AccountId: 011433970860
ContactId: 6d368430-f653-4d1f-9cec-185cf780f02c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 985679 ms
Total Talk Time (AGENT): 251034 ms
Total Talk Time (CUSTOMER): 455266 ms
Interruptions: 6
Overall Sentiment: AGENT=0.9, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/15/6d368430-f653-4d1f-9cec-185cf780f02c_20250115T21:38_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII]. I'm calling for the provider [PII]. Please note that this call will be recorded and monitored for quality and training purpose. I'm calling in today to check on a claim status.
[AGENT][POSITIVE] OK, yeah, I'd love to help you with that claim status today, [PII], and can I have a good callback number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, sure, the callback number would be [PII], which is direct line.
[AGENT][NEUTRAL] And the name on the policy?
[CUSTOMER][NEUTRAL] You mean the patient's name or the member's name?
[AGENT][NEUTRAL] Oh, I, you know what, I really should, I'm not sure why I said that. Can I have the policy number?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, sure, so.
[CUSTOMER][NEUTRAL] Yeah, the member ID is.
[CUSTOMER][NEUTRAL] 02474837.
[AGENT][POSITIVE] Thank you and let me get that pulled up real quick.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] All right. And can you verify for me your patient's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure, just a moment.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] The patient's name is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Thank you. I see him right here. And do you have a claim number in particular you want me to look at or did you want me to search by date of service?
[CUSTOMER][NEUTRAL] Yes, you just wanna search by the date of service as.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I don't have any other.
[CUSTOMER][NEUTRAL] Let me check over here.
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][POSITIVE] No, take your time you're good.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you. So here,
[CUSTOMER][NEUTRAL] Mhm, yeah. I do have a claim number which is 35144.
[CUSTOMER][NEUTRAL] 85025.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, let me take a look at that for you.
[CUSTOMER][NEUTRAL] OK. And we received uh EOP which is page in that I do have a different claim number as well.
[CUSTOMER][NEUTRAL] So that could be 3.
[AGENT][NEUTRAL] OK, what's the claim number for that one?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 349-056-7
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] All right. And can you verify for me the name of the facility on file?
[CUSTOMER][NEUTRAL] Sure, just a moment. So.
[CUSTOMER][NEUTRAL] It's fine like physician practice LLC.
[AGENT][POSITIVE] Alright, wonderful.
[CUSTOMER][NEUTRAL] And if you need the particular practice address, I can give it to you.
[AGENT][NEUTRAL] No, that's OK that's how it came up under on my side too and then.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So I do see that one.
[CUSTOMER][POSITIVE] OK, great.
[AGENT][NEUTRAL] For Pine Lake, um, what, how can I help you with that one?
[CUSTOMER][NEUTRAL] OK. Uh, so I just wanna know the claim status. Actually, it's not clear that we, uh,
[CUSTOMER][NEUTRAL] Partially paid and one CPT code which is outstanding in our hand and on checking. The CPT code 45378 is
[CUSTOMER][POSITIVE] Still outstanding, so I just wanna check on this claim.
[AGENT][NEUTRAL] OK, yeah, so, um, for that particular CPT code, you actually had benefits payable of $500. They were paid by check 1868761, and I see that it says on that that the calendar year maximum for this benefit has been exhausted with the payment of this claim.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, so is that the reason, uh, because, uh, I mean the maximum benefits exhausted, that's the reason why the.
[CUSTOMER][NEUTRAL] CPT is that denied?
[AGENT][NEUTRAL] So, um,
[AGENT][NEUTRAL] Yeah, so that's the.
[AGENT][NEGATIVE] It picked up on that first charge, the 5, I cannot talk 45378, um, it paid that benefit of $500 and then that was that max benefit um and so that next code 43239 um did get denied and it just says that the maximum benefit payable uh has been met.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] You know
[CUSTOMER][NEUTRAL] OK, maximum payable has met. That's why it, it got denied. OK, that's correct?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, so it looks like that benefit of 500 was all there was on that claim.
[AGENT][NEUTRAL] And that should have come through as a check for you.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, I got it. And may I know when it's, let me check here. So is that received on [PII] and paid for the other $500 on [PII] for the allowed amount is $500.
[AGENT][NEUTRAL] And then
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It looks like, I guess I'm not sure about those dates of service. What do you mean it was paid on [PII]?
[CUSTOMER][NEUTRAL] I mean the 500, as you said, uh, the maximum.
[CUSTOMER][NEUTRAL] Uh, amount, I mean, benefits is uh exhausted, right? And it's 500 which is already paid, right? If I'm not wrong.
[AGENT][NEUTRAL] Yes, I'm sorry, I do understand it did, yes, that 500 paid and then it was issued out to you in August.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes, OK. And
[CUSTOMER][NEUTRAL] Could you please wait for me? May I place your call on hold for just 2 minutes while I'll check and I'll get back to you.
[AGENT][POSITIVE] Oh, absolutely.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Thank you for your patience. Could you hear me?
[AGENT][POSITIVE] Oh, my pleasure.
[CUSTOMER][NEUTRAL] Yes, uh, I'm really sorry for the long hold. Uh, so, uh, once again, uh, just to reconfirm that information, that CPT code 45378.
[CUSTOMER][NEUTRAL] Wasn't paid, right? And the other CPT code 43239 was paid with $500 and
[AGENT][NEUTRAL] It's backwards, so that $500 went towards the code [PII], and then the other 1 43239 was the one that ended up getting denied because the benefits had been exhausted.
[CUSTOMER][NEUTRAL] OK, just a moment.
[CUSTOMER][NEUTRAL] Please bear with me for a minute.
[AGENT][NEUTRAL] Oh, you're fine.
[CUSTOMER][NEUTRAL] OK, uh, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is that uh units exists only for, uh, from the same provider or it could be any other providers?
[AGENT][NEUTRAL] What do you mean?
[AGENT][NEUTRAL] Like that benefit is that what you're asking?
[CUSTOMER][NEUTRAL] OK, so it
[CUSTOMER][NEUTRAL] Um, I mean unit, I mean, the CBD code.
[CUSTOMER][NEUTRAL] Which was denied because it exceeded the maximum, right? So is that exceeds only from the same provider, for the same provider or it's for, uh, it could be the any other providers?
[AGENT][NEUTRAL] OK, yeah, so, um, your patient actually just only has that benefit they can use once per calendar year.
[CUSTOMER][NEUTRAL] the more.
[AGENT][NEUTRAL] So they can only receive that benefit on this plan once per calendar year.
[AGENT][NEUTRAL] From anybody.
[CUSTOMER][NEUTRAL] OK. Uh, particular code, particular code will be uh paid one.
[AGENT][NEUTRAL] It's not a particular code. That code fell. I can't check just like codes for you, but that code fell under his um accident sickness and surgical benefit in the facility and he only gets that once per calendar year.
[CUSTOMER][NEUTRAL] OK. Once, and I, it is already paid for, I mean, uh, that benefits, uh, benefit has been met by the patient already before this. That's the reason why it cannot be paid.
[AGENT][NEUTRAL] Yeah, and with that check they sent you for 500, mhm.
[CUSTOMER][NEUTRAL] OK, OK, I got it. So how many units, uh, will allow under the days or week?
[CUSTOMER][NEUTRAL] Or month right I mean year right as you said.
[CUSTOMER][NEUTRAL] Only uh how many units or how many.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] I'm not sure what you mean by units. Like, I don't know units of what.
[CUSTOMER][NEUTRAL] OK, just a moment.
[AGENT][NEUTRAL] I'm sorry, I just wanna be able to answer your question, but I'm not exactly sure, but.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] What you're needing.
[CUSTOMER][NEUTRAL] Yeah, OK, no problem. Uh, so, before that, may I get, uh, the claims mailing address, I mean corrected claims mailing address and appeals mailing address for documentation?
[AGENT][NEUTRAL] Oh yeah, absolutely. Um, the claims mailing address and the appeal and mailing address are the same. You're just going to address one to claims and one to APL appeals, um, but the mailing address is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. Just to reconfirm that it's [PII] and
[CUSTOMER][NEUTRAL] It's city, um, and then [PII] is the ZIP code, right?
[AGENT][NEUTRAL] Yes, absolutely. [PII].
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][POSITIVE] OK, thank you and
[CUSTOMER][NEUTRAL] And when it is appeal, it has to be attention to APL appeals, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, and is there any specific form need to be submitted with the bill?
[AGENT][NEUTRAL] Um, just, just your intent to appeal.
[CUSTOMER][NEUTRAL] yeah
[CUSTOMER][NEUTRAL] OK, and do we need to attach the denial you'll be with that claim or with the appeal?
[AGENT][NEUTRAL] Um, I don't know if you necessarily need to, but I don't think it would hurt.
[CUSTOMER][NEUTRAL] OK, OK, got it. And what's the timely filing limit for crypted claim as well as your
[AGENT][NEUTRAL] Uh, we do
[AGENT][NEUTRAL] We don't have a timely filing limit, so, um, you're more than welcome to resubmit a claim at any time.
[CUSTOMER][POSITIVE] Perfect. OK, thank you. And just to check it up here.
[CUSTOMER][NEUTRAL] May I know the receipt and the date when it was processed?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] Sorry, one second.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] All right, we received it on
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII] and then we processed it on [PII].
[CUSTOMER][NEUTRAL] I mean, denied all, uh, denied on the same date. I mean, I know, right?
[AGENT][POSITIVE] Yes, absolutely.
[CUSTOMER][POSITIVE] OK, I got it. Thank you so much and the claim number is the same which I verified in the pre uh initially, right?
[AGENT][NEUTRAL] Yeah, yeah, the claim number, it's at 349-0567.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Got it. Thank you. And may I get the call reference for a call?
[AGENT][POSITIVE] Yes, absolutely. It's my name, [PII].
[CUSTOMER][POSITIVE] Got it. Thank you so much. I see your wonderful assistance today. Have a great day and take care. Bye-bye.
[AGENT][POSITIVE] Oh my pleasure. Thank you. Bye bye.
[CUSTOMER][NEUTRAL] Bye bye.