AccountId: 011433970860
ContactId: 45c5df01-1dec-4f83-a735-7ce4877abef9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1198000 ms
Total Talk Time (AGENT): 292822 ms
Total Talk Time (CUSTOMER): 452373 ms
Interruptions: 3
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/23/45c5df01-1dec-4f83-a735-7ce4877abef9_20250523T12:45_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Uh, good morning. My name is [PII]. I'm calling from provider office regarding claims.
[AGENT][NEUTRAL] All right, [PII], happy to check a claim. What's the policy number?
[CUSTOMER][NEUTRAL] Sure. 255-596-7.
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient name, [PII]. Date of birth, [PII].
[AGENT][NEUTRAL] Data service.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the build out.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] Uh, bill amount. Let me check one moment.
[CUSTOMER][NEUTRAL] Just one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] $28.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right, yeah, it will be 176, right?
[CUSTOMER][NEUTRAL] 891 and the group name is Travis.
[AGENT][NEUTRAL] OK, we did receive a claim for this state of service. The claim was received on [PII].
[AGENT][NEUTRAL] Claim was denied on [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII] moment, just one moment.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Can you spell your name please, once again?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]. OK, [PII]. Go ahead.
[AGENT][NEUTRAL] The claim is received [PII].
[CUSTOMER][NEUTRAL] I received on.
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] Claim was denied on [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Claim denial is maximum benefits have been previously paid.
[CUSTOMER][NEUTRAL] Uh, yeah, uh, I'll so.
[CUSTOMER][NEUTRAL] It's.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And the claim number for that is 359.
[AGENT][NEUTRAL] 9301.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So claim for maximum benefit has been previously paid.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh, on which date of service?
[CUSTOMER][NEUTRAL] Data is [PII].
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, that's R Romeo.
[CUSTOMER][NEUTRAL] Zebra 8 C Charlie 00 P as in Paul W as in Water K.
[CUSTOMER][NEUTRAL] from [PII]
[CUSTOMER][NEUTRAL] [PII] only for one day.
[AGENT][NEUTRAL] So it looks like the inpatient benefit max per occurrence is $1000.
[AGENT][NEUTRAL] Or is this an outpatient?
[CUSTOMER][NEUTRAL] $1000 right?
[AGENT][NEUTRAL] This was outpatient though, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So their outpatient benefits per occurrence, their benefit max is $500.
[CUSTOMER][NEUTRAL] Outpatient.
[CUSTOMER][NEUTRAL] Benefit limit, right?
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Per year.
[AGENT][NEUTRAL] No, it's per occurrence.
[CUSTOMER][NEUTRAL] What?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Per per occurrence, yeah.
[CUSTOMER][POSITIVE] OK cool ranch.
[CUSTOMER][NEUTRAL] $500 right?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So patients have reached the limit of $500.
[AGENT][NEUTRAL] For, yes, for this particular occurrence, yes, that had already been paid, so nothing additional was payable.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] Excluding this claim or including this claim?
[AGENT][NEUTRAL] Well, not including this claim because claim was denied because the benefits had already been paid, so not including this claim.
[CUSTOMER][NEUTRAL] We don't have
[CUSTOMER][NEUTRAL] So, OK.
[CUSTOMER][NEUTRAL] Mem members uh limit has been $500. So, limit has been given in per year or?
[CUSTOMER][NEUTRAL] Month.
[AGENT][NEUTRAL] No, it's per occurrence. So that means for whatever the patient is seeking treatment for.
[AGENT][NEGATIVE] Uh, whatever they're being treated for, they're allotted $500 for treatment and nothing additional.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yeah, but 2234.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] I need
[CUSTOMER][NEUTRAL] 28.
[CUSTOMER][NEUTRAL] 28.
[CUSTOMER][NEUTRAL] 28. 1 moment, [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] You stated that uh claim to maximum benefit has been previously paid up. So this patient has been taking a service, uh,
[CUSTOMER][NEUTRAL] Inpatient location.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Inpatient location? Are you asking for the place of service?
[CUSTOMER][NEUTRAL] No, no. Patient have taken inpatient, right? Not outpatient. Patient have uh inpatient.
[AGENT][NEUTRAL] Data service was 1221 24, correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] For the build amount.
[CUSTOMER][NEUTRAL] I have checked the medical records showing inpatient.
[AGENT][NEUTRAL] OK, this was, OK, this was billed as outpatient.
[CUSTOMER][NEUTRAL] $28.
[AGENT][NEUTRAL] So if it was, you know, you can resubmit the claim if it was done incorrectly.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] One moment, I'm checking.
[CUSTOMER][NEUTRAL] POS 22.
[CUSTOMER][NEUTRAL] Which place of service uh you have seen in your site on claim form?
[AGENT][POSITIVE] Grand Traverse radiologist.
[CUSTOMER][NEUTRAL] If you I need
[CUSTOMER][NEUTRAL] In a place of service.
[CUSTOMER][NEUTRAL] Showing your side 21 or 22?
[AGENT][NEUTRAL] What are you asking, 21 or 22, the date of service?
[CUSTOMER][NEUTRAL] No, no. Place of service because uh if the uh claim bill with the place of service 21, that's means impatient.
[CUSTOMER][NEUTRAL] If the claim bill with the place of service 22, that means outpatient services.
[CUSTOMER][NEUTRAL] So I have built an inpatient service with the place of service 21.
[AGENT][NEGATIVE] I don't even, I'll have to look at what was submitted on the claim. I don't even, one moment.
[CUSTOMER][NEUTRAL] Mhm. Sure.
[AGENT][NEUTRAL] OK. So the patient's plan defines inpatient as being in the hospital for 18 hours or longer. This is only showing a single date of service as of [PII]. So,
[CUSTOMER][NEUTRAL] Maybe or.
[AGENT][NEUTRAL] It was just for uh lab work.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So defined under the patient plan I don't believe that this would be considered inpatient for lab work.
[AGENT][NEUTRAL] Inpatient on the patient's plan is defined as being in the hospital under confinement for 18 hours or longer.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] So this would be considered an outpatient service.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Not a
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, uh, patients have taken a services, uh, inpatient hospital to it in the service we have provided to a patient who was formally admitted to a hospital for an overnight stay or longer.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] I'm letting you know that lab work is not considered an inpatient service, and that's why it was denied under the outpatient benefits. The claim was denied on [PII]. If you would like to appeal the claim, I'm happy to provide you that information.
[CUSTOMER][NEUTRAL] on.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] So you, insurance considered as outpatient, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] But on medical record of showing up patient class inpatient location, right.
[AGENT][NEUTRAL] I understand. I'm advising that the patient secondary plan.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Lab work is considered an outpatient service.
[AGENT][NEUTRAL] And that's why this claim was denied.
[CUSTOMER][NEUTRAL] Pa
[CUSTOMER][NEUTRAL] Outpatient.
[CUSTOMER][NEUTRAL] Service.
[CUSTOMER][NEUTRAL] Lab work, lab work. Can you explain what is the lab work?
[AGENT][NEUTRAL] Blood work?
[CUSTOMER][NEUTRAL] Lab works
[CUSTOMER][NEUTRAL] You study the lab or considered as outpatient service.
[AGENT][NEUTRAL] Right, that's what this claim was for.
[CUSTOMER][NEUTRAL] What does it mean by life work?
[CUSTOMER][NEUTRAL] Sir?
[AGENT][NEUTRAL] Having blood drawn?
[CUSTOMER][NEUTRAL] Having blood run, right?
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Having blood run.
[CUSTOMER][NEUTRAL] I'm
[CUSTOMER][NEUTRAL] You paid outpatient benefit occurs.
[CUSTOMER][NEUTRAL] How much the inpatient benefit limit process?
[CUSTOMER][NEUTRAL] Inpatient benefit limit for occurrence.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] $1000.
[CUSTOMER][NEUTRAL] Limit for.
[CUSTOMER][NEUTRAL] Your cousins.
[CUSTOMER][NEUTRAL] $1000.
[CUSTOMER][NEUTRAL] So lab work is still the lab work, right?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That's what this claim is for, correct.
[CUSTOMER][NEUTRAL] Lab work or lead work? Can you spell out?
[AGENT][POSITIVE] Lima Alpha Bravo.
[CUSTOMER][NEUTRAL] Lab work, OK. Just one moment. Mhm, just one moment.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] But this is a chest X-ray, single view. Uh, I have verified that procedure code 71045.
[CUSTOMER][NEUTRAL] They
[CUSTOMER][NEUTRAL] Oh you go this doesn't matter.
[CUSTOMER][NEUTRAL] Can you check, [PII]? I have built a procedure code 71045 with the modified 26.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Mhm. This is an, uh, this is a radiologist examination of chest.
[CUSTOMER][NEUTRAL] A single view, not a not a uh uh-huh, not a blood run.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] OK, so at this point, [PII], the claim has been denied because it's under outpatient services. What, what, what other information would you like on this? If it needs to be reprocessed or appealed, you'll have to submit an appeal. I'm not really sure what else you'll you're needing from the claim.
[CUSTOMER][NEUTRAL] No, you, uh, insurance considered as outpatient, right? But claim has been been.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] If you can send in a claim back for reprocess once.
[CUSTOMER][NEUTRAL] They will deny after that we will appeal on that claim?
[CUSTOMER][NEUTRAL] Well.
[AGENT][NEUTRAL] I don't show that the claim has been processed incorrectly.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It was processed correctly on our side so I'm not able to resend it again if you would like to appeal the claim, I'm happy to provide that information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One moment checked on.
[CUSTOMER][NEUTRAL] CMM one moment find in it.
[CUSTOMER][NEUTRAL] Well.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You stated that lab work means having blood run considered as outpatient service but uh showing on medical record patient have uh
[CUSTOMER][NEUTRAL] Taken X-ray.
[CUSTOMER][NEUTRAL] With the procedure code 71045.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So last Friday.
[AGENT][NEUTRAL] I apologize for the error on my part and lab work.
[CUSTOMER][NEUTRAL] Because
[AGENT][NEUTRAL] I see the code 71045 on the claim.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] The X-rays are not considered inpatient. So, the services that the patient had done were not considered inpatient.
[CUSTOMER][NEUTRAL] OK. Actually, uh oh.
[CUSTOMER][NEUTRAL] And X-ray.
[CUSTOMER][NEUTRAL] Not considerized impatient.
[AGENT][NEUTRAL] Right. I mean, we've gone over this multiple times.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Do you think
[CUSTOMER][NEUTRAL] OK, no problem. So can we move to the next date of service?
[AGENT][NEUTRAL] Is it the same patient or a different one?
[CUSTOMER][NEUTRAL] Yes, same, same, same patient.
[AGENT][NEUTRAL] What's the next date of service?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Same bill amount.
[AGENT][NEGATIVE] OK, it's the same denial.
[CUSTOMER][NEUTRAL] Everything is the same, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] Next date of service [PII].
[CUSTOMER][NEUTRAL] Same bill amount?
[CUSTOMER][NEUTRAL] I
[AGENT][NEGATIVE] Same denial.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. And the last date of [PII]?
[CUSTOMER][NEUTRAL] Same bill amount.
[AGENT][NEGATIVE] Same denial.
[CUSTOMER][NEUTRAL] So if we, if member have taken an inpatient services, then you will process and paid, right?
[AGENT][NEUTRAL] If it falls under inpatient, then they would be allotted that amount per occurrence, correct.
[CUSTOMER][NEUTRAL] OK. May the call reference number?
[AGENT][NEUTRAL] Is my name in today's date, [PII] and last initial is [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][POSITIVE] 52,320. OK, sir. Thank you so much for helping us. Have a great day. Take care, stay safe. Bye-bye.