AccountId: 011433970860
ContactId: 68dd16c2-e8e3-4ae1-8ae8-c8668c5537ec
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 424470 ms
Total Talk Time (AGENT): 195228 ms
Total Talk Time (CUSTOMER): 192814 ms
Interruptions: 6
Overall Sentiment: AGENT=1.4, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/02/68dd16c2-e8e3-4ae1-8ae8-c8668c5537ec_20250402T15:22_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hello, ma'am. This is [PII] calling on behalf of provider's office. I'm here for a clarification of a claim. I just checked the claim status on, on your portal and I have some doubts regarding that. So, can you please help me out regarding this?
[AGENT][NEUTRAL] Sure, I can assist you with that. You did say your name was [PII]?
[CUSTOMER][NEUTRAL] Yes, [PII], my name is [PII].
[AGENT][NEUTRAL] [PII], can I have a call back number for you and that policy number?
[CUSTOMER][NEUTRAL] Yeah, the callback number is [PII].
[CUSTOMER][NEUTRAL] And the policy ID is, just a second.
[CUSTOMER][NEUTRAL] It's 01699781 M as in Mike, L as in Lima, number 8.
[AGENT][NEUTRAL] Thank you and what's the member's name and date of birth?
[CUSTOMER][NEUTRAL] Uh yeah, it's [PII] and date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And what is the date of service?
[CUSTOMER][NEUTRAL] Sure. Uh, the date of service is [PII]. The charge amount is $789 even.
[AGENT][NEUTRAL] Let me give you the correct policy number.
[CUSTOMER][NEUTRAL] Yeah, sure, please.
[AGENT][NEUTRAL] The policy number is 2473097. It's 2473097.
[CUSTOMER][POSITIVE] All right. Thank you so much.
[AGENT][NEUTRAL] And what is your bill amount?
[CUSTOMER][NEUTRAL] $798 even.
[AGENT][POSITIVE] Thank you. 7376.
[AGENT][NEUTRAL] This claim was received [PII]. It was processed [PII]. There was no payment made on this claim, and the reason why there was no payment made on this claim, [PII], is because the maximum benefit payable for this date of service has been met.
[CUSTOMER][NEUTRAL] Uh, so, uh, as, as upon checking, when was the last time this claim was paid for the same CPT for the line item?
[AGENT][NEUTRAL] No, it didn't, we didn't say that it was a duplicate. It stated that the benefits were maxed out for that date of service, so that means that she received services, this member received services on the same day and there was a claim submitted before your claim.
[CUSTOMER][NEUTRAL] OK. So, uh, so you mean to say that for the same day, uh, the patient received the services and for that you have paid, right?
[AGENT][NEUTRAL] Yes, that is correct, not the same services, but services for the date of service.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Mm, what was the service bill? Which service was built? Can you provide me the
[AGENT][NEUTRAL] I can't provide you that information. No, I can't provide you that information. That's not pertaining to your claim, unfortunately.
[CUSTOMER][NEUTRAL] So, uh, so you are saying uh
[AGENT][NEUTRAL] So what I'm saying is that the member has, the member has $300 per calendar day for benefits, and on [PII], the member has multiple claims on file for different services for that same date of service. However, the benefits were maxed out with the claims prior to your claim, [PII]. Is there anything else that I can assist you with today?
[CUSTOMER][NEUTRAL] Can you please provide me the.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So, so uh just having a little bit confusion, just, uh, uh, explain me. So you are telling that on [PII], the patient rendered multiple services with the doctor and in due to which the patient has exhausted the $300 limit, right?
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] OK. So that's why you are denying this claim for the bill amount $789 even, right? So, uh, can you provide me the details of the paid claims? Yeah. So, can you, uh, can you please provide me?
[AGENT][NEUTRAL] Yes
[AGENT][POSITIVE] Because the benefits were maxed out.
[AGENT][NEUTRAL] No, I can't give you any information about claims that was paid that you did not submit, Sam.
[CUSTOMER][NEUTRAL] So because until and unless I'm, I'm not getting any confirmation, how can I believe?
[CUSTOMER][NEUTRAL] With your statement.
[AGENT][NEUTRAL] Well, so you received the EOB stating that the benefits was maxed out. What other type of evidence do you need? The EOB that you receive is explanatory.
[CUSTOMER][NEGATIVE] But we have, we, yes, I received the, I got it. I received the UB which is for denial. I, I want the EUB which was paid for uh different.
[AGENT][NEUTRAL] Right. And it was the reason, no, we don't, no, we cannot give you that's violation of HIPAA. Are you familiar with violation of HIPAA? Because we can't give you information about, have you ever heard of HIPAA? Violation of confidentiality.
[CUSTOMER][NEUTRAL] Sorry, come again?
[CUSTOMER][NEUTRAL] OK. So just tell me the rendering provider was same or different?
[AGENT][NEUTRAL] No, this is a different provider. It's not the same. It's not the same. It's not the same services. This is a different provider submitted a claim for the data service. Is there anything else that I can assist you with today?
[CUSTOMER][NEUTRAL] So, so the, just, just.
[CUSTOMER][NEUTRAL] So, yeah, so just want the confirmation that the claim which was paid for the same date of service, the providers were different and the claim which is denied, uh, which is in that scenario, the provider was also different. So, on both scenarios, there were different providers who rendered the services.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK, what is the patient plan name?
[AGENT][NEUTRAL] This patient's plan is a meddling plan?
[AGENT][NEUTRAL] Which became effective [PII]st of 2024. This is a gap insurance. It's a map, a gap insurance.
[CUSTOMER][NEUTRAL] Can you spell that?
[CUSTOMER][NEUTRAL] Uh, can you, uh, repeat the entire plan name?
[AGENT][NEUTRAL] Midlink, mid link.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Meddling gap plan, right?
[AGENT][POSITIVE] Middling gap plan. Yes, that is correct.
[CUSTOMER][NEUTRAL] OK. So, under this policy,
[CUSTOMER][NEUTRAL] Uh, you cannot, uh, uh, means you have to bill to the, um, so we have to bill to the patient.
[AGENT][NEUTRAL] Um, we're not a primary insurance company, so I can't tell you the bill to a patient. I just can verify that APL did not make a payment on the claim that you submitted here.
[CUSTOMER][POSITIVE] OK, no worries. Thank you, thank you so much. Uh, uh, uh, can you provide me the call reference number?
[AGENT][POSITIVE] Thanks for calling APL and have a great day. Goodbye.
[AGENT][NEUTRAL] We don't provide those, [PII]. However, you can use my name and today's date as a reference. It's [PII].
[CUSTOMER][NEUTRAL] OK, and initial to your last name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] OK. Thank you.
[AGENT][POSITIVE] Have a good day. Goodbye [PII]. Thanks for calling [PII]. Bye.
[CUSTOMER][NEUTRAL] Bye.