AccountId: 011433970860
ContactId: 731abbb9-7b11-44e1-9ac3-ac8b9a68bf12
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1324520 ms
Total Talk Time (AGENT): 369444 ms
Total Talk Time (CUSTOMER): 425722 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/07/731abbb9-7b11-44e1-9ac3-ac8b9a68bf12_20250207T15:22_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yes, sir, this is [PII] calling from the provider office Vital MD Group Holding.
[CUSTOMER][NEUTRAL] For claim status.
[AGENT][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] And tell you this call is being recorded for quality and training purpose.
[AGENT][NEUTRAL] OK, um, may I have a callback number just in case we get disconnected, Ms. [PII]?
[CUSTOMER][NEUTRAL] Sure. It is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you and may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Just give me a second. You help me with your name. Can you help me with your, uh, name spelling?
[AGENT][NEUTRAL] Sure, that's [PII] [PII].
[CUSTOMER][POSITIVE] OK. Thank you, sir.
[CUSTOMER][NEUTRAL] And you need policy ID for the member, right?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yes. So the policy ID we have here is 02140714 M as in Mike, L as in Lima, 8.
[AGENT][NEUTRAL] OK. What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Uh, so the first name is [PII] and the last name is [PII]
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][NEUTRAL] All right, and thank you. And may I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yes. So the data service we have here is
[CUSTOMER][NEUTRAL] [PII], sorry, [PII], with the total bill amount of $286 even.
[AGENT][NEUTRAL] OK. All right, let me see if I can find this claim. And again, that was for [PII], the amount of 286, correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Alright, thank you one moment.
[AGENT][NEUTRAL] And for future you can check claim status online through our website at [PII] and that's just optional, OK? And let me pull the details.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] I'm waiting on the UP one moment.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. So we received the claim on [PII], processed [PII].
[AGENT][NEUTRAL] And the claim was denied. The reason for this denial is that the maximum benefit payable for the date of service has been met.
[CUSTOMER][POSITIVE] Uh, met in the sense of dollars or value.
[AGENT][NEUTRAL] OK, let me check and see. I believe it's gonna be a dollar amount. Bear with me.
[AGENT][NEUTRAL] 1
[AGENT][POSITIVE] Yes, this one has a $500 daily benefit.
[CUSTOMER][NEUTRAL] Uh, so,
[CUSTOMER][NEUTRAL] So the code 88305 has $500 of uh daily benefit, right?
[AGENT][NEUTRAL] No, it's not based on codes. It's based on the benefit. Basically, any outpatient service benefit for that date of service, there is $500 for that date of service.
[AGENT][NEUTRAL] So just an example, if she had an office visit and she had a MRI and she has a um injection, she only has $500. So if we get the claim for the injection before we get the claim of the MRI and she already is after her benefits, then it's gonna be denied.
[CUSTOMER][NEUTRAL] OK. Just give me a second. Let me check some details here.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. So can you please help me with the claim number or which claim it got fully exhausted?
[AGENT][NEUTRAL] I can give you your information. I cannot give you information about another provider, so I can only give you the claim number for yours, OK? The claim number for yours is 353-767-73.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. 353
[AGENT][NEUTRAL] 7673.
[CUSTOMER][NEUTRAL] OK. So you are saying that you cannot provide me the information for the second claim.
[AGENT][NEUTRAL] No, I can only provide you your information, the claim information for your claim. I cannot provide you any other information than that.
[CUSTOMER][NEUTRAL] OK. Give me a second. Let me make a note for the same.
[CUSTOMER][NEUTRAL] Uh, can you help me with the plan, uh, for the member?
[AGENT][NEUTRAL] This is a secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] 23
[CUSTOMER][NEUTRAL] Plan for major.
[AGENT][NEUTRAL] It's a, it's a secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And um
[CUSTOMER][POSITIVE] That's good.
[CUSTOMER][POSITIVE] No issue.
[CUSTOMER][NEUTRAL] Thank you for that. And um can you please help me? I have 2 more claims to check. Can you please help me with all two claims?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Mm, sure. I just need to make a note on each one before I move forward if they are different policies, OK?
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] And you don't need any other information on this one, correct?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] All right. And what is the next policy number?
[CUSTOMER][NEUTRAL] Just give me a second here.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. So the next policy number I have is 01857791 M as in Mike, L as in Lima, 8.
[AGENT][NEUTRAL] OK. And what is the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] So the first name is [PII] and the last name is [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][NEUTRAL] OK, what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] So the rate of service we have here, it is on [PII], with the total bill amount of $583 even.
[AGENT][NEUTRAL] $583 even and that was [PII], correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, so I just want, uh, so previously we have sent and faxed to you guys stating, uh, that, uh, uh, this claim, uh, just.
[CUSTOMER][NEUTRAL] OK, so the claim, uh, required primary UB. So we have sent you guys, uh, the primary UV via fax. Can you please help me? Did you guys receive that UB or not?
[AGENT][NEUTRAL] OK, I can check. One moment.
[AGENT][NEUTRAL] What is the procedure code for this one, Ms. [PII]?
[CUSTOMER][NEUTRAL] Uh, so, uh, here, we have multiple procedure code which is 88175. So the balance we have here, it is 87661 for which the primary has left to uh the PR.
[CUSTOMER][NEUTRAL] Patient responsibility.
[AGENT][NEUTRAL] OK, let me see if it's this one. Bear with me, OK? I'll have to pull the information and the claim and everything to determine. OK, one moment.
[AGENT][NEUTRAL] Still waiting on the AB, OK?
[CUSTOMER][POSITIVE] OK, take your time.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Mm OK, yeah, it's this one. Alright, it looks like we processed the claim on [PII] and we send a benefit amount of $48.72 to the provider.
[CUSTOMER][NEUTRAL] OK, so we did not receive anything from you guys. Uh, can you help me with the more detail about the claim you guys received the claim on?
[AGENT][NEGATIVE] Yes, it was received on [PII], processed [PII]. It's not been enough time for you to receive it. Um, the
[AGENT][NEUTRAL] Claim number is 3558347.
[AGENT][NEUTRAL] And that we check.
[CUSTOMER][NEUTRAL] 3558347
[AGENT][NEUTRAL] 8347. Mhm.
[CUSTOMER][NEUTRAL] And you said process it is uh I think uh
[CUSTOMER][NEUTRAL] It is on [PII], right?
[AGENT][NEUTRAL] The [PII]. Mhm.
[CUSTOMER][NEUTRAL] [PII], [PII], it means it is uh recently processed.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] It is recently processed, so we did not receive any you be from your side. So we need to allow more time for the same, right?
[AGENT][NEUTRAL] Correct. Yes, it was recently processed. Mhm.
[CUSTOMER][NEUTRAL] OK. And just help me with the details, how much amount you guys have allowed it and process.
[AGENT][NEUTRAL] OK, we don't have a lot amount. I can only give you the amount we send, which is $48.72.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, so total balance we have, OK.
[CUSTOMER][NEUTRAL] $8.58 72 cents. There is any patient responsibility you guys have?
[AGENT][NEUTRAL] We're not the major medical.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And can you help me with the check number or EFT number?
[AGENT][NEUTRAL] And the tracking number is 2025615.
[CUSTOMER][NEUTRAL] #615. OK?
[CUSTOMER][NEUTRAL] And the check date
[AGENT][NEUTRAL] You say what's the process date?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Just give me a second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, it, it's recently?
[CUSTOMER][NEUTRAL] You need to allow more time.
[CUSTOMER][NEUTRAL] OK. Uh, I just want to know the call reference number will be, uh, similar to all call, right?
[AGENT][NEUTRAL] It's gonna be my name in today's date. We don't have reference numbers.
[CUSTOMER][NEUTRAL] OK. OK. Thank you. Uh, OK, I have one more to check. Can you help me with the same? Just one more.
[AGENT][NEUTRAL] No, that
[AGENT][NEUTRAL] OK, and it's gonna be a different policy, correct?
[CUSTOMER][NEUTRAL] Yes, yes, different.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK, go ahead with the policy number.
[CUSTOMER][NEUTRAL] It is 01749786.
[AGENT][NEUTRAL] What is the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] So then first name is [PII], sorry, [PII] and the last name is [PII] And the date of birth is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] OK, so the date of service I'm checking for is [PII]. And the total bill amount is $185.33 83 cents.
[AGENT][NEUTRAL] OK, that was uh [PII].
[CUSTOMER][NEUTRAL] Yes, exactly. It's quite old claim because we have sent multiple medical records to you guys. And like, we don't have exact detail for the medical records that, sir.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and again that was [PII].
[CUSTOMER][NEUTRAL] No, it is number [PII].
[AGENT][NEUTRAL] [PII], OK. [PII].
[AGENT][NEUTRAL] Alright, one moment.
[CUSTOMER][NEUTRAL] So as I told you, uh, we have sent medical records for the same.
[AGENT][NEUTRAL] Bear with me. Mhm.
[CUSTOMER][NEUTRAL] We can.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] OK, we received the claim on [PII].
[AGENT][NEUTRAL] And we processed on [PII].
[AGENT][NEUTRAL] And the claim was denied. The reason for this denial is that outpatient benefits for the calendar year has been met.
[CUSTOMER][NEUTRAL] OK. Uh, so,
[CUSTOMER][NEUTRAL] OK. So, previously, uh we have uh
[CUSTOMER][NEUTRAL] Send an appeal to you guys we got help, uh, upheld stating the incomplete medical records.
[AGENT][NEUTRAL] OK. Um, we do not we have not received that appeal.
[AGENT][NEUTRAL] And we're not asking for medical records, but if you need to send an appeal, you had 180 days to submit that appeal. We have not received any appeal today.
[CUSTOMER][NEUTRAL] OK. So previously, previously we made a call to you guys and, and you guys confirmed that the medi uh benefit max has been exhausted as the price limit, uh, as the price limit was $500 as per calendar years and the limit was met on date of service um [PII] with the rendering provider was the uh.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII] oh it's [PII].
[CUSTOMER][NEUTRAL] Right?
[CUSTOMER][NEUTRAL] Is this information is confirmed or correct?
[AGENT][NEUTRAL] Again, um, the only thing I can give you is what I have in front of me, OK, Miss [PII], in front of me for that date of service, the only claim I receive or the only claim I see here, including any appeals, any claims, any other information, is the one that I just mentioned, which is the one that it was processed and received on [PII], processed [PII], and denied for outpatient benefits for the calendar year has been met. That's all I got.
[CUSTOMER][NEUTRAL] OK. Denied for max benefit. Uh, can you help me, can you help me, uh, what is the exact, uh, max benefit value?
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] Or the dollar value which is exhaust.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK, this one had a calendar, your maximum of $500 for outpatient service.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Uh, OK, so can you help me at what date of service is what existed or
[AGENT][NEUTRAL] We can release that information. I can only give you information about your claim.
[CUSTOMER][NEUTRAL] OK, no issues there. Just give me a second. And can you help me with the plan name of the provide uh patient?
[AGENT][NEUTRAL] This is, this was a secondary supplemental plan to the major medical.
[CUSTOMER][NEUTRAL] It is secondary supplemental plan.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And uh just confirm uh the claim number which is
[CUSTOMER][NEUTRAL] 324-5583, right?
[AGENT][NEUTRAL] It is, mhm.
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So that's all I needed. Uh thank you for helping me with this claim. Thank you. Have a great day. Bye-bye. And you said uh the call reference number will be your name and today's date which is SOLM as [PII].
[AGENT][POSITIVE] Correct, yes.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Correct, yes.