent the claim but.
[AGENT][NEUTRAL] Well, the way that this policy was written is, is not based on the service, it's based on the date of service. The way this policy is written, the benefit is based on the date of service.
[CUSTOMER][NEUTRAL] Yeah, that, that's
[AGENT][NEUTRAL] Not on the procedure. It's based on the date of service and for the date of service, the benefit maximum was reached. That's why the claim continues to deny.
[CUSTOMER][NEUTRAL] No, no, it is.
[AGENT][NEUTRAL] Because there's no more benefits for that date of service.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, OK, you can send the claim back and what is the reference number for this call?
[AGENT][NEUTRAL] I'm not sending the claim back. You can use my name and the date, today's date for the reference number. My name is [PII]. It's spelled [PII]
[CUSTOMER][NEUTRAL] then please transfer the call to your supervisor.
[AGENT][NEUTRAL] I'll see if one is available. One moment.
[CUSTOMER][NEUTRAL] Please transfer the call to your supervisor.
[AGENT][NEUTRAL] I'll see if one's available. One moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] OK, my, you'll be the customer in the my insurance lounge you'll be it.
[AGENT][NEUTRAL] OK, [PII]. Thanks for your patience. There's no supervisor available to speak with you. You can try back in about an hour or so. Is there anything else I can assist you with?
[CUSTOMER][NEGATIVE] Yeah, I, I need a resolution. I can't be able to call back once again.
[CUSTOMER][NEUTRAL] That's why I said you to send the claim back.
[AGENT][NEUTRAL] Is there anything else that I can assist you with? I already told you that I don't send claims back. We don't do that, sir. You can resubmit the claim if you like, but I'm unable to send the claim back.
[CUSTOMER][NEUTRAL] Is there anything else that I can search you about?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] You can submit the sign like. No. If the claim is on file, why I can't, why I need to resubmit the claim?
[AGENT][NEUTRAL] I'm sorry, [PII]. I have other calls holding. You can, you can call back and speak with the supervisor if you like in about an hour. So, is there anything else that I can assist you with?
[CUSTOMER][NEUTRAL] I probably call I have
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Like about.
[CUSTOMER][NEUTRAL] I can
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Well.