AccountId: 011433970860
ContactId: 7616dfd9-1935-47a2-b86a-90f3da1ca4a3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 575659 ms
Total Talk Time (AGENT): 149010 ms
Total Talk Time (CUSTOMER): 240417 ms
Interruptions: 0
Overall Sentiment: AGENT=1.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/16/7616dfd9-1935-47a2-b86a-90f3da1ca4a3_20250116T18:25_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII] and I'm calling from provider office and uh [PII], this call may be recorded for quality and training purposes. I have a question on a claim. Could you please help me with that?
[AGENT][POSITIVE] Yeah, I'm happy to check on a claim for you today, [PII]. What is the patient policy number?
[CUSTOMER][NEUTRAL] Yeah, the policy number it is uh.
[CUSTOMER][NEUTRAL] 02462631 M as in Mike L as in Lima number 8.
[AGENT][POSITIVE] Thank you for that. And do you have a good callback number, [PII]?
[CUSTOMER][NEUTRAL] Yeah, my callback number is [PII].
[AGENT][NEUTRAL] Thank you. What is the patient name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, the patient name it's um.
[CUSTOMER][NEUTRAL] [PII], date of birth it's uh [PII].
[AGENT][POSITIVE] Alright, thank you so much for that. And then what is the date of service?
[CUSTOMER][NEUTRAL] Yeah, the detail service it is um.
[CUSTOMER][NEUTRAL] [PII] with a bill amount of $500 even.
[CUSTOMER][NEUTRAL] And uh this claim is initially got denial for um.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Primary will be so we fax this primary will be on [PII].
[AGENT][NEUTRAL] Do you have an amount after the primary?
[CUSTOMER][NEUTRAL] Yeah, the primary amount, um, 33.30.
[AGENT][NEUTRAL] So the residual after the primary was $33.30.
[CUSTOMER][NEUTRAL] Let me check one more time.
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] My [PII].
[CUSTOMER][NEUTRAL] Yeah, the primary was processed 8 $383.30 30 cents as a deductible which was forwarded to you.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] So we do have a claim on file for that date of service in this provider. There was a benefit payment sent in the amount of $350.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh when it got paid?
[AGENT][NEUTRAL] This was done on [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And uh what will the remaining amount like uh.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] $33.30.
[AGENT][POSITIVE] They build them out
[AGENT][NEUTRAL] And the bill amount that we received was for $350 on this claim, and that was the amount paid.
[CUSTOMER][NEUTRAL] Uh, I think it's not for $350 because what I'm seeing in the claim form I found that it's a bill for $500 not for the $350.
[AGENT][NEUTRAL] Well, the original claim that we received for $500 was denied asking for the primary EOB. This is the only other claim that I see on file.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] So like initially you got the uh claim for the $500 right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yeah, so that's uh only the claim number claim which we billed.
[AGENT][NEUTRAL] So that claim was denied requesting the primary EOB.
[CUSTOMER][NEUTRAL] Yeah, so for that reason we faxed the primary will be on [PII].
[CUSTOMER][NEUTRAL] And also we faxed it on [PII] also.
[AGENT][NEUTRAL] The only other thing I see on file for this patient is that claim. I don't see anything else.
[CUSTOMER][NEUTRAL] But what I'm saying is that the pri the pri the claim was billed for $500 not for the $350 claim.
[CUSTOMER][NEUTRAL] So it's processed I think incorrectly because uh the claim was billed for $500 and initially as you said me that initially got the bill for $500 which was denied for the primary UB we faxed the primary be also on [PII] also.
[CUSTOMER][NEUTRAL] Uh, as a primary UB and uh then uh I think it's worth reprocess, but it was reprocessed incorrectly because $350 is not the payment which uh was left by the primary UB. They, they, the primary was left $383.30 for the $500 claim.
[AGENT][NEUTRAL] One moment, please.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The claim was received for $383.30. The benefit payment was just for $350. There was nothing additional payable.
[CUSTOMER][NEUTRAL] So like what will the uh other like additional $33.30 will be like it's got denied or it's like something else would happen? I just want to know that.
[AGENT][NEUTRAL] So it looks like with this check, this was the max benefit payable for this particular date of service.
[AGENT][NEUTRAL] There was nothing additional payable for the claim.
[CUSTOMER][NEUTRAL] But it should get paid, right? Because, uh, see, the primary uh insurance left $383.30. So if you're saying that uh.
[CUSTOMER][NEUTRAL] There is only $350 payments, so what will be the other payment should be like it was denial for what reason?
[AGENT][NEUTRAL] Because that was the max allowed for that date of service, there was nothing else allowable for that date of service.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So, uh, that amount is a patient responsibility or like it's, it denial as in like uh max benefit met.
[AGENT][NEUTRAL] It was the the max net for the calendar day. The patient's plan only pays a max of $350 per day. It paid the 350, so there's nothing additional payable.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] OK, so you're like you're saying that your allowed amount is only for $350 only.
[AGENT][POSITIVE] Correct, a calendar day.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Just a second.
[CUSTOMER][NEUTRAL] Can you provide me the claim number for this, uh, the claim is billed for paid for $300 350 dollars sorry.
[AGENT][NEUTRAL] 351.
[AGENT][NEUTRAL] 452 7.
[CUSTOMER][NEUTRAL] Just a second.
[CUSTOMER][NEUTRAL] So there will be no additional like payment for this claim. Only $350 it will be processed per day per visit.
[AGENT][POSITIVE] Correct. Correct.
[CUSTOMER][NEUTRAL] OK, and remaining balance is not a patient responsibility or like it's a patient responsibility like the $33 should we get billed to the patient or?
[AGENT][NEUTRAL] Oh, we're not able to advise on patient responsibility. That's gonna be up to the provider facility.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it. Um, can you please spell your name for me?
[AGENT][NEUTRAL] My name is spelled [PII].
[CUSTOMER][NEUTRAL] OK, and the call reference number?
[AGENT][NEUTRAL] Call references my name with my last initial and today's date. My name again is [PII]. Last initial is [PII].
[CUSTOMER][POSITIVE] Thank you so much bye for now.
[AGENT][POSITIVE] Mhm. Have a good day.