AccountId: 011433970860
ContactId: 677bf6fd-9b29-49b1-9398-b93c70716b72
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 477750 ms
Total Talk Time (AGENT): 151683 ms
Total Talk Time (CUSTOMER): 213425 ms
Interruptions: 2
Overall Sentiment: AGENT=0.6, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/677bf6fd-9b29-49b1-9398-b93c70716b72_20250121T22:16_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, [PII], this is [PII]. My last initial is [PII]. I'm checking for the claim status.
[AGENT][POSITIVE] OK, and I'll be more than happy to assist you with the claim status, [PII]. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Two claims.
[AGENT][NEUTRAL] OK, may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yeah, 02275146.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][POSITIVE] OK, you make time for me.
[CUSTOMER][NEUTRAL] Yeah, [PII], [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim you'd like me to check on?
[CUSTOMER][NEUTRAL] What.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] And the total bill amount?
[CUSTOMER][NEUTRAL] Total bill amount $210.10.
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] And the.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] It's Alpha Medical Center.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah sure I'm.
[AGENT][NEUTRAL] Alright, so I'm sure to receive the claim on [PII].
[CUSTOMER][POSITIVE] Mhm. Pros on.
[AGENT][NEUTRAL] The claim
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, claim number.
[AGENT][NEUTRAL] The claim number is 3521261.
[CUSTOMER][NEUTRAL] 03
[CUSTOMER][NEUTRAL] OK, it is denied or paid.
[AGENT][NEUTRAL] And the claim was
[AGENT][NEUTRAL] I'll give you all the claim details, um, just give me a moment. So the claim was denied because the calendar year max for the outpatient office visit has been met.
[CUSTOMER][NEUTRAL] 3
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I'm not understand, uh, so the outpatient visits has been made, right?
[AGENT][NEUTRAL] So this policy
[CUSTOMER][NEGATIVE] So, it is denied for.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Go ahead.
[AGENT][NEUTRAL] This policy covers 6 physician office visits at $75 per visit.
[CUSTOMER][NEUTRAL] 6.
[AGENT][NEUTRAL] So this um the now.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So the denial reason is saying that the 6 visits have been used for the calendar year. So by the time your claim came in, they used all the benefits.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] The 6 visits.
[CUSTOMER][NEUTRAL] Used.
[CUSTOMER][NEUTRAL] Calendar year, right?
[AGENT][NEUTRAL] Yes, the 6 digits were used.
[CUSTOMER][NEGATIVE] Claim denied for already 6 visits.
[CUSTOMER][NEUTRAL] 6 visits used per calendar year.
[CUSTOMER][NEUTRAL] One of uh.
[CUSTOMER][NEUTRAL] Yeah, which CPD code you are talking about?
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] OK, so there's several CPT code, I mean, there's several codes on this claim, but they were all denied for the same reason.
[CUSTOMER][NEUTRAL] OK. Already 6 visits used per calendar year, uh, with the different providers, right, or same providers?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Same facility.
[AGENT][NEUTRAL] This is, this is the same provider. This is all one claim.
[CUSTOMER][NEUTRAL] Uh, with the same facility, right, with the same.
[CUSTOMER][NEUTRAL] Facility
[CUSTOMER][NEUTRAL] And the same patient.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Can you give me uh all the data of service which has been used with the facility?
[AGENT][NEUTRAL] Um, no, we can't provide that because those belong to other claims, but the benefit has been used for the calendar year.
[CUSTOMER][NEUTRAL] OK, per calendar year, we need to obtain only 6 visits, right?
[AGENT][NEUTRAL] Right, but the 6 visits, the 6 visits are not all are not your provider's claim, so we can't give that information, but to answer your question, the benefit has been used for the calendar year. That's the reason your claim was denied.
[CUSTOMER][NEUTRAL] But uh they already
[CUSTOMER][NEUTRAL] With the different facility, OK.
[AGENT][NEUTRAL] It's not, well, yeah, it was denied with with different claims.
[CUSTOMER][NEUTRAL] Different.
[CUSTOMER][NEUTRAL] Yeah, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so what is the current timely for the limit?
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Um, there's no timely filing limit as long as the policy was active on the data service.
[CUSTOMER][NEUTRAL] OK, one second there.
[CUSTOMER][NEUTRAL] OK. What is the current claim num uh claim mailing address?
[CUSTOMER][POSITIVE] Thank you
[CUSTOMER][NEUTRAL] I'm gonna need to get the ID number.
[AGENT][NEUTRAL] It's PO [PII].
[AGENT][NEUTRAL] 950.
[CUSTOMER][NEUTRAL] Mhm. Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] Yes I'm.
[CUSTOMER][NEUTRAL] OK, come on.
[CUSTOMER][NEUTRAL] OK. What is the phone number?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Can you fax me the copy of the UB?
[AGENT][NEUTRAL] Sure, what's a good fax number for you?
[CUSTOMER][NEUTRAL] Yeah, that is uh [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And to whose attention?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] Yes, my name is [PII].
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and are you ready for the next member's policy number?
[CUSTOMER][NEUTRAL] No, that's all. Can you provide me the reference number?
[AGENT][NEUTRAL] So there's no call reference number, which you can use my name in today's date.
[CUSTOMER][POSITIVE] OK. Thank you, [PII]. Have a great day. Bye-bye.
[AGENT][POSITIVE] You also, [PII] and thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] You too.