AccountId: 011433970860
ContactId: 07e83e20-73bc-401e-a7f4-b5f759fe0889
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 618849 ms
Total Talk Time (AGENT): 182240 ms
Total Talk Time (CUSTOMER): 190869 ms
Interruptions: 1
Overall Sentiment: AGENT=1, CUSTOMER=1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/24/07e83e20-73bc-401e-a7f4-b5f759fe0889_20250424T19:15_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII], and I'm calling for provider to check on additional information about a claim that has been denied. Please note this call will be monitored and recorded for quality and training purposes. How was your day?
[AGENT][POSITIVE] It is going all right thank you how's yours?
[CUSTOMER][POSITIVE] That's good.
[AGENT][POSITIVE] Thank you. All right, um, I can definitely get clarification on that claim for you. I'm so sorry, what did you say your name was?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] OK. [PII], can I get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] The callback number is [PII]. It's a direct line with no extension.
[AGENT][NEUTRAL] Thank you. And then do you have that policy number?
[CUSTOMER][NEUTRAL] The member ID number is 02486379.
[AGENT][NEUTRAL] OK, and uh what was the name and date of birth for the member, please?
[CUSTOMER][NEUTRAL] Member's first name is [PII]. Last name [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK, um,
[AGENT][NEUTRAL] Let's see, do you have that claim number, that one?
[CUSTOMER][NEUTRAL] Uh, the claim number for that is 3584864.
[AGENT][NEUTRAL] OK thank you one moment please.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK. Give me just a moment. Let me take a look.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, so I'm showing that this claim was a duplicate, uh, so give me just a moment, I'll try to find that original claim.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] That's
[AGENT][NEUTRAL] OK, so I did find this original claim, a bad one, so for this original claim we did pay a benefit of $75 and that did meet their maximum for this date of service.
[CUSTOMER][NEUTRAL] OK, so all the other codes are denied as a non-covered service.
[AGENT][NEGATIVE] It's not that they're not covered we simply could not they met their maximum, so there was no additional benefit for us to be able to pay.
[CUSTOMER][NEUTRAL] So only $75 is allowed per day or
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, just a moment, please.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] And you have made payment for the code 99214.
[AGENT][POSITIVE] Yes, that's correct. Yes, that's correct.
[CUSTOMER][NEUTRAL] For $75.
[CUSTOMER][NEUTRAL] And all other codes, so that's the benefit maximum for, for the claim for that day and was for all the code were they need for the reason of benefit maximum reached.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Thank you. May I know the claim num original claim number, please?
[AGENT][NEUTRAL] Yes, that original claim number is 3576577.
[CUSTOMER][NEUTRAL] And this process, the original claim process is not.
[AGENT][NEUTRAL] Uh, this was processed on [PII].
[CUSTOMER][NEUTRAL] Mo
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] And the uh and the duplicate claim process now?
[AGENT][NEUTRAL] Um, give me just a moment, let me get that was.
[AGENT][NEUTRAL] Uh, [PII].
[CUSTOMER][NEUTRAL] And may I know what is, why you paid only $75?
[AGENT][NEUTRAL] That was the maximum benefit per day.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Uh, OK. Mm, OK. Thank you. And before moving to the last claim, can I have the, uh, spelling of your name on the card reference number?
[AGENT][NEUTRAL] Uh, reference number would be the same uh for any that we check. That would be, um, reference number would be my first name, last initial, and today's date. Uh, so my name is spelled [PII] and this other claim card one, is this for the same number or is this for a different member?
[CUSTOMER][NEUTRAL] Different number.
[AGENT][NEUTRAL] OK, give me just a moment. I'll let you know when I'm ready for that policy number.
[CUSTOMER][POSITIVE] OK, take your time.
[CUSTOMER][NEUTRAL] Is there any time I need to uh bring it up?
[CUSTOMER][POSITIVE] OK, that's lovely and do you have a fax number to bill?
[AGENT][NEUTRAL] OK, I'm ready for that next policy number when you are.
[CUSTOMER][NEUTRAL] The policy number is?
[CUSTOMER][NEUTRAL] 02455926
[AGENT][NEUTRAL] OK, and then uh what was the name and date of birth for this number?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Member's first name is [PII]. Last name [PII].
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Did you have that date of birth?
[CUSTOMER][NEUTRAL] I need
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you for verifying that. What was the date of service for this claim?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII] and then uh what was that bill amount, please?
[CUSTOMER][NEUTRAL] So the.
[CUSTOMER][NEUTRAL] The amount is 5 $454.80. And do you want the claim number?
[AGENT][POSITIVE] OK. Yes, please, that would be great.
[CUSTOMER][NEUTRAL] 358
[CUSTOMER][NEUTRAL] 5311
[AGENT][NEUTRAL] I'm sorry I cut out there was that that was 358-531-1?
[CUSTOMER][POSITIVE] That's right.
[AGENT][NEUTRAL] OK, OK thank you one moment.
[AGENT][NEUTRAL] OK, so for this claim, Gladwin, um, we were unable to pay a benefit as this policy allows payments for outpatient surgery in an outpatient hospital or a physician's office.
[CUSTOMER][NEUTRAL] Uh, well,
[CUSTOMER][NEUTRAL] So patients are not covered under your guidelines.
[AGENT][NEUTRAL] Correct. Um, it's not a covered facility for an outpatient surgery.
[CUSTOMER][NEUTRAL] Outpatient surgeries are not covered under your guidelines, right?
[AGENT][NEUTRAL] Outpatient surgery is only covered in an outpatient hospital or a phys excuse me, physician's office under this policy.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So in this case, uh, in this claim, the outpatient uh office sur uh outpatient surgery is not covered under the mam under your guidelines, right?
[AGENT][NEUTRAL] Outpatient surgery is covered if it takes place in an outpatient hospital or a physician's office.
[CUSTOMER][NEUTRAL] Oh well.
[CUSTOMER][NEUTRAL] Of this place of services. Just a moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK, just a moment, please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK. Thank you for your patience.
[CUSTOMER][NEUTRAL] So until this, uh, the surgery was, uh, not done in a physician's office, uh, so it is not covered, right?
[AGENT][NEUTRAL] Correct. Yes. It's not a covered facility for outpatient surgery. Yes.
[CUSTOMER][NEUTRAL] Under your guidance until it is not done. Thank you.
[CUSTOMER][POSITIVE] Thank you. And
[CUSTOMER][POSITIVE] Thank you. And this claim is processed on.
[AGENT][NEUTRAL] Um, let's see, this claim was processed on [PII].
[CUSTOMER][POSITIVE] Thank you so much, [PII]. Thank you for assisting me today. Kindly. Have a great, great day.
[AGENT][NEUTRAL] Alright, yeah, was there anything else I could help you with?
[CUSTOMER][NEUTRAL] Uh, no, thank you.
[AGENT][POSITIVE] All right well thanks for giving us a call. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] Bye for now.
[AGENT][POSITIVE] Thank you. Bye-bye.