AccountId: 011433970860
ContactId: 5983c17a-fbee-4cec-bc89-d084f9595d84
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 540530 ms
Total Talk Time (AGENT): 180890 ms
Total Talk Time (CUSTOMER): 185421 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/28/5983c17a-fbee-4cec-bc89-d084f9595d84_20250128T20:20_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] and I'm calling for provider to check on the status of an appeal that was submitted for a previously denied claim. Please note this call will be monitored and recorded for quality and training purposes. How's your day going?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] That's good. Thank you, Mr. [PII]. Sure, I can assist you with claims. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, it is [PII] and it's a direct line with no extension.
[AGENT][NEUTRAL] OK. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Yes. Patient's policy number is 022630.
[CUSTOMER][NEUTRAL] 86 M as in Mike, L as in Lima, 8.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] I you
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] The name of the patient is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] OK, thank you. And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Date of service is 9-132024 with the amount of 1 $10,976.15.
[AGENT][NEUTRAL] OK, so that's [PII] for $10,976.15.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I can find this one moment.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I don't think it is.
[CUSTOMER][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. I don't see an appeal. I see that there are 2 submissions after the original and they are processed as duplicates.
[CUSTOMER][NEUTRAL] I think
[CUSTOMER][NEUTRAL] OK, so the appeal was uh some uh processed as a claim, correct?
[AGENT][NEUTRAL] Um, all I see here is our claims. I don't see an appeal.
[CUSTOMER][NEUTRAL] From
[CUSTOMER][NEUTRAL] OK, so the, the recent one is we submitted on [PII]. That denied a duplicate, correct?
[AGENT][NEUTRAL] Let me check and see if that's the day we received the claim.
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] OK, so the last one that we received and it was processed as a duplicate and it was a claim, it was on [PII].
[CUSTOMER][NEUTRAL] OK. And I have a
[CUSTOMER][NEUTRAL] Reference claim number is 354-8798. Is that correct?
[AGENT][POSITIVE] That is correct, yes.
[CUSTOMER][POSITIVE] Thank you so much. And may I know the original status of the claim status of the original claim?
[AGENT][NEUTRAL] OK, let me pull that up.
[AGENT][NEUTRAL] OK, I'm already on there you'll be one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so the original claim was processed [PII] and we send a benefit amount of $605.40.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] And I'm specifically looking for the CPT code 29826 and that's been denied. Can I get any additional information about that denial?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] The denial on that one is the maximum benefit payable for the date of service has been met.
[CUSTOMER][NEUTRAL] OK. And may I know the maximum allowable payable service?
[AGENT][NEUTRAL] OK, let's see one moment.
[AGENT][POSITIVE] This one has a daily benefit of 750 per day.
[CUSTOMER][NEUTRAL] So $700 and $750 per day, correct?
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] And it has been already exhausted?
[AGENT][NEUTRAL] Yes, that's been adjusted for that date of service. With the check of the $605.40 with that check, it completed the $750 for that day.
[CUSTOMER][NEUTRAL] OK. So that 750 was completed on that day in the, uh, that CVV code [PII], correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Thank you so much and.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Can I get the, can you please spell your name just for my documentation purpose?
[AGENT][NEUTRAL] Sure. My name is [PII].
[CUSTOMER][POSITIVE] Thank you so much. And I do have one more claim, [PII]. Can you help me with that too?
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Is it for a different member or the same member?
[CUSTOMER][NEUTRAL] Different member?
[AGENT][NEUTRAL] OK. Let me go ahead and finalize the note on this one and then we can move forward to the next 11 moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And is the card reference number going to be the same or will it be different?
[AGENT][NEGATIVE] And there's no reference numbers you can use my name in today's name.
[CUSTOMER][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] You're welcome one moment.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and what is the next policy number?
[CUSTOMER][NEUTRAL] It is 02298629.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] It is [PII]. Date of birth, [PII].
[CUSTOMER][NEUTRAL] Ma
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, so it's gonna be the pendent and what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It is [PII] and the bill amount is $243 and even.
[AGENT][NEUTRAL] OK, let me see if I find this that was [PII].
[AGENT][NEUTRAL] OK, so this one was also processed um twice. The last time it was processed was a duplicate, so let me pull the original information.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And before the original one.
[CUSTOMER][NEUTRAL] The duplicate line, the duplicate one was processed on.
[AGENT][NEUTRAL] OK, let me see.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Yes, correct, yes.
[CUSTOMER][NEUTRAL] And the claim number is 3549329, correct?
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] And now can I get the personal claim status?
[AGENT][NEUTRAL] Sure. The original claim was processed [PII].
[AGENT][NEGATIVE] And it was denied stating office visits are not covered by the policy.
[CUSTOMER][POSITIVE] OK. Thank you so much. And
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] May I know the policy name?
[AGENT][NEUTRAL] This is a secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] OK. Secondary supplemental plan, the name of the policy?
[AGENT][NEUTRAL] Yes, it's a secondary plan. It's a supplemental secondary plan.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][POSITIVE] Thank you so much. And just to verify the
[CUSTOMER][NEUTRAL] That claim number, the original claim number is 3,539,930, correct?
[AGENT][POSITIVE] That is correct, yes.
[CUSTOMER][POSITIVE] Thank you so much. And that's it for today, [PII]. Thank you for assisting me today. You have a great day ahead.
[AGENT][NEUTRAL] Yeah.
[AGENT][POSITIVE] You as well thank you for calling APL. Have a good day, Mr. [PII].