AccountId: 011433970860
ContactId: 472503b2-20b8-4010-a185-701442849730
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1365239 ms
Total Talk Time (AGENT): 331702 ms
Total Talk Time (CUSTOMER): 306065 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/14/472503b2-20b8-4010-a185-701442849730_20250314T19:38_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL this is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] calling from provider's office seeking any claim status.
[AGENT][NEUTRAL] OK, I can help you with claim status sir. Can I please get your name again and your callback number?
[CUSTOMER][NEUTRAL] Sure, my name is [PII] and my first initial last name is [PII]. My callback number would be [PII] with an extension of [PII].
[AGENT][NEUTRAL] OK, and it's [PII]? How you say your name?
[CUSTOMER][NEUTRAL] It's [PII]
[AGENT][NEUTRAL] Oh,
[AGENT][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] And then what is the patient's name, date of birth, and policy number, sir?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, and the patient's first name is [PII] and last name is [PII]. And date of birth would be [PII]. And the member ID is uh [PII].
[AGENT][NEUTRAL] OK, let me look that up real quick.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, and then what is the date of service for [PII]?
[CUSTOMER][NEUTRAL] OK, the date of service would be [PII].
[AGENT][NEUTRAL] And the charge amount, sir?
[CUSTOMER][NEUTRAL] $3,045 even.
[AGENT][NEUTRAL] And then what is the charge amount after the primary insurance paid their part?
[CUSTOMER][NEUTRAL] Uh, 4:41 even.
[AGENT][NEUTRAL] 441. OK, and then what is the name of the facility that you're calling from?
[CUSTOMER][NEUTRAL] Galloway Anesthesia Associates.
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold while I look up that claim for you and I I'll be right back sir.
[CUSTOMER][POSITIVE] Yeah. OK. Take your time. Not a problem. I'll be waiting for you.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 53
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, this is [PII] back with you again. I've got the claim pulled up.
[AGENT][NEUTRAL] The
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Claim number is 353-2718.
[AGENT][NEUTRAL] The claim was denied because the occurrence for this.
[AGENT][NEUTRAL] Uh, service has been met. So let me read to you what it says. The maximum amount payable for this occurrence has been met. Per occurrence means treatment for the same or related condition unless separated by 90 days. Treatment for the same or related conditions separated by 90 days or an unrelated condition will be considered a new percurrency. So,
[AGENT][NEGATIVE] This has been done within that 90-day period, and it wasn't separated by 90 days, so it was denied.
[CUSTOMER][NEUTRAL] I got
[CUSTOMER][NEUTRAL] This
[CUSTOMER][NEUTRAL] OK. Uh, how much was the, uh, so you say it's, it was exhausted in the dollar value, right?
[AGENT][NEUTRAL] Right, payable for this occurrence was met, the maximum.
[CUSTOMER][NEUTRAL] OK, for the CPT code is 00813.
[CUSTOMER][NEUTRAL] But it was or something.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright and.
[CUSTOMER][NEUTRAL] OK, just one moment, can you please provide me the claim received and processed dates.
[AGENT][NEUTRAL] Yes sir.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Let me look that up. The claim was received on [PII], and the claim was processed on [PII].
[CUSTOMER][NEUTRAL] O.
[CUSTOMER][NEUTRAL] OK, what was the, uh, allowed amount for the, uh, for the CPT code?
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] A.
[AGENT][NEUTRAL] OK, let me see.
[AGENT][NEUTRAL] OK, so what happens with this kind of a policy, this is a secondary insurance that's billed after the primary, so it doesn't go by code, it goes by benefit amount and the insured had, and this is just to verify benefits, it's not a guarantee of payment, had uh outpatient benefit amount of $500.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Per occurrence.
[CUSTOMER][NEUTRAL] Just.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And each occurrence has to be separated by 90 days.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] That.
[CUSTOMER][NEUTRAL] $100 within 90 days. So you mean that if a patient visit uh more than uh
[CUSTOMER][NEGATIVE] Like once or twice within the 90 days it is not paid.
[AGENT][NEUTRAL] Correct. Uh only 1 time every 90 days.
[CUSTOMER][NEUTRAL] OK, alright. When was the, uh, patient, uh, last time visit visit, uh, visitor billed?
[CUSTOMER][NEUTRAL] Under this code on this.
[AGENT][NEUTRAL] Let me look.
[AGENT][NEUTRAL] Mm, I can't give that information because it's not your facility.
[CUSTOMER][NEUTRAL] OK, all right. And could you please fax me a copy of EOV?
[AGENT][NEUTRAL] Yes, I can do that. What is your fax number?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold while I get that fax ready for you and I will be right back.
[CUSTOMER][NEGATIVE] Yeah. You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] OK, thank you for holding for me, sir. I've got that fax on its way to you now.
[CUSTOMER][POSITIVE] OK, I wait to it. Thank you so much for that. And when can I expect the fax to be received?
[AGENT][NEUTRAL] Uh, it's been since you just have to give it time to get there.
[CUSTOMER][NEUTRAL] OK, alright then, and [PII], can I get the claim number? OK, you already provided me the claim number.
[CUSTOMER][NEUTRAL] The claim number which you provided is 353-2718, is that correct?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Alright, and could you please provide me the call reference number, [PII]?
[AGENT][NEUTRAL] Yes, sir, you can use my name and today's date.
[CUSTOMER][NEUTRAL] OK, and what's your first and last name?
[AGENT][NEUTRAL] A
[CUSTOMER][NEUTRAL] All right. And if you don't mind, I have got a few more data service for different members. Uh do you mind helping me with those?
[AGENT][NEUTRAL] No, I don't mind. Can you please give me the next member's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Yeah, just give me a quick moment. Let me close this uh this patient's information and pull out the next patient's information. Just a quick moment.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, go ahead and take your time.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] And by the way, how's this day going on?
[AGENT][NEUTRAL] Sir?
[AGENT][NEUTRAL] What did you say?
[CUSTOMER][NEUTRAL] Uh, I was just asking how was your day going on?
[AGENT][POSITIVE] It's going so far, it's going good.
[AGENT][POSITIVE] It's Friday. That's good.
[CUSTOMER][POSITIVE] Oh good, yeah, good to hear that.
[CUSTOMER][NEUTRAL] Waiting for the weekend holidays.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] All right. And here we go for the next member ID the next patient's name is.
[CUSTOMER][NEUTRAL] [PII] and, and first name is [PII] and last name is
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Date of birth would be [PII].
[CUSTOMER][NEUTRAL] And the member ID is [PII].
[AGENT][NEUTRAL] OK, let me look that one up.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] OK, alright, and what is the data service uh for Yvonne?
[CUSTOMER][NEUTRAL] Data services by [PII].
[AGENT][NEUTRAL] And the charge amount?
[CUSTOMER][NEUTRAL] $3,045 even.
[AGENT][NEUTRAL] And then the charge after the primary paid.
[CUSTOMER][NEUTRAL] $324 even.
[AGENT][NEUTRAL] OK, and then um is it for the same facility? Galloway?
[CUSTOMER][NEUTRAL] Yeah, Galla anesthesia Associates, same facility.
[AGENT][NEUTRAL] OK alright I'm gonna put you on a quick hold I'm gonna look this one up and I'll be right back.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, thank you for holding for me. So for this one, the claim number is 3556468.
[AGENT][NEUTRAL] The claim was
[CUSTOMER][NEUTRAL] 355
[AGENT][NEUTRAL] 646 8.
[CUSTOMER][NEUTRAL] 3468
[AGENT][NEUTRAL] No, 355-6468, yeah.
[CUSTOMER][NEUTRAL] OK, 6466.
[AGENT][NEUTRAL] And the claim was.
[CUSTOMER][POSITIVE] Alright, got it, thank you.
[AGENT][NEUTRAL] It was received on [PII] and processed on [PII].
[AGENT][NEUTRAL] And the claim was denied because the outpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] OK. Outpatient benefit.
[AGENT][NEUTRAL] Yes, for the calendar year was met.
[CUSTOMER][NEUTRAL] Is it met with the dollar value or was it value?
[AGENT][NEUTRAL] It's met with dollar amount, um, which was.
[AGENT][NEUTRAL] They had an outpatient calendar year benefit amount and again this is to verify benefits it's not a guarantee of payment of $1000 and that calendar year benefit for the year had been exhausted.
[CUSTOMER][NEUTRAL] OK, uh, can I have the data service when it's exhausted?
[AGENT][NEUTRAL] Oh,
[CUSTOMER][NEUTRAL] Is it, it has been exhausted with this claim or prior to this claim?
[AGENT][NEUTRAL] It was
[AGENT][NEUTRAL] Prior to this claim, and it's not your facility.
[CUSTOMER][NEUTRAL] So you can provide the information of that.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] And not even the date of service.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] It got exhausted there was payments made in February and November.
[AGENT][NEUTRAL] Of [PII].
[CUSTOMER][NEUTRAL] OK, on February and November, so.
[AGENT][NEUTRAL] Yeah, and then, um.
[AGENT][NEUTRAL] Yeah, but that's when the payment was made. The date of service was.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] So they only get it for one year.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] And it was exhausted then.
[CUSTOMER][NEUTRAL] OK, all right.
[CUSTOMER][NEUTRAL] OK, alright.
[CUSTOMER][NEUTRAL] All right, and could you please
[CUSTOMER][NEUTRAL] Max me a copy of EUB.
[AGENT][NEUTRAL] Yes sir, same fax number?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me get back over there so we can look that up.
[AGENT][POSITIVE] OK, I'm gonna put you on a quick hold and I'm going to get that fax ready for you and I'll be right back.
[CUSTOMER][NEUTRAL] Yep, done. You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, I've got that fax on its way to you now.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] And the conference number would be your name and your date, right?
[AGENT][NEUTRAL] Yes, on all of them.
[CUSTOMER][NEUTRAL] OK. And shall we move on for the next member?
[AGENT][NEUTRAL] Yes, sir. What's the member's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] OK, just a moment, let me pull up that information.
[CUSTOMER][NEUTRAL] OK. Uh, all right, G, I think that's all for the day.
[AGENT][NEUTRAL] Oh, OK.
[CUSTOMER][POSITIVE] I'm done, thank you.
[AGENT][POSITIVE] You're very welcome. I hope you have a wonderful rest of your weekend and we thank you for calling APL.
[CUSTOMER][POSITIVE] All right, thank you so much for the information. I really appreciate your patience. Have a wonderful day ahead. Bye-bye.
[AGENT][NEUTRAL] Bye-bye, sir.