AccountId: 011433970860
ContactId: 29a1e3a6-038c-4bdf-8ea1-c2555d66a2da
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 718409 ms
Total Talk Time (AGENT): 291469 ms
Total Talk Time (CUSTOMER): 307981 ms
Interruptions: 3
Overall Sentiment: AGENT=0.6, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/29a1e3a6-038c-4bdf-8ea1-c2555d66a2da_20250219T14:46_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], I have a man on the phone that needs some help with HR policy.
[AGENT][NEUTRAL] OK, what's that policy number?
[CUSTOMER][NEUTRAL] His name is [PII].
[CUSTOMER][NEUTRAL] The policy number is 02356765.
[CUSTOMER][NEUTRAL] His callback number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] He's calling on claim number 3430091.
[CUSTOMER][NEUTRAL] The anesthesia charge. I told him we paid 125 and the max was met. He wants to know what the max met and all that is for the anesthesia.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And I wasn't sure.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Mm, OK. I'm gonna have to find the surgery charge because it's gonna be a percentage.
[AGENT][NEUTRAL] just a second, see if I can pull up that surgery real quick.
[AGENT][NEUTRAL] Alright, room and board.
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] Oh, I see.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I got it.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes, is this [PII]?
[CUSTOMER][NEUTRAL] Uh, yeah, my name is [PII].
[AGENT][NEUTRAL] Hey, [PII], my name is [PII]. I'm from the claims department. Um,
[AGENT][NEUTRAL] I am under the unders
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Uh, did you spell your name, uh, uh, like, did you, said [PII], your name?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Me
[CUSTOMER][POSITIVE] OK, [PII]. Uh, yeah, thank you for your confirmation of your name, and how are you doing today?
[AGENT][POSITIVE] I'm good how are you?
[CUSTOMER][POSITIVE] I'm doing great. Uh, so this is regarding the claim.
[AGENT][NEUTRAL] OK, and I'm under the understanding that you're trying to figure out um why we paid what we did on anesthesia.
[CUSTOMER][NEUTRAL] Yeah, I just want to understand that now is the benefit maximum, uh, for this time period or a quote has been, uh, and previous representative, um, and that just told me that uh there is in a category max benefit and uh.
[CUSTOMER][NEUTRAL] Like, uh, um, as my understanding in that one, like, uh, there is an, uh, like a set of amount that particularly insurance pay for a particular member and once it's, uh, done, they are not going to pay for any other services that uh gonna be a patient responsibility. So I just want to uh know one more thing, like how much amount you uh set for, for the max benefit. What is the max benefit for the member according to you and uh um it, it met or not yet?
[AGENT][NEUTRAL] So for anesthesia, um, it is a percentage of whatever we pay for um the surgery that was performed, and it's 25% of that surgical benefit. So that benefit will vary depending on how much we pay for the surgery. Um, the maximum for their surgery benefit is gonna be $1000 per surgery.
[AGENT][NEUTRAL] Um, and that's the maximum that we will pay for a surgery. So, if you're looking at what a possible maximum for anesthesia could be, um, that's gonna be $250. But again, we don't always pay the full $1000 because it depends on what surgery you have on how much we pay. So that amount varies depending on the surgery. Um, and there is no maximum per year. It's just per surgery.
[CUSTOMER][NEUTRAL] I'll
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] OK, so it's uh it's for the basically avoiding the surgery and you are going to pay for 25% of the surgery amount and uh it's uh um also um not like uh that you're going to pay for the 25% uh in like fully weight because in uh $2310 so I think the 25% is more than uh like uh more than $125. So, mm.
[CUSTOMER][NEUTRAL] In this, uh, in this, there is, uh,
[AGENT][NEUTRAL] Well, so the surgery benefit is determined by the relative value and whatever their benefit pays. So their, their benefit.
[AGENT][NEUTRAL] It was only $500 for the surgery. That's all we paid for the surgery. So 25% of $500 is $125 and that's why we paid $125.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, in this one, we um submitted the expected amount of $2310.
[AGENT][NEUTRAL] Yeah, that, again, the sur the surgery is dependent on their relative value and we pay 25% of whatever we pay for the surgery. We paid $500 for their surgery and 25% was $125. So $125 was the maximum that we were gonna pay for that anesthesia.
[CUSTOMER][NEUTRAL] OK. OK. So like you have a $500 amount for any particular surgery and uh of the 25% of that $500 is $125 and that's you submitted or pay basically. Is it correct, ma'am?
[AGENT][NEUTRAL] Um, somewhat, yeah. The surgery benefit varies on how much we pay depending on what the surgery is. So, you know, more complicated surgeries may pay more, um, surgeries that not, that are not as complicated could only pay as high as $25 you know, it depends. It, but we,
[AGENT][NEUTRAL] We calculate that on our end once we receive the bill and then 25% of whatever that surgery benefit is goes towards their anesthesia.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, [PII]. Uh thank you for that information. But uh there is one line too as well over there. So didn't you pay for that one, that basically denied only.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, that's a CPT code, uh, and that's for
[CUSTOMER][NEUTRAL] I don't know what it is for, but uh this is anesthesia code 64447. And you can um do check that one in claim form. That basically denied only they didn't uh like, uh, IMA didn't pay anything on that one. So, uh, is it OK with that one or like uh you need to pay for that one?
[CUSTOMER][NEUTRAL] Because the denial over there is the same as in line one.
[AGENT][NEUTRAL] So, the reason why that was denied was because the maximum anesthesia benefit for this surgery had been met. We'd already paid the maximum of 125.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, but, uh, uh, this is not for the anesthesia, like I'm just asking you, this is not personal, like this, uh, and the anesthesia code, it's 01214. This is the anesthesia code, but the second code is not for anesthesia, I think, so that's why I'm asking you. So this is the only answer like with the anesthesia you are going to pay for that 1, 25% and the rest of that is going to be denied.
[AGENT][NEUTRAL] Um, I would have to send this back to the examiner to review to see if this code was payable. If it was payable and anesthesia was administered for this, it could be considered, um, but we would have to review and see if it would be a payable surgical procedure before we would be able to determine if any anesthesia would be payable as well.
[CUSTOMER][NEUTRAL] OK, [PII]. So, uh, like, is there any ticket number or case number? Like I have, uh, for, like I need to document this, uh, like after, after, like in second follow-up, we can ask for with that um ticket number like uh reprocesses on, so uh what is the status of reprocess.
[AGENT][NEUTRAL] Um, so you would just provide them with the claim number that you have and then um.
[AGENT][NEUTRAL] Let them know that you spoke to me on [PII] and um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that
[CUSTOMER][NEUTRAL] It's, uh, so sorry. Uh, is that your extension?
[AGENT][NEUTRAL] It was being sent back for review.
[AGENT][NEUTRAL] No, that you spoke to me today, [PII].
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] OK, OK. Today you said. OK, so sorry. I just said, OK, sorry.
[AGENT][NEUTRAL] Yeah, that's OK.
[AGENT][NEUTRAL] That's OK and then.
[CUSTOMER][NEUTRAL] Uh, so your name is [PII] and that today's date is [PII]. And uh, uh, just confirm me, uh, just correct me if I'm wrong. It's the claim number for this one is 3430091.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][POSITIVE] OK. Thank you for all that entire information and uh yeah, that's it from my side. Uh.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK. Is there anything else that I can do for you?
[CUSTOMER][NEUTRAL] Uh, uh, like you, uh, yeah, no, no, no, that's it from my side. I just ask you one more thing, like, uh, um, um, like you submitted, uh, reprocess, uh, you like you send back the, uh, claim or not yet.
[CUSTOMER][NEUTRAL] Like I need to wait on call or something.
[AGENT][NEUTRAL] Uh, yes, so let me verify, um, a good call back is [PII], correct?
[CUSTOMER][NEUTRAL] Uh, yeah, I'm repeating it for you. If, uh, it's wrong, you can tell me. It's [PII].
[AGENT][NEUTRAL] Yes, that's what I have. So what we'll do is um we'll do a review of this claim and um if it looks like benefits were missed we will go back and process um but either way uh someone will give you a call back and let you know if this claim is being reprocessed for payment or not.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, so how much time it will take, like, uh, what is the tactic for?
[AGENT][NEUTRAL] Um, I would ask that you allow at least 24 hours, um, just because the calls coming in today, so any other occurrences that need to be taken care of from maybe yesterday will be handled and then they'll move on to today's so I would ask that you give it at least until tomorrow um for them to review.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] go.
[CUSTOMER][NEUTRAL] OK. So, like I can mention over here that uh the claim is uh went for reprocess or not yet? Like uh
[AGENT][NEUTRAL] I would, I would just say that it's under review.
[CUSTOMER][POSITIVE] OK. OK. Thank you for that one.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And call reference number would be your name and the today's date.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] OK, [PII], thank you for the entire conversation and thank you for the information and thank you for the process as well. Um, bye for now. If you require something, you can tell me.
[AGENT][POSITIVE] Have a great day. Thank you, [PII].
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Bye bye.