AccountId: 011433970860
ContactId: 29c8355e-e3fc-4fae-900e-5155dfb095df
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 278250 ms
Total Talk Time (AGENT): 96992 ms
Total Talk Time (CUSTOMER): 107296 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/26/29c8355e-e3fc-4fae-900e-5155dfb095df_20250226T18:45_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII]. I'm calling from Children's Lung and Sleep Associates in [PII]. I need to check a claim status, please.
[AGENT][POSITIVE] All right, [PII] Happy to check a claim for you today. What's the patient's policy number?
[CUSTOMER][NEUTRAL] Policy number is 01677458.
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] And then if I could get the patient name and date of birth?
[CUSTOMER][NEUTRAL] The name is [PII]. The date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you for that. What's the date of service?
[CUSTOMER][NEUTRAL] Um, data service is [PII] and [PII].
[AGENT][NEUTRAL] 24, OK, and the bill amount?
[CUSTOMER][NEUTRAL] $422.66.
[AGENT][POSITIVE] Thank you so much let's see here.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Hm.
[AGENT][NEUTRAL] So it looks like we got a claim for this. It looks like a couple times. Uh, there are two different claim numbers. The first one was denied just needing the explanation of benefits from the primary.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Uh, the second one that we received was denied stating the max benefit for the data service had already been met.
[CUSTOMER][NEUTRAL] OK, so we did send in um um the copy of the explanation benefits from Blue Cross Blue Shield. I actually have a fax number and a reference number for that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, and so then my next question would be, so this is an interpretation for a sleep study that was done at Memorial at the hospital here in [PII]. Um, is it, is it, do you see the charge for the same data service for the same charges but with a TC modifier instead of a 26?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] By any chance? I'm just wondering if they're denying against that because it should be a split, a split bill service. The hospital should be paid for the technical portion and the doctor should be paid for the interpretation.
[AGENT][NEUTRAL] Uh, let me see.
[AGENT][NEUTRAL] Yeah, so the only other claim that I see doesn't have the 26 modification. It's just a facility charge it looks like.
[CUSTOMER][NEUTRAL] OK, so there's no like technical component identified there?
[AGENT][NEUTRAL] Not that, not that I see. Hmm mm.
[CUSTOMER][NEUTRAL] OK, is that why they're saying max benefits for that service was?
[AGENT][NEUTRAL] Yeah, so the other claim, let me see.
[CUSTOMER][NEUTRAL] Because it was paid to the hospital.
[AGENT][NEUTRAL] Yeah, it looks like the facility and it looks like, let me pull up the member benefit.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Yeah, the outpatient benefit max per calendar day on their plan is $1000 and so that $1000 was sent to the facility it looks like.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Got you. So if that's the case, then is this is our portion, the interpretation portion, is that family I mean patient responsibility or is it adjusted or?
[AGENT][NEUTRAL] Yeah, I mean their secondary plan with us isn't gonna pay anything additional it's up to you guys as far as the facility or provider uh to bill for the difference, yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] I got you.
[CUSTOMER][NEUTRAL] OK, per day. OK, I'll put these notes in there. OK, I'll give mom a call. Um, do you have a reference number for me?
[AGENT][NEUTRAL] Yeah, [PII], that's gonna be my name with my last initial today's date. My last initial is T like [PII], first name [PII].
[CUSTOMER][POSITIVE] So, um, and today's date is [PII]. OK, alright, I appreciate it, Miss [PII]. You have a great day.
[AGENT][NEUTRAL] Yup.
[AGENT][NEUTRAL] You too, [PII]. bye bye.
[CUSTOMER][NEUTRAL] Bye bye.