AccountId: 011433970860
ContactId: 5534a19d-a706-4097-a3ba-7a85a4c10087
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1543869 ms
Total Talk Time (AGENT): 456604 ms
Total Talk Time (CUSTOMER): 512133 ms
Interruptions: 1
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/11/5534a19d-a706-4097-a3ba-7a85a4c10087_20250311T19:59_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII]. I'm calling for a provider for Medicare Health INC to check on additional information claim that is denied. Please note this call will be required for quality and training purpose. Can you repeat once your name for me?
[AGENT][NEUTRAL] Sure, my name is [PII]. That's [PII]. That's initial [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And may I have a callback number just in case we get disconnected Mr. [PII].
[CUSTOMER][NEUTRAL] Of course, callback number is [PII] is a direct line.
[AGENT][NEUTRAL] OK, what's the patient's policy number?
[CUSTOMER][NEUTRAL] Patient ID number is 02441374.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Patient's name is uh [PII] and the date of birth for this one is uh [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] for me.
[AGENT][NEUTRAL] And what is the data service and the amount of the claim?
[CUSTOMER][NEUTRAL] Date of service for this claim is there?
[CUSTOMER][NEUTRAL] [PII] and total bill for this claim is a 525 event.
[AGENT][NEUTRAL] OK, so that's [PII], I'm sorry, [PII] or [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Is that correct? OK, thank you. Let me see if I can find them.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] OK, let me pull the EOB one moment. And for future you can check claim status online through our website at [PII] and that's just optional.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] We
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK, so. OK, we processed the claim on [PII].
[CUSTOMER][NEUTRAL] Alright
[AGENT][NEUTRAL] And we um send a benefit amount of $75 to the provider.
[CUSTOMER][NEUTRAL] Yeah uh.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Which is the maximum benefit for that date of service.
[CUSTOMER][NEUTRAL] No, actually I have one particular procedure code. It's uh 99203 with modified to 539. So behind a specific reason.
[AGENT][NEUTRAL] I'm sorry, can you repeat what you said?
[CUSTOMER][NEUTRAL] Yes. The 99203.
[CUSTOMER][NEUTRAL] Is a
[AGENT][NEUTRAL] 992799203 with modifier 25 is the one pay. The one that was denied was the J code.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEGATIVE] Checo or denied. Just one second.
[AGENT][NEUTRAL] Jcode, yeah, Jcode 2919 is the 19 maximum benefit has been exhausted for the date of service.
[CUSTOMER][NEUTRAL] OK, so according to our system, the remark code, the procedure code is denied as a 99203 with modified to 5. We have received for the.
[AGENT][NEUTRAL] Do you need a copy of the EOB?
[CUSTOMER][NEUTRAL] What?
[AGENT][NEUTRAL] You need the copy of the EOB for your records so you can update your system.
[CUSTOMER][NEUTRAL] Of course. Do you have the, who can make the payment, the payment details do you have?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Um, do you need the check number?
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Uh yes, uh, you can.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] So you can send back the you will be via fax is not, not an issue. I can provide the fax number. So can you provide additional information like the home and how much the paid amount, what is the allowed amount, what is the patient's response to the particular line item one only. So according to our system, there one is.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm mm.
[AGENT][NEUTRAL] OK, um, Mr. um [PII], let me give you the information that I can. Um, this particular policy is a limited policy. We're not a major medical.
[AGENT][NEUTRAL] Um, so I can give you the amount of the claim or the payment, which it was $75. $75 was the maximum benefit, and that's the amount that was sent under this claim. I can give you the check number of the payment that was sent for $75 which is 2028757. I can tell you that it was 202-87557.
[CUSTOMER][NEUTRAL] 202
[AGENT][NEUTRAL] And I can tell you that.
[CUSTOMER][NEUTRAL] This is the check number?
[AGENT][NEUTRAL] That's the check number and I can tell you that it's OK, and I can tell you that that check date was the same as the process date, which is [PII].
[CUSTOMER][NEUTRAL] OK, sorry to interrupt you.
[AGENT][NEUTRAL] And that was applied to procedure code 99203. Other than that, we don't have um any amounts applied towards the payments or the members responsibility because we're not the major medical, so um we don't do member's responsibility and um there's no co-payments, co-insurance or deductibles.
[AGENT][NEUTRAL] There's no network information because this is a limited policy, so those are the information that I provided to you is the only information I can provide and we also have a claim number if you need it.
[CUSTOMER][NEUTRAL] So, once again, I have also claim number. One second, just I'm verifying the claim number if I have the.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Mhm. OK, the claim number is 3566021.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Yes, 356-602-1, right? I have the clear check number also is there, right? Is it 2028757. The policy number and the number 02441374.
[AGENT][NEUTRAL] Mhm. Yeah.
[AGENT][NEUTRAL] Mhm. Yes.
[CUSTOMER][NEUTRAL] So actually for this claim we are the 99203, as I have this also the paid the remark code is a line item too. OK. So it is a $75 you paid amount, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm. Yes.
[CUSTOMER][NEUTRAL] It is allowed and paid amount is $75 even.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, I got it.
[CUSTOMER][NEUTRAL] So, no is no patients responsibility for this one. So, and what is the remaining amount for $200 even $200. So we are $275 and the remaining amount is $200 even. So any.
[AGENT][NEUTRAL] Again, we're not a major medical, so it's up to the provider's discretion. We don't have any contractual involvement on the remaining.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. It is any like uh the provider discount, the doctor accept discount, right?
[AGENT][NEUTRAL] We, we're not the major medical, Mr. [PII].
[CUSTOMER][NEUTRAL] I'm, I'm understand your point. OK. OK, I'm not asking the, I was asking for the outstanding issue was say the $75 is paid and remaining for the $200. If you're not the major medical group, so we have the exactly the reason, so it is not denied that it is paid. So I need a proper proper amount to be calculated for the $275 right?
[AGENT][NEUTRAL] I'm not sure. I can only tell you what we paid um again we don't have any contractual involvement. If there's any remaining balance for any of the claims that we receive with the limited policy, um, it's up to the provider's discretion to know what to do with the remaining balance and we, we don't know how much is the remaining balance. Um, there is no network so we don't do repricing on this one, so what we pay is just a flat amount.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, can you reprocess the claim if it's possible?
[AGENT][NEUTRAL] Only if you send us an appeal because we, we do not, uh, we process correctly based on the benefits of the policy and the benefits of the policy was $75 for the state of service. So if um you need to appeal the decision, you have 180 days from the decision date to appeal the decision, um, but we cannot reprocess because it was processed correctly.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So according to your system you are you are say that previously like it is paid as a flat rate listed from on your provider contract right?
[AGENT][NEUTRAL] We pay a flat amount based on the payment or the benefits of the policy. This is a limited policy. It's not a major medical.
[AGENT][NEUTRAL] So there's no
[AGENT][NEUTRAL] Provider discount or provider contract or anything like that. It's just the benefits on the policy and the limitation of the policy.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So that's why I'm asking to, is it paid as a flat rate listed on the
[AGENT][NEUTRAL] It's a flat rate.
[CUSTOMER][NEUTRAL] What?
[AGENT][NEUTRAL] Yes, it's a flat rate and it's based off the payment and benefits of the policy.
[CUSTOMER][NEUTRAL] OK, I got it.
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Your point?
[CUSTOMER][NEUTRAL] And no more patients responsible for this patient for this claim, right?
[AGENT][NEUTRAL] That's up to the provider's discretion again, we, we don't have any contractual involvement, Mr. [PII].
[CUSTOMER][NEUTRAL] OK, no issue. Could you send back explanation benefit or via fax number?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, what is the fax number?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. To what attention?
[CUSTOMER][NEUTRAL] Attention, the one difference number I can give you is uh [PII] V as in Victor 9679.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the fax number is [PII]. Is that correct?
[CUSTOMER][NEUTRAL] [PII]. Yes, correct.
[AGENT][NEUTRAL] OK, do you mind holding for me while I send this out to you while I got you on the line?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding. I'm being patient for you, Mr. [PII]. Yeah, I went ahead and send that over to you should be there in a few minutes. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Yes, thank you for sending for the EOB. So could you help with the work we need to submit if you submit a character claim have any mail mail ID, sorry, mail address, payer ID.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, um, the address to submitted claims is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So what is time frame to submit a character claim? Do you have any specific time frame time period?
[AGENT][NEUTRAL] Not for a corrected claim. You only have um 180 days to submit an appeal.
[CUSTOMER][NEUTRAL] OK, according to your system, you don't have the correct claim file limit, right?
[AGENT][NEUTRAL] We don't have corrected claims filing limits or submission claims filing limits.
[CUSTOMER][NEUTRAL] OK. So I have a few more accounts. Can you help me also?
[AGENT][NEUTRAL] I'm sorry, can you repeat?
[CUSTOMER][NEUTRAL] I have a few more accounts, few more patients or different, different patients.
[AGENT][NEUTRAL] Well, um.
[AGENT][NEUTRAL] How many more is a few?
[CUSTOMER][POSITIVE] So totally I have 5.
[AGENT][NEUTRAL] OK, bear with me.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][POSITIVE] Exactly
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, what's the next policy number?
[CUSTOMER][NEUTRAL] 02559255.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] What's the name and date of birth?
[CUSTOMER][NEUTRAL] Member's first name is uh [PII] Last name is uh [PII], sorry, first name is [PII]. Last name is it [PII] and the date of birth for this patient is it?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] What's the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] D of service for this claim is it [PII] and total bill for this claim is it 266.34% cents.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, it looks like we received the claim on [PII], processed [PII].
[AGENT][NEUTRAL] The claim was denied, stating that office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] The office visit, right?
[AGENT][NEUTRAL] Office visits are not covered by the policy.
[CUSTOMER][NEGATIVE] Not covered by the policy.
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] So it is not covered as a patient's plan according to the provider's plan. So can you elaborate it?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Patients plan. Patient plan.
[CUSTOMER][NEUTRAL] OK, so it's patients plan.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So, uh, give me one moment, one second. I
[AGENT][NEUTRAL] Sure. Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, thank you for patience with us. So it is not covered and not covered as a patient's plan, right, this policy.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] OK, so this is also the same address to where we need to submit the correct claim, right? If it
[AGENT][NEUTRAL] Mhm. Yes.
[CUSTOMER][NEUTRAL] OK. So have the next patient also the same member, same patient, but the date of service, OK, once again, I'm checking the date of service. The date of service will be different.
[AGENT][NEUTRAL] OK, well
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, the data service is the uh.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] It's the same amount?
[CUSTOMER][NEUTRAL] No, [PII].
[CUSTOMER][NEUTRAL] [PII] and the same amount, sorry, bill amount for this is 266.34 cents.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes, it's the same amount and the procedure code is also same.
[CUSTOMER][NEUTRAL] But they have the added modifier.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, it's, it's the same denial reason, and it was received the same date, processed the same date.
[CUSTOMER][NEUTRAL] like the previous one is issued on.
[CUSTOMER][NEUTRAL] [PII] and the process on the same date, right?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Receive [PII], process on [PII].
[AGENT][NEUTRAL] Denied office visits are not covered.
[CUSTOMER][NEUTRAL] OK, give me one
[AGENT][NEUTRAL] By the member's plan.
[CUSTOMER][NEUTRAL] OK, the same reason you said, right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, give me 1 2nd.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Just I mentioned my notes.
[CUSTOMER][NEUTRAL] OK. Could you uh with the, for these two patients call reference number if it's possible?
[AGENT][NEUTRAL] We don't have reference numbers you can use my name in today's name.
[CUSTOMER][NEUTRAL] OK. Your name is [PII]?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Yes I will.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Two days 3 1120 25, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, give me one second. I will give the next patient. I'm looking for the next patient. Just stay with me one moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Please note down next member ID.
[AGENT][NEUTRAL] Mhm. Go ahead.
[CUSTOMER][NEUTRAL] 016178
[CUSTOMER][NEUTRAL] 74 ML.
[AGENT][NEUTRAL] What's the name and date of birth?
[CUSTOMER][NEUTRAL] Patience. One second, I can provide the name.
[CUSTOMER][NEUTRAL] Patient's first name is [PII]. Last name is uh [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. What's the date of birth?
[CUSTOMER][NEUTRAL] Date of birth for this patient is [PII].
[AGENT][NEUTRAL] OK, what's the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Of course, once again. date of service for this patient is [PII] and total bill for this claim is a 460 even.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] 7.
[AGENT][NEUTRAL] OK, we received the claim [PII], processed [PII]. The claim was denied, office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] It is also the like same is the office fees is not covered under the patient's plan.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] One second, I mentioned patients plan. So for this one also the character claim final limit is also the same address, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, just give me one second. I will give the last patient.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Name and the tax ID. Just give me one second.
[AGENT][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] OK. Please note on the member's ID for the last one.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] It's M as in Mike 253-573.
[AGENT][NEUTRAL] OK, we don't have letters in the beginning of our numbers. Do you see the policy certificate number on this one?
[CUSTOMER][NEUTRAL] OK, sorry about it. This is maybe the different, sorry the different.
[CUSTOMER][NEUTRAL] Insurance name? OK. So the qualification number, it will be the same, the, like the, your name and the two digit date, right?
[AGENT][NEUTRAL] Hm
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] But
[CUSTOMER][POSITIVE] OK, no issue.
[CUSTOMER][POSITIVE] Thank you for assisting with the 4 accounts. Have a great day. Bye for now. Thank you.
[AGENT][POSITIVE] You as well. Thank you for calling APL. Bye-bye, Mr. [PII].
[CUSTOMER][NEUTRAL] Bye-bye.
[AGENT][NEUTRAL] Bye.