AccountId: 011433970860
ContactId: 6721ce80-cc47-4e38-b99b-bd2d105e2360
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 873190 ms
Total Talk Time (AGENT): 251545 ms
Total Talk Time (CUSTOMER): 298245 ms
Interruptions: 8
Overall Sentiment: AGENT=-0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/15/6721ce80-cc47-4e38-b99b-bd2d105e2360_20250515T20:44_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], I'm [PII] calling on behalf of providers of Imperial Health LLP. I want to discuss a directly with you if you can help me with that.
[AGENT][NEUTRAL] I'm sorry, could you repeat that?
[CUSTOMER][NEUTRAL] Hi, [PII], I'm [PII] calling on behalf of providers of Imperial Health LLP.
[AGENT][NEUTRAL] Checking for eligibility, I can help you with that.
[CUSTOMER][NEGATIVE] No, no please.
[AGENT][NEUTRAL] Can I get a good callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] Get
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] [PII] and what was the rest?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Let me repeat it once again for you. It's [PII].
[AGENT][POSITIVE] OK, thank you so much.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] the
[AGENT][NEUTRAL] And can I get the policy number?
[CUSTOMER][NEUTRAL] I get the policy number
[CUSTOMER][NEUTRAL] And the policy number for this is gonna be.
[CUSTOMER][NEUTRAL] 01633180.
[AGENT][NEUTRAL] 3310.
[CUSTOMER][NEUTRAL] It's 01633180.
[AGENT][POSITIVE] 80 OK thank you so much.
[CUSTOMER][POSITIVE] Thank you so much
[AGENT][NEUTRAL] Let me check on that for you.
[AGENT][NEUTRAL] Can I get the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, the patient's name it's gonna be.
[CUSTOMER][NEUTRAL] [PII], and date of birth is [PII].
[AGENT][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] It looks like this policy is active with an effective date of [PII].
[CUSTOMER][NEUTRAL] is active.
[CUSTOMER][NEUTRAL] Till now.
[AGENT][NEUTRAL] Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] No, I was looking for claim status.
[CUSTOMER][NEUTRAL] For eligible
[AGENT][NEUTRAL] Oh, claim status, do you have the claim number or the date of service?
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] I do have a data services of [PII] and I do also have a claim number.
[AGENT][NEUTRAL] February [PII].
[CUSTOMER][NEUTRAL] February [PII] [PII].
[AGENT][NEUTRAL] And what's the claim number?
[CUSTOMER][NEUTRAL] Just to check.
[CUSTOMER][NEUTRAL] 35410001.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] It looks like we received that claim on December, I'm sorry, on [PII], and it was processed on [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] The exact same.
[CUSTOMER][POSITIVE] I'm sorry
[CUSTOMER][NEUTRAL] 2024.
[CUSTOMER][NEUTRAL] And it was.
[AGENT][NEGATIVE] That claim was denied.
[CUSTOMER][POSITIVE] Good
[AGENT][NEGATIVE] The maximum benefit for the outpatient sickness writer has been exhausted for the calendar year.
[CUSTOMER][POSITIVE] Maximum benefit for the out sickness.
[CUSTOMER][NEUTRAL] Medicine benefit for?
[AGENT][NEUTRAL] And then the policy also does not provide a benefit for surgery uh services in which no charges were incurred.
[CUSTOMER][NEUTRAL] And then the policy also.
[AGENT][NEUTRAL] So those are the two reasons why the the claim got denied.
[CUSTOMER][NEUTRAL] May.
[CUSTOMER][NEUTRAL] I want to know the exact reasons for the CPT 99204 and 9300 why these two CPT have been denied.
[AGENT][NEGATIVE] Yes, it has been denied because the maximum benefit for the outpatient sickness writer.
[CUSTOMER][NEGATIVE] It has been denied because the.
[CUSTOMER][NEUTRAL] out
[AGENT][NEUTRAL] Has been exhausted for the calendar year.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Outpatients is.
[AGENT][NEUTRAL] And then there were also charges there was also uh services in which there were no charges incurred, and the policy does not provide a benefit for charges in which no charge does not provide a benefit for services in which no charges were incurred.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] and the.
[CUSTOMER][NEUTRAL] Hi
[CUSTOMER][NEGATIVE] Please provide me only for this 9924 and 9300. I'm not looking for the charge. These are bill with $0. So not for that. I'm asking about. I'm asking about only these two CBDs 99204 and 9300 denied as maximum benefit for the outpatient sickness.
[AGENT][NEUTRAL] Yes sir.
[CUSTOMER][NEUTRAL] I don't know
[CUSTOMER][NEUTRAL] Outpatient sickness. What if you can exactly tell me?
[AGENT][NEUTRAL] And I'm sorry, can you repeat what you're saying? I cannot hear you.
[CUSTOMER][NEUTRAL] Can you please tell me only for these two CPDs 99204 and 93,000.
[CUSTOMER][NEUTRAL] 000 for these two CPTs.
[AGENT][NEUTRAL] Is that another claim number?
[CUSTOMER][NEUTRAL] That is not another claim number for the same claim I'm asking for the CBT 99204 and 93,000.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] Yes, those were denied.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Yes, those were denied because the maximum benefit.
[CUSTOMER][POSITIVE] Good
[AGENT][NEGATIVE] was exhausted.
[AGENT][NEUTRAL] For those two codes.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] So the max some benefit for outpatient sickness have exhausted, right?
[AGENT][NEUTRAL] Right, and then the other codes.
[CUSTOMER][NEUTRAL] So
[AGENT][NEGATIVE] were denied because no uh no charges were given.
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] I'm looking only for this. May I know why this, uh, dela for maximum benefit, how much is allowed and how much is paid?
[CUSTOMER][NEUTRAL] And it is
[CUSTOMER][NEUTRAL] It is an office visit.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Office is it. So if you can help me with that.
[AGENT][NEUTRAL] You know.
[AGENT][NEUTRAL] Let me see here.
[CUSTOMER][NEUTRAL] Because I already paid here.
[AGENT][NEUTRAL] Give me just a moment.
[AGENT][POSITIVE] I can pull that up for you.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] I'm looking at that benefit for you, give me just a moment.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Sorry.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It looks like they're outpatient sickness writer.
[AGENT][NEUTRAL] Provides up to $25.
[AGENT][NEUTRAL] Uh, with a maximum days with uh maximum days per calendar year, 5 per covered person.
[CUSTOMER][NEUTRAL] The maximum date.
[CUSTOMER][NEUTRAL] Maximum
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] So when this claim was filed, they had exhausted all of that.
[CUSTOMER][NEUTRAL] 5 per year.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I think the maximum allowed is 5 per year.
[AGENT][NEUTRAL] Correct, and that is a verification of benefits and not a guarantee of payment.
[CUSTOMER][NEUTRAL] And that
[AGENT][NEUTRAL] The claim was denied because the patient had met that benefit already.
[CUSTOMER][NEUTRAL] 5.
[CUSTOMER][NEUTRAL] And that's that that's it.
[CUSTOMER][POSITIVE] My that benefit.
[CUSTOMER][NEUTRAL] And 25 per visit were allowed, right?
[AGENT][NEUTRAL] $25 per day of treatment.
[CUSTOMER][NEUTRAL] Per day and only 5 were allowed in a year.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So may I know is it going to be the patient responsibility or something if you can help me with that?
[AGENT][NEUTRAL] I don't know that, sir.
[AGENT][NEGATIVE] I don't know what their responsibility would be for this.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Because patient is a me so it's going to be the patient responsibility.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] Oh yeah, I'm sorry, are you asking me a question?
[CUSTOMER][NEUTRAL] Yeah, I ask you a question.
[CUSTOMER][NEUTRAL] Like, uh, is it going to be the patient responsibility or not, but it has been, uh, made by the patient only. The patient is going to take the services. So is it going to be the patient responsibility?
[AGENT][NEUTRAL] Right. Once it's been exhaust once it's been exhausted, it is up to the patient.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Exhausted it to the patient. Can you bill this screen to the patient?
[AGENT][NEUTRAL] Uh, we would not bill the patient, that would be the provider.
[CUSTOMER][NEUTRAL] Uh, we would not build the patient that would be the.
[CUSTOMER][NEUTRAL] Yeah, I'm asking that we can bill it to patients.
[AGENT][NEUTRAL] I do not have that. That would be up to the provider.
[AGENT][NEGATIVE] I can't provide patient responsibility.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] It is all the patient discounts for you.
[AGENT][NEUTRAL] Right, that would be up to the provider to give patient responsibility. I am not allowed to give patient responsibility.
[CUSTOMER][NEGATIVE] I don't think I'm not going to get.
[AGENT][NEUTRAL] It would be up to the provider since this claim was denied.
[CUSTOMER][NEUTRAL] So.
[AGENT][NEUTRAL] Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] What is this
[CUSTOMER][NEUTRAL] Just give me a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, I can see you'll be, you'll be there's nothing mentioned only it is mentioned outpatient sickness benefit.
[CUSTOMER][NEUTRAL] And nothing else is mentioned in the CB.
[AGENT][NEUTRAL] Right, that denial was in the EOB that was sent by the press to the provider.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] We just
[CUSTOMER][NEUTRAL] So what we can further do this case if you can help me with that.
[AGENT][NEUTRAL] It was sent to Imperial Health.
[CUSTOMER][NEUTRAL] and
[CUSTOMER][NEUTRAL] Yeah, I know that was set will be there. So what we can do further on this payment to get the payment if you can help me with that.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] I'm sorry, I can't hear what you're asking. Can you speak up just a little bit?
[CUSTOMER][NEUTRAL] I'm saying what we can further do on this claim.
[CUSTOMER][NEUTRAL] So that you can get paid.
[AGENT][NEGATIVE] Um, it can't get paid because it was denied through us.
[CUSTOMER][NEGATIVE] Uh, we get paid because it was denied so can we build this to or something.
[AGENT][NEUTRAL] Because they had exhausted all of their benefits.
[CUSTOMER][NEUTRAL] Sure. Please provide the call reference.
[AGENT][NEUTRAL] We don't have a call reference number, but you can use my name and last initial, so [PII] in today's date.
[CUSTOMER][NEUTRAL] to call the
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Hello
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][NEUTRAL] Yes sir.
[AGENT][NEUTRAL] And is there anything else I can help you with?
[CUSTOMER][POSITIVE] Thank you, [PII]. It was great. No, [PII], it was great talking to you.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Well thank you for letting me help you with your eligibility and claim status and if there's nothing further, thank you for calling APL and have a great day.
[CUSTOMER][NEUTRAL] let me
[CUSTOMER][NEUTRAL] Nothing
[CUSTOMER][POSITIVE] You too have a great day. Bye-bye.
[AGENT][NEUTRAL] Bye.