AccountId: 011433970860
ContactId: 2ecbb09d-3bc2-4765-9dc6-f91858a896bd
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 717440 ms
Total Talk Time (AGENT): 235063 ms
Total Talk Time (CUSTOMER): 326672 ms
Interruptions: 1
Overall Sentiment: AGENT=1, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/03/2ecbb09d-3bc2-4765-9dc6-f91858a896bd_20250203T14:42_UTC.wav
--------------------------------------------
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hey, [PII]. I'm calling from the provider's office regarding a claim.
[AGENT][POSITIVE] OK, I'll be more than happy to help you with the claim status. May I have your name and a good contact number?
[CUSTOMER][NEUTRAL] Yeah, it will be Kia KIA, uh, phone number is [PII].
[AGENT][NEUTRAL] Thank you for that. And Kia, may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, it will be, I'll go back and pull it up. It'll be uh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 02516679.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yes, it's [PII], [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim you want me to check on?
[CUSTOMER][NEUTRAL] Yes, that will be, it's a service of
[CUSTOMER][NEUTRAL] 828 of 24 total bill is $3,564.
[AGENT][POSITIVE] Thank you for that. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And again, just for the call, all the information provided is a verification of benefits, not a guarantee of payment. And what is the name of the facility's office?
[CUSTOMER][NEUTRAL] Should be under our MUSC community physicians.
[AGENT][NEUTRAL] Um, what's the tax ID? It might have just came over with a different name.
[CUSTOMER][NEUTRAL] Um, OK, uh, the tax ID is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It can be under a different name. Yeah, group, it might be under group hospital ID or something.
[AGENT][NEUTRAL] Yeah, it, go ahead.
[AGENT][NEUTRAL] It's under MUSC FLO Health Florence, yeah.
[CUSTOMER][NEUTRAL] The floor, floor health, yeah, yeah.
[AGENT][NEUTRAL] But we received the claim on
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 354-4109.
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] And on [PII], the claim was denied, um, because the calendar year max for accident and sickness surgery has been used for the calendar year.
[CUSTOMER][NEUTRAL] So what do you guys mean by that? Because
[CUSTOMER][NEUTRAL] Um, can you check to see why is it Max? Because I don't see that's max.
[AGENT][NEUTRAL] So,
[AGENT][NEUTRAL] So the benefit is $1000 for one surgery. So it might not be matched to you, but by the time your claim came in, this benefit was used.
[CUSTOMER][NEGATIVE] Can you tell me when was it used, so I can bring it back to our our coding department cause they're saying that they reviewed and this is not, it's denying correctly.
[AGENT][NEUTRAL] Let me see if this is the same tax ID or if this is a different provider. Hold on one moment.
[CUSTOMER][POSITIVE] Oh, OK. Thank you.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK, so it's a different tax ID, but it's your provider. So basically you all submitted a different claim for [PII] and we paid out the $1000. So when the second claim came in, we couldn't pay again because we paid out the other claim. It's only one surgery per calendar year.
[CUSTOMER][NEUTRAL] OK, so you said there's one that we, we sent to you guys on different tax ID.
[AGENT][NEUTRAL] Yes, um, and we paid out on that claim [PII].
[CUSTOMER][NEUTRAL] For data service of 828 or 24.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And I'm gonna look into that because I know we have all the tax ID too please just give me one second here so I can verify that and send it back. So you're saying there's another data service for
[CUSTOMER][NEUTRAL] 828.
[CUSTOMER][NEUTRAL] Do you know the total charge on that one?
[CUSTOMER][NEUTRAL] For that one that you said that was built on 828.
[AGENT][NEUTRAL] So, legally we can only give you your information for your provider, since it's a different tax ID, it's a different branch of your facility. I can, I really couldn't give the date, but I don't.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] That's fine because I I'm checking here. Uh, give me one second here. I just wanna make sure because I know that there's another one that was billed to you guys too, so give me one second here.
[AGENT][NEUTRAL] It was issued to you all on [PII]. We received it on [PII].
[CUSTOMER][NEUTRAL] This one
[CUSTOMER][NEUTRAL] Let's see here. I know there's another one that was billed to you guys too on [PII] for a total bill of 826. Do you see that one too?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] That one's for $826 for the same date, [PII].
[CUSTOMER][NEUTRAL] That's gonna be the same.
[AGENT][NEUTRAL] Hold on one second, give me a second.
[CUSTOMER][NEUTRAL] Tax ID I gave you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I'm gonna clear all this out so I can see what you're talking about.
[CUSTOMER][NEUTRAL] um.
[AGENT][NEUTRAL] OK, 8:26, yes, but that one was also denied, um.
[CUSTOMER][NEUTRAL] 9, OK. For the same reason?
[AGENT][NEUTRAL] Hold on 1 2nd.
[CUSTOMER][POSITIVE] I'll make sure.
[AGENT][NEGATIVE] No, for that one it was denied because the policy doesn't provide anesthesia um benefits.
[CUSTOMER][MIXED] OK good policy doesn't.
[CUSTOMER][NEUTRAL] Apply.
[CUSTOMER][NEUTRAL] Anesthesia.
[CUSTOMER][NEUTRAL] Service.
[CUSTOMER][NEUTRAL] OK, so that one off the but, let me go to our other.
[CUSTOMER][NEUTRAL] So we must be the hospital that bill you guys give me a second here. Uh, hospital, where's the hospital.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hospitals.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] You things from us too, so.
[CUSTOMER][NEUTRAL] Let's see here.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Let's see what the hospital did.
[CUSTOMER][NEUTRAL] Count
[CUSTOMER][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So so.
[CUSTOMER][POSITIVE] That's one good but.
[CUSTOMER][NEUTRAL] OK fine OK.
[CUSTOMER][NEUTRAL] I see [PII] show me how to get filled.
[CUSTOMER][NEUTRAL] Oh, OK. So charge.
[CUSTOMER][NEUTRAL] Was that one billed and the total charge is $46,648 on 828 that you're telling? OK, so they're saying that you guys they billed this one out.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Oh, OK, let me write this down so I know to send it back to them.
[CUSTOMER][NEUTRAL] So we will be patient responsibility if they use all their benefits for surgery, correct?
[AGENT][NEUTRAL] Um, so we don't determine patient responsibility because we're not a major medical. It would be whatever the procedures are for outstanding balances after, um, denial.
[CUSTOMER][NEUTRAL] Yeah, so if they, they only max that out and then it has to be their responsibility then, OK, um, let's see here.
[CUSTOMER][NEUTRAL] Uh, you say it was a for uh the hospital clean.
[CUSTOMER][NEUTRAL] The claim is 828 to 24, and they have $46,64. OK, I'll send this back to according to review and I'll put it to patient responsibility telling them that they only have a benefit max of $1000 per calendar year you said.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, and, and, and they have no anesthesia, um, service too, correct? So I can put that down to patient responsibility. OK. I just wanna make sure I write all that down so when patient call, I can tell them what you said too. Um, can I get a reference number, [PII]?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Sure, um, so there's no call reference number, but you can use my name in today's date. The first initial of my last name is [PII].
[CUSTOMER][POSITIVE] OK awesome thank you so much for your help today.
[AGENT][POSITIVE] You're very welcome, Kea. Was there anything else I could assist you with today?
[CUSTOMER][POSITIVE] No, that should be it. Thank you for your help and your patience today. You have a good day.
[AGENT][POSITIVE] You're welcome and thanks for calling APL.
[AGENT][NEUTRAL] Bye bye.
[CUSTOMER][NEUTRAL] Bye-bye. Oh, I do have one more question. If we were to do an uh a dispute, do you guys have a form that we have to use or anything like in a pill?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, no, you just have 180 days from the denial date to um sending the appeal.
[CUSTOMER][NEUTRAL] OK, do we fax it to you guys? Do we email it to you guys?
[AGENT][NEUTRAL] You can, you can fax it, you can mail it, or you can send it electronically to us. Um, hold on one second, let me see how your, which, actually, hold on one moment.
[CUSTOMER][NEUTRAL] How do we do that?
[CUSTOMER][NEUTRAL] Because I was on your.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, cause I was on your site, I couldn't do it through like your site, that's why.
[AGENT][NEUTRAL] So for this product.
[AGENT][NEUTRAL] So for this product, um, you can fax it or you can send it electronically because it's going to IMA.
[CUSTOMER][NEUTRAL] So when you say electronically, what do you mean for that? By email?
[AGENT][NEUTRAL] Using a payer ID, using a payer ID. The payer ID is 64556.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] 4556.
[CUSTOMER][NEUTRAL] Oh, so you guys don't have it on the site where I can just do it through your site, correct?
[AGENT][NEUTRAL] For this particular product, no, um, because it's not coming to APL, it's going to IMA which is um a repricing, and then it comes to us. So for IMA the only options are fax or I'm sorry, the only options are mailing or the payer ID.
[CUSTOMER][NEUTRAL] OK. You said there's no facts, right?
[AGENT][NEUTRAL] Correct. There's no facts.
[CUSTOMER][NEUTRAL] No facts.
[CUSTOMER][NEUTRAL] OK, I don't know how to do it by the payer ID, but what is the address that I can send it to?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][POSITIVE] Oh, OK. Thank you.
[AGENT][POSITIVE] You're very welcome and thanks for calling APL. Have a good day.
[CUSTOMER][POSITIVE] Take care. Bye-bye.
[AGENT][NEUTRAL] Bye bye.