AccountId: 011433970860
ContactId: 6297d13f-d188-4c5a-8f88-e94cc8a018f2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 940299 ms
Total Talk Time (AGENT): 289606 ms
Total Talk Time (CUSTOMER): 174595 ms
Interruptions: 2
Overall Sentiment: AGENT=0, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/6297d13f-d188-4c5a-8f88-e94cc8a018f2_20250109T15:35_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello, good morning. This is [PII] from provider's office regarding the claim status.
[AGENT][NEUTRAL] OK, [PII], um, can I ask you um for a good callback number please?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII] it's a direct line.
[AGENT][NEUTRAL] OK, and what provider's office are you calling with?
[CUSTOMER][NEUTRAL] Optum Care Colorado Springs LLC.
[AGENT][NEUTRAL] OK, and what is that policy number for the claim we're looking for?
[CUSTOMER][NEUTRAL] 4019.
[CUSTOMER][NEUTRAL] 641-777.
[AGENT][NEUTRAL] OK, give me just one moment so that I can get that pulled up.
[AGENT][NEUTRAL] OK, can you verify the patient's name and date of birth for me?
[CUSTOMER][NEUTRAL] Sure, it's gonna be first name [PII] and the last name [PII] with the date of birth [PII].
[AGENT][NEUTRAL] OK, thank you for that and what is the date of service and build amount that we're looking for?
[CUSTOMER][NEUTRAL] I'm looking for the date of service [PII].
[AGENT][NEUTRAL] OK, and the total bill amount?
[CUSTOMER][NEUTRAL] It's uh $26 even.
[AGENT][NEUTRAL] 26. OK. Give me just one moment.
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] It looks like I found it. I'm just gonna get it pulled up to make sure.
[AGENT][NEUTRAL] OK, I do have that claim. Um, it is claim number 352.
[AGENT][NEUTRAL] 951 2.
[AGENT][NEUTRAL] Um, it was received on [PII], so [PII].
[AGENT][NEUTRAL] And it was processed on [PII].
[AGENT][NEUTRAL] And it looks like this claim was denied as outpatient treatment for the same or related condition must be separated by 90 days before benefits can be can be paid.
[AGENT][NEUTRAL] And I'm going to try and better explain that let's see it looks like.
[AGENT][NEUTRAL] This insured for their outpatient benefits.
[AGENT][NEUTRAL] Let's see, it looks like it's per calendar year.
[AGENT][NEUTRAL] Let me see if I can get up get there um.
[AGENT][NEUTRAL] Policy pulled up.
[AGENT][NEUTRAL] OK, let's see.
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] And just one moment, I'm just researching this claim in the policy real quick.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Take your time.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah the last time.
[CUSTOMER][NEUTRAL] So 877758.
[CUSTOMER][NEUTRAL] I come here I.
[CUSTOMER][NEUTRAL] 1.
[CUSTOMER][NEUTRAL] Yeah, 47218-380.
[CUSTOMER][NEUTRAL] D as in Delta 114,074,740.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] So that's.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] What.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And there is no policy.
[AGENT][NEUTRAL] OK, so I am
[AGENT][NEUTRAL] Looking at the policy, um, and it looks like, um, per
[AGENT][NEUTRAL] The policy um.
[CUSTOMER][NEUTRAL] That.
[AGENT][NEUTRAL] When an individual is sane.
[AGENT][NEUTRAL] Um, for a same-related condition, um.
[AGENT][NEUTRAL] It has to be.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Separated by 90 days to be considered a payable benefit. Um.
[CUSTOMER][NEUTRAL] You mentioned that
[AGENT][NEUTRAL] And that is the reason for the um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Uh, the denial.
[CUSTOMER][NEUTRAL] Yeah, I got it. The, I got it. The denial, uh, I just need the basic information like what is the allowed amount and then it should be patients responsibility or provided right off.
[AGENT][NEUTRAL] Um, so we do not make determinations on um.
[AGENT][NEUTRAL] Patient responsibility this is a supplemental gap plan um so any remaining balance for the patient would be up to the provider or the facility on how to handle that.
[CUSTOMER][NEUTRAL] Yeah, you, uh, you're saying that, uh, you can write off right provide write off right.
[AGENT][NEUTRAL] That's completely up to your physician if they wanna write it off they can, um, but we do not make that determination.
[CUSTOMER][POSITIVE] Fine, thank you. Uh.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it and for the same patient, uh, I do have uh.
[CUSTOMER][NEUTRAL] I have more claims. Can you help me out with the same situation, I guess.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so it's the same patient just the different data service?
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] OK, what's the other date of service for this patient?
[CUSTOMER][NEUTRAL] Uh, it's [PII].
[AGENT][NEUTRAL] OK, and the total charge for that date?
[CUSTOMER][NEUTRAL] 7.
[CUSTOMER][NEUTRAL] It is for $17 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, I do have that claim that is claim number 352.
[AGENT][NEUTRAL] 3999.
[AGENT][NEUTRAL] Um, we received that.
[AGENT][NEUTRAL] On
[AGENT][NEUTRAL] 1029 of [PII], it was processed on [PII].
[AGENT][NEGATIVE] And it was denied for the same reason that it wasn't separated by 90 days for the same or related condition.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][POSITIVE] Yeah, uh, thanks for that, and I, I do have a more one claim on the same day.
[CUSTOMER][NEUTRAL] Which is for whenever we're ready.
[AGENT][NEUTRAL] Same date of service just a different build amount or just the same patient a different date of service?
[CUSTOMER][NEUTRAL] Yeah, same patient, same data service, but the different bill amount which is for uh $423 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 423. OK, let me see what I can find.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, let's see here.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, I'm not finding one for $423.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Um, I do have multiple claims for that date of service and even when I add up the different charge amounts or look into that claim, I don't see a total.
[CUSTOMER][NEUTRAL] No, it's for uh.
[CUSTOMER][NEUTRAL] Yeah, my mistake is $425.
[AGENT][NEUTRAL] OK, one more time, what was that total charge?
[CUSTOMER][NEUTRAL] $425.
[AGENT][NEUTRAL] OK, I don't have any claims that are for 400 and anything.
[AGENT][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Uh, thank you.
[AGENT][NEUTRAL] Maybe if I added them together and they came over separately and for some reason that's why they're on different claim numbers um but because it does look like most of these claims that we've received came from you all um so it may have just came over as two separate claims and that could be why um I will let you know that everything for that date of service was denied for the same reason or as a duplicate.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] So if it did come over separately and that's why we're not showing that total charge um.
[AGENT][NEUTRAL] It looks like it could be the same denial, but I I don't know for sure because I don't have that total charge amount.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, that's just from my end, uh, and can I get the call call reference?
[AGENT][NEUTRAL] Yeah, so it's just gonna be my name, so that's [PII], last initial [PII] with today's date.
[CUSTOMER][NEUTRAL] It's spelled as [PII], is it correct?
[AGENT][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] So that's my mistake.
[AGENT][NEUTRAL] That's OK. Is there anything else I can do for you, [PII]?
[CUSTOMER][NEUTRAL] Yeah, uh.
[CUSTOMER][NEUTRAL] Nothing much. Have a good day, [PII].
[AGENT][POSITIVE] Thank you you as well and thanks for calling IPO.
[CUSTOMER][NEUTRAL] Bye.
[AGENT][NEUTRAL] Bye bye.