AccountId: 011433970860
ContactId: 47028350-551b-4dde-86bd-1f13aa38d7e7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 369609 ms
Total Talk Time (AGENT): 138821 ms
Total Talk Time (CUSTOMER): 145400 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/28/47028350-551b-4dde-86bd-1f13aa38d7e7_20250128T13:42_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh, hi, [PII]. My name is [PII] calling from the Community Healthcare. How are you?
[AGENT][POSITIVE] I'm doing well. How are you?
[CUSTOMER][NEUTRAL] I'm good, thanks for asking. Uh, [PII], I have one claim, right? So, the claim was partly paid and partly denied. So I just need a few information from your end. Could you help me?
[AGENT][NEUTRAL] Sure, I'll be more than happy to help you with the claim denial, and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][POSITIVE] that's right.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And the member's policy number?
[CUSTOMER][NEUTRAL] One second. The policy number which I have, it's uh
[CUSTOMER][NEUTRAL] 02363674
[AGENT][NEUTRAL] OK, 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] Uh patient first name [PII] is [PII] and the last name [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the date of service for the claim?
[CUSTOMER][NEUTRAL] The data service is [PII] and the charge amount is $292 even.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it was $292. Hold on one second.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Uh, Community Healthcare.
[AGENT][NEUTRAL] OK, here it is. So I'm showing we received the claim on [PII].
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Claim number is 3544062.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII].
[CUSTOMER][NEUTRAL] And.
[AGENT][NEUTRAL] Um, the claim was paid out on, I'm sorry, [PII]. The claim was paid out on to the provider, a total of $50.
[CUSTOMER][NEUTRAL] Yeah, I just checking the it's it's in my system, the same thing I have, but when I checked with the uh remaining, you just pay for the for line item to pay for the only for the line item first it's 99213, right? After that, the remaining the CPG code was denied for some reason, so I just need that information because.
[AGENT][NEUTRAL] The policy doesn't provide a benefit for services where no charges were incurred.
[CUSTOMER][NEUTRAL] So the SIP code is [PII] and
[AGENT][NEUTRAL] There's several, everything except 99213. So, I'll just go through all the codes. So 99213 was paid out a total of $50?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 90688.
[AGENT][NEUTRAL] The policy does not provide benefits for vaccines or immunizations?
[CUSTOMER][NEGATIVE] OK, one second for not covered.
[CUSTOMER][NEUTRAL] Vaccine, OK.
[AGENT][NEUTRAL] That's the same um reason for 90471.
[CUSTOMER][NEUTRAL] OK, one second.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what about the 8303 yeah.
[AGENT][NEUTRAL] So 36
[AGENT][NEUTRAL] I'm gonna go through all the codes.
[AGENT][NEUTRAL] So 36415 was denied because viny puncture is not covered on the policy?
[CUSTOMER][NEUTRAL] Just give me a second. Uh, OK. What about the?
[AGENT][NEUTRAL] 83, I'm gonna go through all the codes. 83036.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] was denied because the maximum benefit payable.
[AGENT][NEUTRAL] For the data service has been met, which was the $50.
[CUSTOMER][NEUTRAL] OK. For the in a in a dollar term, right?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] So, uh, you said that the 83036 was enough for the maximum benefit has been met, right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] In in a dollar term because you have already paid for the one speed code for the that paid amount is $50 dollar, right? So what, what is the maximum benefit for the, for, for the year because you just pay the $50 right?
[AGENT][NEUTRAL] It's $50.50 dollars up to 5 visits per calendar year. So because it's all the same data service.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The um $50 was applied to 99213. We can only apply it once.
[CUSTOMER][NEUTRAL] OK, I got your point.
[CUSTOMER][NEUTRAL] Uh, OK, can you give me the call reference number for this one?
[AGENT][NEUTRAL] Sure, 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].
[AGENT][NEUTRAL] And again, all the information provided was a verification of benefits, not a guarantee of payment.
[AGENT][NEUTRAL] Rame sure, is there anything else I could assist you with today?
[CUSTOMER][NEUTRAL] OK, so what
[CUSTOMER][NEUTRAL] Uh, the card is your name is today's date, right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] It's uh your name is [PII], your name is, right?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] If
[CUSTOMER][POSITIVE] OK. Thank you so much. Thank you and thank you.
[AGENT][POSITIVE] You're very welcome and thanks for calling APL. I hope you have a great day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][NEUTRAL] Bye bye.