AccountId: 011433970860
ContactId: 46d2e9aa-42af-405e-9881-b6dbd4196421
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 548580 ms
Total Talk Time (AGENT): 185845 ms
Total Talk Time (CUSTOMER): 245847 ms
Interruptions: 6
Overall Sentiment: AGENT=0.3, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/01/46d2e9aa-42af-405e-9881-b6dbd4196421_20250401T19:52_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah, hi, [PII]. This is [PII] calling from the provider's office to check on the claim status.
[AGENT][POSITIVE] OK, I can definitely help you with the claim statusona. May I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, sure. My contact number is [PII] and my [PII] number is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yeah, sure. The member's policy number is going to be 60801.
[AGENT][NEUTRAL] So that's our payer ID, um, the member's ID number would be the policy certification number.
[CUSTOMER][NEUTRAL] Wait a moment.
[AGENT][NEUTRAL] It should start with a 01 or 02?
[CUSTOMER][NEUTRAL] Sorry, I don't have any uh policy number start with 0 or something else.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, I can also search the policy with the member's social.
[CUSTOMER][NEUTRAL] Oh, I don't.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Uh uh.
[CUSTOMER][NEUTRAL] I could see there is no social security number. Could you please verify the member's name and the date of birth?
[AGENT][NEUTRAL] Yes, what's the member's first and last name?
[CUSTOMER][NEUTRAL] The first name is [PII], spelled like [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the last name is?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] That is [PII].
[AGENT][NEUTRAL] I'm sorry, what's the last name?
[CUSTOMER][NEGATIVE] The the screen no.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, so I'm just waiting for the policies to come up here. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you verify the member's date of birth?
[CUSTOMER][NEUTRAL] The member's date of birth is going to be [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And the policy number is 233.
[AGENT][NEUTRAL] 6066.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] And may I have the date of service for the claim and the total bills?
[CUSTOMER][NEUTRAL] Could you please repeat again the policy number 233?
[AGENT][NEUTRAL] 6066.
[CUSTOMER][NEUTRAL] I'll be.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] That's the whole policy number 2336066.
[CUSTOMER][NEUTRAL] Thank you for the information. I'm calling regarding for the data service which is November [PII].
[CUSTOMER][NEUTRAL] And the charge amount of $193 even 193.
[AGENT][NEUTRAL] [PII] $193.
[CUSTOMER][NEUTRAL] [PII], I mean [PII].
[AGENT][NEUTRAL] Alright.
[AGENT][NEUTRAL] So it's [PII]. Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] That is University of Miami Medicine Department of Ophthalmology.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] So I'm showing the claim was received on [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] The claim number is 356999799.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because this is not a covered loss under the plan, therefore, no amount payable, no amount is payable for this expense.
[CUSTOMER][NEUTRAL] Why the claim is denied as non-covered service?
[AGENT][NEUTRAL] OK, so it looks like this is for code 99213. Hold on one moment, let me look at the the um benefits.
[CUSTOMER][NEUTRAL] Because, as I could see, you have recently paid for the same CPD for the same patient.
[AGENT][NEUTRAL] What claim number?
[CUSTOMER][NEUTRAL] Yeah, wait a moment.
[AGENT][NEUTRAL] So, the reason 99213 is not covered is because, so the member has the office treatment rider, so the treatment in the office can be covered.
[CUSTOMER][NEUTRAL] But I remember.
[AGENT][NEUTRAL] But if it's a facility charge or a place of service code like 99213 or 99214, that most likely will not be covered because there's no in-office coverage, only only treatment in office.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Because you have already paid for the same CPT under the claim number of 3424503.
[AGENT][NEUTRAL] 342-450-3
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] OK, I mean, I can send this back if you'd like for them to um request the refund, but this should not have been paid out because it is a place of service code. Um, I can send this back to claims to reprocess though.
[CUSTOMER][NEUTRAL] Which one for the delayed one or the paid one?
[AGENT][NEUTRAL] For the paid one.
[CUSTOMER][NEUTRAL] Uh, it will be recouped, uh, in future, I'm right?
[AGENT][NEUTRAL] Um, I can get a member of the claims department to assist us with that further. I'm not sure how that would work because I'm not a claims examiner, but I can definitely ask.
[CUSTOMER][NEUTRAL] Um, but the member has no offices coverage, I'm right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Thank you for that information. And uh I have one more uh claim for the same patient for the different data service which is [PII].
[AGENT][NEUTRAL] And the total bill amount?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That is going to be the same. It is $193 even.
[AGENT][NEUTRAL] OK, and is this, uh, well, let me give you the, hold on one second.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] So we received, we also received this claim on [PII] and um it was processed on [PII]. The claim number is 356.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] 9991.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And it was denied because um this is not a covered loss under the policy plan.
[CUSTOMER][NEUTRAL] OK, thank you. Can I get the claim re uh, I mean call reference number?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] Can I get your name, the spelling, please?
[AGENT][NEUTRAL] Sure, my name is [PII], [PII].
[CUSTOMER][POSITIVE] Thank you for the information, [PII] and have a good day bye.
[AGENT][POSITIVE] Thank you. You also around. Was there anything else