AccountId: 011433970860
ContactId: 517c409f-7193-480c-8261-8cc8595771fe
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 580590 ms
Total Talk Time (AGENT): 193459 ms
Total Talk Time (CUSTOMER): 179545 ms
Interruptions: 1
Overall Sentiment: AGENT=1, CUSTOMER=1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/06/517c409f-7193-480c-8261-8cc8595771fe_20250206T13:02_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII] and I'm calling from provider's office. I'm calling in regards to a claim please.
[AGENT][NEUTRAL] OK, [PII], you have one claim that you're needing to check status on, is that correct?
[CUSTOMER][NEGATIVE] And not exactly the status.
[AGENT][NEUTRAL] You said I
[AGENT][NEUTRAL] OK. How can I help you then, [PII]?
[CUSTOMER][NEUTRAL] Um, actually, uh,
[CUSTOMER][NEUTRAL] Uh yes. So previously, the claim was denied as maximum benefit exhausted for dollar amount. However, the member, uh, the services was for ER.
[CUSTOMER][NEUTRAL] So, uh, for ER claim, the claim should have been processed and paid. So I just want to ask if you could send the claim back to reprocessing.
[AGENT][NEUTRAL] OK [PII], so you're wanting a claim reprocessed because you believe that it is processed incorrectly, is that correct?
[CUSTOMER][POSITIVE] Yes, that is right.
[AGENT][POSITIVE] Yes, ma'am. I'll be, I will be happy to help you with this. I will pull, look at the claim with you. Um, first off, what is a good callback number for you?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] That will be [PII].
[AGENT][NEUTRAL] Thank you and the member's policy number please [PII]?
[CUSTOMER][NEUTRAL] Uh yes, it is 02443965.
[AGENT][POSITIVE] Thank you. One moment, please.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And like I said, any information that is provided today would be a verification of benefits and not a guarantee of payment. What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, the name is [PII] and the date of birth is [PII].
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And what is the data service [PII] and total bill amount that you're calling in regards to?
[CUSTOMER][NEUTRAL] Mhm. The date of service was [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the billed amount, $3930.56.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the claim number you have for this data service?
[CUSTOMER][NEUTRAL] The claim number would be 341-75997.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, one moment while I get this information pulled up, please.
[CUSTOMER][NEUTRAL] Of course.
[AGENT][NEUTRAL] It's just taking a moment to load the information that I need to look at, [PII]. Thank you for your patience.
[CUSTOMER][NEUTRAL] Mhm sure.
[AGENT][NEUTRAL] OK, so [PII], I do see that this claim was denied stating benefit maximum for this state of service has been met, and that is correct. The maximum benefit payable for this state of service is $75 and that was processed under another provider's claim for the same date of service prior to your claim being received.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now, if you wish to file an appeal, you may do that in writing within 180 days from the date of the decision.
[AGENT][NEUTRAL] On this claim, I can give you the address that the appeal would need to be sent to.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm, OK.
[AGENT][NEUTRAL] So an appeal would be sent to [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Attention appeals department with any supporting documentation.
[CUSTOMER][NEUTRAL] Bear with me.
[CUSTOMER][NEUTRAL] OK, so unfortunately, you won't be able to send the claim back to reprocessing uh as you're saying that benefit has.
[AGENT][NEUTRAL] No, ma'am.
[AGENT][NEUTRAL] Oh, I'm sorry. Go ahead.
[CUSTOMER][NEUTRAL] Uh, so, uh, like you said, that member has already met benefit of $4 amount and it was already uh paid with another claim and the amount that they were.
[CUSTOMER][NEUTRAL] Allowed with $75 per day and it is already exhausted, right? OK, so.
[AGENT][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, so in order for us to uh send the claim back to reprocessing, we should appeal, but that would be within 180 days from the date of decision and uh may I know the date of decision as well if you don't mind?
[AGENT][NEUTRAL] Mhm, one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] This claim was reviewed on and processed on.
[AGENT][NEUTRAL] [PII]. So you are beyond the 180 day period.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh, yes, yes.
[CUSTOMER][POSITIVE] Alrighty and uh.
[CUSTOMER][NEUTRAL] And just one last question. Is it members responsibility, the amount or not?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We do not determine patient responsibility like of it that would be up to the provider.
[CUSTOMER][NEUTRAL] Uh huh.
[CUSTOMER][POSITIVE] Oh, OK. Thank you so much for that.
[AGENT][POSITIVE] Well, you're very welcome. And is there anything else that I can help you with?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, no, and, uh, may I know how do you spell your name and, uh, with the initial to your last name?
[AGENT][NEUTRAL] My name is [PII]
[AGENT][NEUTRAL] And if you need a copy of the explanation of benefits, you should be able to obtain that by going to our portal [PII] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] Uh, we have received the UOB, however, yeah, but, uh, however, there's no description, there's, uh, no payment, no PR or.
[AGENT][POSITIVE] Oh, OK. OK, good then.
[AGENT][NEUTRAL] OK, so on page 2 of all of our claims, whether that's a separate 2nd page of our explanation of benefits rather, or it's on the back, you know, it's printed double sided, the remarks are always on the 2nd page.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] Oh, alrighty. Thank you so much, [PII] for clearing that out for me. And uh may I have the reference please?
[AGENT][POSITIVE] Yeah, yeah, absolutely.
[AGENT][NEUTRAL] My name and today's date.
[CUSTOMER][POSITIVE] OK, thank you so much, [PII], for your help. You have a great rest of the day.
[AGENT][NEUTRAL] Yeah
[AGENT][POSITIVE] Oh well, I hope you have a nice day too, and if that's all I can help you with, and thank you again for calling APL and I hope that you have a great day.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] You're welcome, [PII]. Uh-huh.
[AGENT][NEUTRAL] Bye-bye.