AccountId: 011433970860
ContactId: 18ec3c4f-45ea-4f89-b3ab-265db393c935
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 398619 ms
Total Talk Time (AGENT): 152076 ms
Total Talk Time (CUSTOMER): 161118 ms
Interruptions: 3
Overall Sentiment: AGENT=0.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/31/18ec3c4f-45ea-4f89-b3ab-265db393c935_20241231T16:53_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Thanks for calling to Shiloh. How may I assist you?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hi, good good morning. My name is [PII] and I'm calling from provider's office to check on claim status.
[AGENT][NEUTRAL] Sure, I can assist you with that. [PII]. Could I have a callback number for you and the spelling of your name?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, sure. It's [PII]. And my spelling of my name is [PII]. Last name initial is [PII].
[AGENT][NEUTRAL] Can I have that policy number of the member that you're inquiring benefits for?
[CUSTOMER][NEUTRAL] It's 01780658, Mike Lima number 8.
[AGENT][NEUTRAL] And can you verify the patient's name and date of birth, and I'll be able to assist you with the claim status.
[CUSTOMER][NEUTRAL] [PII], patient's name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] And what is the date of service?
[CUSTOMER][NEUTRAL] It's [PII] for the total bill amount, $1000 even.
[AGENT][NEUTRAL] Do you have a procedure code?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes, it's 261-16 with modifier F1.
[AGENT][NEUTRAL] This claim was received [PII]. It was processed [PII]. There was no payment made on this claim because the benefits for the calendar year for the policy was maxed out.
[CUSTOMER][NEUTRAL] OK. And what is the maximum value, uh, dollar amount for the calendar year?
[AGENT][NEUTRAL] Give me one moment.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] The outpatient benefits per calendar year is $2500.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] This was utilized by the same provider or different provider?
[AGENT][NEUTRAL] I can't provide you with that information, however, the benefits were exhausted by the time your claim came here.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Is there anything else that I can assist you with today?
[CUSTOMER][NEGATIVE] Because upon checking in my system, uh, we can't see that the $2500 have been exhausted because American Public Life Insur have never made that much of payment.
[AGENT][NEUTRAL] No, I never stated that there was a payment for your claim. I stated that the benefits for the calendar year for the member's policy was term was maxed out.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] No, no. Yes. Uh, I'm saying, I'm saying about the calendar year only. Uh, I'm checking the details for all the calendar year and I didn't see many payment like for $2500.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I mean if the if the
[CUSTOMER][NEUTRAL] By calculating whole, whole.
[AGENT][NEUTRAL] If the insured has multiple physicians, if the insurer has multiple physician visits, multiple facility bills, then I'm pretty sure you won't see it because you're not affiliated with those providers.
[CUSTOMER][NEUTRAL] whole year
[AGENT][NEUTRAL] You're calling from a doctor's office, correct?
[CUSTOMER][NEUTRAL] OK, fine.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] That doesn't mean that the patient will only come to your facility. The patient may have been to several different facilities. However, the benefits were maxed out by the time your claim came, [PII].
[CUSTOMER][NEUTRAL] OK, got it.
[AGENT][NEUTRAL] And there is no available funding for [PII].
[CUSTOMER][NEUTRAL] OK. I do, I do have one more data of service for this patient, so could you assist me with that too?
[AGENT][NEUTRAL] Yes, what's the what's the date of service?
[CUSTOMER][NEUTRAL] The date of service is [PII].
[CUSTOMER][NEUTRAL] And the total bill amount is $472.55.
[AGENT][NEUTRAL] I'm not showing the claim on file for the date of service.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] What's your procedure code?
[CUSTOMER][NEUTRAL] It's 20,550 with modified LTN 59.
[CUSTOMER][NEUTRAL] And also the
[CUSTOMER][NEUTRAL] The fix code is J3301.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] The claim was received [PII]. It was processed [PII] per the member's policy, Diego. The policy does not cover office visits or the treatment received in the office.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] And what's the member's policy?
[CUSTOMER][NEUTRAL] plan name
[AGENT][NEUTRAL] Pardon. This is Midland Gap Insurance.
[CUSTOMER][NEUTRAL] Sorry, uh, could you repeat that?
[AGENT][NEUTRAL] Mein Gap Insurance.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] And can you repeat the denial reason again just for my records?
[AGENT][NEUTRAL] Office visits and treatment received in the office is not covered under the policy.
[CUSTOMER][POSITIVE] OK, fine. Thank you so much for that information. This is for both the codes like 20,550 and J 3301, correct?
[AGENT][NEUTRAL] Repeat that.
[CUSTOMER][NEUTRAL] I'm not talking about the CPT code 99214 with modified 25. I'm calling for the CPT code 20,550 with modifier LT.
[AGENT][NEGATIVE] Right, that's the treatment received and the the treatment received in the office is not covered under the policy. Regardless if this procedure 20,550 or J3301, it still doesn't change. The benefits are not covered. There's no services covered under the policy for those services.
[CUSTOMER][NEUTRAL] OK, fine, got it.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] Is there anything else that I can assist you with? We don't provide those, [PII], however, you can use my name in today's day as a reference. It's [PII].
[CUSTOMER][NEUTRAL] Can I get a call reference for this call?
[CUSTOMER][NEUTRAL] No, no, thank you.
[CUSTOMER][POSITIVE] OK, fine. Thank you so much. Thank you for your assistance and have a great day. Bye for now.
[AGENT][POSITIVE] Thanks for calling APO. You have a great one as well. Bye bye.