AccountId: 011433970860
ContactId: 1c8a3e3c-e1f5-4199-ad63-ee35e903460d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1067140 ms
Total Talk Time (AGENT): 314569 ms
Total Talk Time (CUSTOMER): 537430 ms
Interruptions: 2
Overall Sentiment: AGENT=-0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/1c8a3e3c-e1f5-4199-ad63-ee35e903460d_20250109T18:20_UTC.wav
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[AGENT][NEUTRAL] APL, this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Good afternoon [PII]. Hey, this is [PII]. I have a provider on the line, [PII]. I have gone over claim status with several claims for a particular member under policy number 251-2377.
[CUSTOMER][NEUTRAL] He wants to know um.
[CUSTOMER][NEUTRAL] Like I said, I have several claims I've already gone over with him now he wants to know why some were paid after the.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I told him that they are processed in the in order they are received now he does have questions as to why some were paid after a certain date, um, so I.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] So for instance, the last two claims I have 35147997, that's [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That one I think the 9 797 yeah and then we had one for.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 351-479-5.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And then we had, let's see.
[CUSTOMER][NEUTRAL] 351-479-1
[CUSTOMER][NEUTRAL] OK, and 4789.
[CUSTOMER][NEUTRAL] That's just a list of few, uh, yeah, but, um, he wants to know. I told him that per the policy only 4 offices are allowed per year.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And we are not responsible for any type of um responsibility we don't determine that, but he wants to know why some were paid I guess after we.
[CUSTOMER][NEUTRAL] It was
[CUSTOMER][NEUTRAL] He wants to know why.
[AGENT][NEUTRAL] Some office visits were paid, I is, is they all the same provider?
[CUSTOMER][NEUTRAL] Um, I didn't go in depth as far as the provider, as far as specific provider, but they're with community, um.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][POSITIVE] Community medical associates, so is very well made a different.
[CUSTOMER][NEUTRAL] Doctor.
[CUSTOMER][NEUTRAL] But he wants to know why some were paid after.
[CUSTOMER][NEUTRAL] We say the max was allowed.
[AGENT][NEUTRAL] OK, I'll have to look at some of the claims that he's referring to, that he's questioning.
[CUSTOMER][NEUTRAL] OK, so, OK, so, um, 351-479-97, that's the last 13.
[AGENT][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] 351-479-5
[CUSTOMER][NEUTRAL] 351479-1
[CUSTOMER][NEUTRAL] Another is 351-4789 and he if he asks you tell him I will get all of them faxed over [PII] 1011 sometime today.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So all those claims that were processed on
[AGENT][NEUTRAL] Looks like 108 of 24.
[AGENT][NEUTRAL] So the 791 795.
[AGENT][NEUTRAL] I'll just talk to him, just send them to me.
[CUSTOMER][POSITIVE] OK, good luck with that. OK, um, his name is [PII], and again I'm, I'm sure he'll ask you again, tell him if you would please. I'll get all those you'll be faxed over to him sometime today.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, will do.
[CUSTOMER][POSITIVE] Alright thank you one moment please thank you.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sorry, you already informed the.
[AGENT][NEUTRAL] Claims department, this is [PII]. How can I assist you?
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] calling from Pros office, and previously we spoken of the representative and we are checking about the claims. So the representative, I mean not to you because need more information about the claims you only providing, right? That's why they opened the claim to you.
[AGENT][NEUTRAL] OK, so what, what claim in data service do you have a question in regards to?
[CUSTOMER][NEUTRAL] OK, sure, can I provide the source, or do you need to verify the member ID patient date of birth?
[AGENT][NEUTRAL] I have the patient that she already provided the patient information to me.
[CUSTOMER][NEUTRAL] OK, OK, thank you, and so the date was on.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the total charge amount is $228 even.
[AGENT][NEUTRAL] OK, so that's for data service of [PII] for $228.
[AGENT][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Yeah, uh, sorry, sir, sorry.
[AGENT][NEUTRAL] So that was for a data service of [PII] for $228.
[CUSTOMER][NEUTRAL] Yeah, I see, uh, I, I'm checking multiple claims but the previous the you in, so and they provide all the information for the claims, but our some clarification and it seems to do clarify it to me. So that is why I connect to you. I mean, you, you, you will better, right? So we need to claim, I mean specific question for this claim because, um, the age of.
[AGENT][NEUTRAL] I'm sorry, I can barely unders I can barely hear you. You sound muffled.
[CUSTOMER][NEUTRAL] OK. And [PII], upon uh spoke with the angel, so the angel stated as per the patient plan. So, per year, 4 office visits allowed per year. So the maximum allowable office visit is 4 only. So, upon checking in my end, so for the date of service, [PII], claim was denied as the maximum office visits already met.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, I show that claim was processed as the max has been met for.
[CUSTOMER][NEUTRAL] OK, so you also say like, so the claim is processed like this one. So we need to know, so after July month, or I mean the August or September or October for uh some of the claims will be for the same office visits with the payment.
[AGENT][NEUTRAL] You said for the same office visit?
[CUSTOMER][NEUTRAL] You know, like office visits, but the same not CPD same CPT code.
[CUSTOMER][NEUTRAL] It's kind of office visit but that.
[AGENT][NEGATIVE] So in regards to a a different office visit, so for the [PII], the maxes had already been met, so no benefit was payable for that data service. So you're referring to other office visits as well.
[CUSTOMER][NEUTRAL] Claim to update this so.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, did not. So, uh, upon I I understand that, and so they all, I mean the maximum office which is made on.
[CUSTOMER][NEUTRAL] The year of [PII], right?
[AGENT][NEUTRAL] They've met their max for the calendar year of [PII].
[CUSTOMER][NEUTRAL] Yeah, I understand. So as for the year of [PII], the maximum allowable office visit is 4 only, and the 4 units already met 3 [PII] [PII].
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, yes, that is correct. It has already been met.
[CUSTOMER][NEUTRAL] Is that right?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK, so after [PII], whenever we bill the claims, we receive the denial like offices is already met.
[AGENT][NEUTRAL] Is there a different date of service because there was a, it'll be issued out for [PII].
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] That the max has already been met.
[CUSTOMER][NEUTRAL] No, I'm asking to you. So [PII] itself, the maximum office visits met means. So when we bill the claim to [PII] to [PII], that claim will process unpaid.
[AGENT][NEUTRAL] For what date of service was that? You said August?
[CUSTOMER][NEUTRAL] 5, I'm simply asking to you because so for the maximum allowable offices is met on [PII] uh prior data service [PII].
[CUSTOMER][NEUTRAL] If we build the claims for August month for any office which is under the claim, we build August month, so we need to know whether that claim process isn't paid.
[AGENT][NEUTRAL] OK, so you're wanting to know if you build any claims for a date of service in the month of August?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, I can check and see if we have a claim on file for the month of August. However, they've already met their max for 2024. Therefore, no additional benefits would be payable under their policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK and so you mentioned that so the.
[CUSTOMER][NEUTRAL] As the patient policy, the maximum benefit is already met paid. So may I know when was the patient reached the full office which is met? Do you have information.
[AGENT][NEUTRAL] it was met in [PII].
[AGENT][NEUTRAL] They met their max in [PII].
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] They exhausted their benefits in [PII].
[CUSTOMER][NEUTRAL] Let me
[CUSTOMER][NEUTRAL] Yes, so you mentioned that the 4 units on the allowable rate. So when was the patient exam for office visits? May I know that rate, right?
[AGENT][NEUTRAL] I can't provide the date that it was exhausted unless it was a claim that you submitted into us. Is there a particular date of service and I can let you know as far as that? I can just let you know that they did meet their max in [PII].
[AGENT][NEUTRAL] Is there a particular August data service that you would like for me to look at? I can take a look at the data service.
[CUSTOMER][NEUTRAL] Can I even was.
[CUSTOMER][NEUTRAL] No, no, I'm just generally spoke with that information so because we received the payment, uh, for the data servers.
[CUSTOMER][NEUTRAL] September I think September, just give me one moment.
[CUSTOMER][NEUTRAL] OK, so and.
[CUSTOMER][NEUTRAL] Can I provide the data service for the other offices be receiving the payment for [PII].
[AGENT][NEUTRAL] So for a data service of [PII]?
[CUSTOMER][NEUTRAL] In the [PII]
[CUSTOMER][NEUTRAL] Yes, [PII]. On the we will the [PII] claim. This is the first falls on [PII].
[AGENT][NEUTRAL] And what is the billed amount of the claim for for [PII]?
[CUSTOMER][NEUTRAL] Uh, so the bill amount is $336 even.
[AGENT][NEUTRAL] Thank you. So that's for [PII] for $336.
[AGENT][NEUTRAL] OK, I show on that particular claim that we did pay on that claim.
[AGENT][NEUTRAL] I show a benefit was issued for that particular claim.
[CUSTOMER][POSITIVE] Mhm yeah that's so much.
[AGENT][NEUTRAL] A payment was made for $50.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] You have you know that's why I'm asking to you, right, so.
[CUSTOMER][NEUTRAL] Then why the [PII] claim was not paid.
[AGENT][NEUTRAL] I'm sorry, can you repeat that?
[CUSTOMER][NEUTRAL] [PII] data service of us paid means. May I know why that [PII] claim was not paid.
[AGENT][NEUTRAL] [PII] or [PII] was paid $50 was paid.
[CUSTOMER][NEUTRAL] May I know why the claim was not paid.
[AGENT][NEUTRAL] So you're wanting to know why it was not paid.
[CUSTOMER][NEUTRAL] You know, we need to know why the claim we built for data service [PII]. We didn't see any payment for the claim, you know why.
[AGENT][NEGATIVE] Because they met their max for the calendar year. These claims were submitted in [PII]. They all were processed on [PII]. They were all, the max was met during that time frame, so when the claim for [PII] was processed, they have already exhausted their benefits at that time.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEGATIVE] They were all processed on the same day. So once the max of 4 office visits were met, there was no additional benefits payable.
[CUSTOMER][NEUTRAL] [PII], so it's for the [PII].
[AGENT][NEUTRAL] The office visit was paid. At the time the claim was processed on that same day, they also exhausted their max calendar year as well.
[CUSTOMER][NEUTRAL] That you know people with me so we need to know. So if you pay the claim for [PII] office receipts, so the number doesn't exited the allowable offices, is that right?
[AGENT][NEGATIVE] I'm sorry, can you repeat that? You sound very muffled. I can barely understand what you're saying because you sound very muffled.
[CUSTOMER][NEUTRAL] OK, sure, I will explain it one more time.
[CUSTOMER][NEUTRAL] So for the details of the [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] You, you guys probably paid for the office visits.
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] Then you should pay for.
[CUSTOMER][NEUTRAL] [PII] also right because when we when you process them paid.
[AGENT][NEUTRAL] No, that we
[AGENT][NEUTRAL] No, because at the time that claim was processed and then once [PII] was received, they've met their max. The claims were processed the same day.
[AGENT][NEUTRAL] So they've met their max. So there's no additional benefit payable. If you disagree with the claim decision, you do have the option to submit an appeal, and this appeal can appeal can be submitted in 180 days from the claim decision date and I can provide you with that information.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] You know, you mentioned that as per the patient policy only 4 offices is allowable, right? Now you stated that as per the time so the
[CUSTOMER][NEUTRAL] I was been exacted.
[CUSTOMER][NEGATIVE] I'm a little bit confused.
[AGENT][NEGATIVE] They've met their max. For [PII], they've already exhausted their four office visits for the calendar year. Therefore, no additional benefits are payable under the policy.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] OK, could you please explain, uh, uh, could you please explain the current from which month to which month is the one year policy?
[AGENT][NEUTRAL] It
[AGENT][NEUTRAL] I'm sorry, can you repeat that?
[CUSTOMER][NEUTRAL] Main
[CUSTOMER][NEUTRAL] May I know which month to which month is the one year you're calculating from [PII] 1 year from the patient policy.
[AGENT][NEUTRAL] The calendar year is [PII].
[CUSTOMER][NEUTRAL] OK, so the current year from [PII], I mean [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, so
[CUSTOMER][NEUTRAL] We receive the payment was September month data services. It means the patient doesn't met the allowable office visits, is that right? On the date of [PII]. This is the payment for [PII] of.
[AGENT][NEUTRAL] The calendar year is [PII]. So no matter what day the service was submitted in, no matter what day the service was submitted in.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] They only get 4 visits for calendar year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] So we received several previous claims prior to that claim, and they all were processed on the same day where they met 4 office visits when all claims were processed for the calendar year. They met therefore, there's no additional benefits payable for [PII].
[CUSTOMER][NEUTRAL] So for the for the year of [PII], only 4 offices is allowable, and you guys probably paid for the four office visits. So the remaining all of the planes, you guys deny that no benefits, I mean the maximum allowable visit is existed, is that right?
[AGENT][NEUTRAL] Yes, they've already exhausted their benefits for the calendar year of [PII].
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, sure. OK, [PII], thank you for visiting me. And is there any person for this call?
[AGENT][NEUTRAL] No, it'd be just my name in today's date. Is there anything else that I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] No, yeah, previously we request the copy of the UB through our fax number, so you'll receive the fax number within 1 to 2 business days, right?
[AGENT][NEUTRAL] Yes, we'll get those faxes sent over to you, the copy of the OB's.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome. Thanks for calling Afield. You have a good day. Bye.
[CUSTOMER][POSITIVE] OK thank you [PII] thank you for.