AccountId: 011433970860
ContactId: 6e05bdf3-d921-4f96-bce8-3bf4131b5183
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 337380 ms
Total Talk Time (AGENT): 133707 ms
Total Talk Time (CUSTOMER): 111861 ms
Interruptions: 0
Overall Sentiment: AGENT=1.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/23/6e05bdf3-d921-4f96-bce8-3bf4131b5183_20250423T17:52_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yes, hi, my name is [PII]. I'm calling from Super Medical Foundation, checking on the claim status.
[AGENT][NEUTRAL] OK, I can check in a claim for you. uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, [PII].
[AGENT][NEUTRAL] OK, thank you and then do you have the policy number?
[CUSTOMER][NEUTRAL] Yes, it's 02550829.
[AGENT][NEUTRAL] OK, and then what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] Yes, uh, name [PII] and [PII].
[AGENT][POSITIVE] Perfect, thank you for verifying that uh what was the date of service for this claim?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] I'm sorry, that was [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and what was that bill amount please?
[CUSTOMER][NEUTRAL] $2,272 even.
[AGENT][POSITIVE] OK, thank you one moment please.
[CUSTOMER][NEUTRAL] Mm yes.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh, I'm sorry, uh, [PII], what was the name of this provider's office?
[CUSTOMER][NEUTRAL] Settle Gold Medical Foundation.
[AGENT][POSITIVE] OK awesome so we did receive this claim uh looks like we paid a benefit of $500 and that did meet their maximum for this occurrence.
[CUSTOMER][NEUTRAL] Uh, can you please help me with the uh claim receive date?
[AGENT][POSITIVE] Sure, give me just a moment, I'll get that for you.
[AGENT][NEUTRAL] So this claim was received [PII].
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] And it was processed [PII].
[CUSTOMER][NEUTRAL] OK. And it was paid only $500 right?
[AGENT][NEUTRAL] Correct, that was the maximum amount payable.
[CUSTOMER][NEUTRAL] OK. Uh, can you please help me with the, uh, like, uh, I do see that it was only paid for the CPT 70553. Actually, we have built the claim with the three CPTs, right?
[AGENT][POSITIVE] Yes, we did receive all of those.
[CUSTOMER][NEUTRAL] And we do have another 2 CPTs as well.
[AGENT][NEUTRAL] Yes, yes, we received both of those as well. Um, this is just, it just paid the $500 for this occurrence, so that was just simply the maximum amount we could pay for any of these codes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. The complete, uh, only the payable amount is only $500 for the complete like bill amount, right?
[AGENT][NEUTRAL] Yes, it's, uh, their benefit amount is $5 per occurrence.
[CUSTOMER][NEUTRAL] OK. That is only payable for the CPT 70553. And you're not going to pay uh for CPTA 9585?
[AGENT][NEGATIVE] We are unable to as it was a part of the same occurrence, in which case only $500 was payable.
[CUSTOMER][NEUTRAL] Uh, may I know the reason why, uh, you're stating something like it is a part of?
[AGENT][NEUTRAL] So it's this policy pays per occurrence, so meaning it's for the same thing, uh treatment for the same um accident, injury or sickness. So if this was all for the same occurrence, $500 was the maximum amount we could pay regardless of the CPT codes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, we can consider the remaining balance is the patient responsibility.
[AGENT][NEUTRAL] We don't say what is patient responsibility that would be up to the provider.
[AGENT][NEUTRAL] And if you would like, [PII], I can send you a copy of this EOB.
[CUSTOMER][NEUTRAL] Uh, I do have that UOB. So that is the reason like, uh, we only receive the payments only for one CPT. Yeah, for other two CPTs were not paid because yes, yeah, you're stating that uh this, this procedure is already included in the, that procedure.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] That is correct, yes, as they are all part of the same occurrence and that's how this is paid.
[CUSTOMER][NEGATIVE] That is not payable.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can you please help me with, mm.
[CUSTOMER][NEUTRAL] Yeah, help me with your name and the conference number.
[AGENT][NEUTRAL] Sure, reference number would just be my first name, last initial, and today's date, and so my name is spelled [PII] And was there anything else I can help you with, [PII]?
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][NEUTRAL] No, uh, [PII].
[CUSTOMER][POSITIVE] OK, thank you, yeah, that's it for now.
[AGENT][POSITIVE] All right well thanks for giving us a call have a great rest of your day.
[CUSTOMER][POSITIVE] Thank you bye bye.
[AGENT][POSITIVE] Thank you, bye bye.