AccountId: 011433970860
ContactId: 29a57c3b-f75c-46d2-b8d8-b83305ce63c4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 977219 ms
Total Talk Time (AGENT): 293114 ms
Total Talk Time (CUSTOMER): 523138 ms
Interruptions: 22
Overall Sentiment: AGENT=0.2, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/26/29a57c3b-f75c-46d2-b8d8-b83305ce63c4_20250226T18:00_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hi, [PII], this is [PII] calling from the provider's office to check on the current status.
[AGENT][POSITIVE] All right. I'm happy to check on a claim. What's the policy number?
[CUSTOMER][NEUTRAL] My policy number is D as in Delta 41203335.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I unfortunately can't pull the number with that number. Do you have a claim number or their name or social?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Let me check for social.
[CUSTOMER][NEUTRAL] Yeah, the Social Security number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] All right. Let me take a look here. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah I find that they are with that.
[CUSTOMER][NEUTRAL] The number ID that I provided you.
[CUSTOMER][NEUTRAL] It.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] What is the patient's first name and last name?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Patient name is
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] First name is [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Can you spell the last name?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK. Let me try by the member's name because I didn't pull anything up here.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] The policy number
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm mm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, uh
[AGENT][NEUTRAL] All right, what is [PII]'s date of birth?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Alright thank you so much and then what is the date of service that we're looking for?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] In the build amount?
[CUSTOMER][NEUTRAL] $256 even.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK. One moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] But.
[AGENT][NEUTRAL] So it looks like we did receive a claim for the state of service. The claim was received [PII]. The claim was denied.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] A claim was denied the maximum benefit for the state of service had already been met.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, but I I just.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Claim was denied [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I am, you know.
[CUSTOMER][NEUTRAL] It's the same uh.
[CUSTOMER][NEUTRAL] Maybe this is.
[AGENT][NEUTRAL] Did you need the claim number?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] 353-3375.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] 353-337-5353375 or 375 mhm.
[AGENT][POSITIVE] Mhm. Correct.
[AGENT][NEUTRAL] 353.
[AGENT][NEUTRAL] 337 5.
[CUSTOMER][NEUTRAL] OK, you're stating it's as non-covered.
[AGENT][NEGATIVE] The maximum benefit for this date of service had already been met. There was nothing additional payable.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] Maximum benefit is met.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] May I know the bed date?
[CUSTOMER][NEUTRAL] know.
[AGENT][NEUTRAL] The daily rate, is that what you're looking for?
[CUSTOMER][NEUTRAL] Yes, when was the last date it was me?
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] It was meant to visits or dollars.
[AGENT][NEUTRAL] Yeah, so it was meant for that date of service. The patient had other claims for date of service [PII] that were paid out. This maximized the date of service benefit, so there was nothing additional payable for that date.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] You state that it's maximum benefits has been met, right? I'd like to know it's visit or dollars.
[AGENT][NEUTRAL] It was for that date. Nothing additional payable for that date.
[CUSTOMER][NEUTRAL] yeah.
[CUSTOMER][NEUTRAL] So this is from the visit, right? When was the last date?
[CUSTOMER][NEUTRAL] The patient met.
[AGENT][NEUTRAL] Great, so the patient was paid out for date of service [PII] for a different claim. That's why there's nothing additional payable for this date because it had already been met for [PII].
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] You.
[CUSTOMER][NEGATIVE] The service also is the [PII]. So this is an incorrect dial.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Patient last date was met on date of service. So this is an incorrect, right?
[AGENT][NEUTRAL] Yes, for a different, for a different claim.
[CUSTOMER][NEUTRAL] So what happened to this client?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, so the patient is only allowed one office visit per day, and they were already paid for that, so there was nothing payable for this one.
[CUSTOMER][NEUTRAL] So it's not a duplicate again, right?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] drama.
[AGENT][NEGATIVE] It was denied because the max benefit was met for the date of service.
[CUSTOMER][NEUTRAL] So only one visit allowed per day. May I know how many visits, yeah, patient has visited twice or?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] There were other claims for that date. The patient was seen by other providers.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] Oh no.
[AGENT][NEUTRAL] Are you still there?
[CUSTOMER][NEUTRAL] If I'm still here, the another client is denied a duplicate, right?
[AGENT][NEUTRAL] The claim was denied for max benefits met on the date of service. Yeah, there's there's no duplicate denial.
[CUSTOMER][POSITIVE] Yes, I know it's been added as maximum benefit.
[CUSTOMER][POSITIVE] Yes, that's the maximum benefit.
[CUSTOMER][NEUTRAL] to.
[AGENT][NEUTRAL] OK, so there was no duplicate denial for this claim.
[CUSTOMER][NEUTRAL] I'm showing here, it's to be a for the claim number 202412050121.
[AGENT][NEUTRAL] What was that number again? 202.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] 412050121.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Is that a claim number that you have?
[AGENT][NEUTRAL] OK, that's not a claim number for us, it's too long.
[CUSTOMER][NEUTRAL] OK, just a second, please.
[CUSTOMER][POSITIVE] Thank you so much for staying online. If the remaining balance is uh patient responsibility for this claim.
[AGENT][NEUTRAL] We're not able to advise on patient responsibility that's up to the facility or the provider to bill the patient.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] So it's uh completely member's fault, right?
[AGENT][NEUTRAL] I'm sorry, what was that again?
[CUSTOMER][NEGATIVE] It's completely a member fault, right?
[CUSTOMER][NEUTRAL] One.
[AGENT][NEUTRAL] The member is currently active, yes, but it's up to the facility or provider to bill the patient. We can advise on that.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK. You said that the last date was met on [PII]. But the member only visit one.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] One of the
[CUSTOMER][NEGATIVE] That is why it's confusing for me.
[CUSTOMER][NEUTRAL] We don't have to date of service here.
[CUSTOMER][NEUTRAL] Could you please take this claim back for review?
[AGENT][NEUTRAL] There may have been
[AGENT][NEUTRAL] There may have been another provider that the patient had seen that billed us for that date of service and that claim was paid. Therefore, that's why there was nothing additional payable.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] On the same day, members met two providers.
[AGENT][NEUTRAL] Yeah, there are other claims for other providers here, correct.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I only need for this client.
[AGENT][NEUTRAL] I understand that I'm advising that for this state of service, the max benefit has already been met so there's nothing to reprocess.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] But, but you're saying the last met date was in the, was [PII]. It was date of service. The member has
[CUSTOMER][NEUTRAL] Take the treatment on the date of service day.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So this, this is not a correct denial, so you have to take the claim back for a process.
[CUSTOMER][NEUTRAL] Also you're stating only one visit is allowed per day, but remember one visit one.
[AGENT][NEUTRAL] OK, so the claim that was denied was for Norton Community Medical Associates.
[CUSTOMER][POSITIVE] I think we'll get here now. I'll get you.
[AGENT][NEUTRAL] Was another claim for that date of service from Community Medical Associates.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And it was a date range from [PII] which maxed out the benefits that's why there's nothing additional payable.
[CUSTOMER][NEUTRAL] No, wait.
[CUSTOMER][NEUTRAL] We don't have [PII] here. We only have [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Well right.
[AGENT][NEUTRAL] I'm letting you know that the benefit was already paid for 63 of 24 for community medical associates procedure code 99203.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, do you have a CPT of 80,050 and 83036 and 80061?
[CUSTOMER][NEUTRAL] For the CPT it was paid.
[AGENT][NEUTRAL] Maybe for the claim for maybe for the 256, but this is what I'm trying to advise is that this other claim from Community Medical Associates for [PII] already paid patients benefit for that date. We can't pay anything additional for that date of service.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. It's the maximum benefits for the visits or dollars.
[CUSTOMER][NEUTRAL] If it is visit means when was the patient's last visited date?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] The patient was seen on [PII] for an office visit at Community Medical Associates. This benefit was paid towards that provider which therefore maxed out their benefits.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] one.
[CUSTOMER][NEUTRAL] Yes, that's what I'm telling. The date of service is [PII]. Patient was met on the date of service date.
[CUSTOMER][NEUTRAL] This is not a valid denial reason. You have to take the claim back for review for further verifications. Kindly please take it back for the process.
[AGENT][NEUTRAL] The claim does not need to be reprocessed. It was a correct denial.
[CUSTOMER][NEUTRAL] But you, but you're saying the last date was [PII]. And you're stating it's denied. May I know why?
[AGENT][NEUTRAL] Because the benefit was already paid to another provider, Community Medical Associates.
[CUSTOMER][NEUTRAL] That is not our fault, right?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] I'm letting you know that another provider submitted a claim for that date of service therefore maxed out the patient's benefits.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Could you please explain this to my supervisor? Just a second, please.
[AGENT][NEUTRAL] Sure.