AccountId: 011433970860
ContactId: 1503f258-a6a1-454c-ad6f-e8be3574e110
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 580419 ms
Total Talk Time (AGENT): 191733 ms
Total Talk Time (CUSTOMER): 200292 ms
Interruptions: 2
Overall Sentiment: AGENT=1.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/31/1503f258-a6a1-454c-ad6f-e8be3574e110_20241231T16:36_UTC.wav
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[AGENT][POSITIVE] Good morning.
[CUSTOMER][NEUTRAL] Oh yes.
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from provider's office to check on claim status.
[AGENT][POSITIVE] [PII], it would be a pleasure to assist you with claim status. What is a good callback number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's [PII] direct line.
[AGENT][NEUTRAL] Thank you, [PII], and the policy number for the patient?
[CUSTOMER][NEUTRAL] It's 01780658 M as in Mike, L as in Lima, number 8.
[AGENT][NEUTRAL] Thank you, [PII] and the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Patient's name is [PII]. Date of birth is [PII].
[AGENT][POSITIVE] Alright, thank you, and it would be my pleasure to help you with that claim status. Do you have a claim number or date of service?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm. The date of service is [PII] and the total bill amount is $1000 even.
[AGENT][NEUTRAL] All right, thank you. And what is the facility name?
[CUSTOMER][NEUTRAL] It's uh [PII].
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] [PII], we did receive that claim on [PII].
[CUSTOMER][POSITIVE] Keep you going
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And processed on [PII].
[AGENT][NEUTRAL] And that claim was denied if the outpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Uh, but the CPD code, I don't think this is for outpatient.
[CUSTOMER][NEUTRAL] CPD code is 26116 with the modifier F1.
[CUSTOMER][NEUTRAL] Let's see next year.
[AGENT][NEUTRAL] It depends on the place of service that was coded on the claim.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] they just
[AGENT][NEUTRAL] Uh, bear with me just.
[CUSTOMER][NEUTRAL] May I know the quantity?
[AGENT][POSITIVE] I'm so sorry.
[AGENT][NEUTRAL] Can you repeat that?
[CUSTOMER][NEUTRAL] May I know the uh quantity of units, how much time it can be built in a single year.
[AGENT][NEUTRAL] Yeah, it's a dollar amount, and that maximum dollar amount per calendar year is $2500.
[AGENT][NEUTRAL] Let me check this claim for you, bear with me just one second.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEGATIVE] It wasn't a place service 19.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] The benefit
[AGENT][NEUTRAL] That does include for outpatient facility.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, they are uh
[CUSTOMER][NEUTRAL] That means you're saying that maximum benefit has been exhausted as for the dollar amount, correct?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. And the maximum dollar amount is $2000.
[AGENT][NEUTRAL] 2500 per calendar year.
[CUSTOMER][NEUTRAL] So the, is the provider is capitated?
[AGENT][NEUTRAL] That that means that the benefit amount has been met and therefore there are no benefits payable for the remainder of 2024.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mm, can I place the call on hold for a minute while I check the details for this patient?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, still checking.
[AGENT][POSITIVE] No problem. Take your time.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] Are you a health insurance?
[AGENT][NEUTRAL] We are a medical uh gap provider.
[CUSTOMER][NEUTRAL] Medical care providers.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Medical care provider.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] OK, fine. Uh, I do have one more date of service for the same patient, so could you check for this?
[AGENT][POSITIVE] It, it would be my pleasure. And what is that next date of service?
[CUSTOMER][NEUTRAL] I am.
[CUSTOMER][NEUTRAL] It's, um, uh, first, can you provide me the claim number for this date of service?
[AGENT][NEUTRAL] Sure, absolutely. That claim number is 353.
[AGENT][NEUTRAL] 9551
[CUSTOMER][POSITIVE] Thank you so much. And should I proceed with the next date of service?
[AGENT][POSITIVE] I'm ready, [PII].
[CUSTOMER][NEUTRAL] It's uh [PII].
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] And that bill amount?
[CUSTOMER][NEUTRAL] morning.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] A couple.
[CUSTOMER][NEUTRAL] The bill amount is $472.55.
[AGENT][POSITIVE] All right, thank you.
[CUSTOMER][NEUTRAL] With each other.
[AGENT][NEUTRAL] Now that claim we received on 129 is for the same provider, correct? [PII].
[CUSTOMER][NEUTRAL] I kind of
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you. And that claim we received on 129 processed on [PII].
[AGENT][NEGATIVE] And this claim was just denied as the services are non-covered.
[AGENT][NEUTRAL] The 99214.
[AGENT][NEUTRAL] Was denied as office visits not covered?
[CUSTOMER][NEUTRAL] I have done with that parent of nearly 4.
[AGENT][NEUTRAL] And then the 20,550 and the J 3301 was denied as services are not covered when performed in a doctor's office.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Services are not covered.
[AGENT][NEUTRAL] That's right. Um, it's because it was in a doctor's office.
[AGENT][NEUTRAL] Services are not covered when performed in a doctor's office. That would be included for procedures or treatments, as well as for the office visit co-pay.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] But primary has already made a payment for this, so.
[AGENT][NEUTRAL] Mhm. But it's.
[CUSTOMER][NEUTRAL] How can you deny this?
[AGENT][NEUTRAL] It's a non-covered benefit on the patient's gap policy, and that is per the policy guidelines of the patient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can you provide me the claim number for this also?
[AGENT][NEUTRAL] Claim number 3539546.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] My pleasure. Anything else I can help you with, [PII]?
[CUSTOMER][NEUTRAL] So for this claim, I need to submit a corrected claim.
[AGENT][NEUTRAL] The place of service is non-covered.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, fine. Got it.
[CUSTOMER][NEUTRAL] And also can you provide me the call reference for this call?
[AGENT][NEUTRAL] The call reference number is my name and today's date, and I spell my name, [PII]
[AGENT][POSITIVE] First initial and my last name is [PII]. [PII], it was a pleasure to assist you with that claim status. Anything else I can help you with?
[CUSTOMER][POSITIVE] No, no, thank you. Thank you for your assistance and have a great day. Bye for now and happy New Year.
[AGENT][POSITIVE] I hope you have a happy New Year to you as well, [PII]. Thank you for calling APL. Take care.
[CUSTOMER][NEUTRAL] Yeah.