AccountId: 011433970860
ContactId: 77490b3a-96c5-443d-9228-2c46fc739bc7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 432760 ms
Total Talk Time (AGENT): 149610 ms
Total Talk Time (CUSTOMER): 183317 ms
Interruptions: 1
Overall Sentiment: AGENT=0.4, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/21/77490b3a-96c5-443d-9228-2c46fc739bc7_20250121T18:48_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh, hi, this is [PII]. I'm calling for.
[CUSTOMER][NEUTRAL] Genesis 3rd Medical Center to check additional information about the claim that has been denied. Please note this call will be monitored and recorded for quality and training purposes. I've already checked you the and hotel have information around. And how are you doing today, [PII]?
[AGENT][POSITIVE] I'm doing well, [PII]. How are you?
[CUSTOMER][POSITIVE] Yes, I'm doing good also.
[AGENT][NEUTRAL] That's good. And may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Sure, sure. Our callback number is [PII] with no extension. And the policy ID is going to be 022972772.
[AGENT][NEUTRAL] Alright, and you said it was for clarity with the denial?
[CUSTOMER][NEUTRAL] Yeah, I'm looking for the claim denial reason.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, and can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, the first name is going to be [PII], as a middle name, and the last name is going to be [PII].
[CUSTOMER][NEUTRAL] And the date of birth is going to be [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim you like me to check on?
[CUSTOMER][NEUTRAL] Yeah, sure. The date is going to be [PII] and the total bill amount is going to be
[CUSTOMER][NEUTRAL] $416.24.
[AGENT][NEUTRAL] OK, thank you. Hold on one moment.
[AGENT][NEUTRAL] Let me.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yeah, it is Jenny Sturwood Medical Center.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I shall receive the claim.
[AGENT][NEUTRAL] On [PII].
[AGENT][NEUTRAL] Claim number is 354-463-3.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, and uh just let you know that I'm looking for.
[AGENT][NEUTRAL] So this claim
[CUSTOMER][NEUTRAL] Yeah, I, sorry for, sorry for the interruption. Uh, yes, I'm just looking.
[AGENT][NEUTRAL] Right, I understand that you need the denial.
[CUSTOMER][NEUTRAL] Yeah and just let you know that.
[AGENT][NEUTRAL] I was just making sure I had the correct claim.
[CUSTOMER][POSITIVE] OK, sure, sure, no worries. You can, you can tell the details. Sorry for the interruption.
[AGENT][NEUTRAL] It's OK. So, um, I'm showing that for code 99213, we paid out on that claim and then for code 87 that code, and for code 87428, um, that code was denied, but only because the benefit maximum has been was met.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, I understand that. Uh, just, uh, I need that information. The benefit has been exhausted in the dollar value, in the, or in this, uh,
[AGENT][NEUTRAL] It's both the dollar and the number of visits.
[CUSTOMER][NEUTRAL] Uh, like it is, uh, also in the dollar value also in the number of visit also, you're saying that information?
[AGENT][NEUTRAL] Right, like it's $50 with a max of 4 times per calendar year. So for that date of service, the $50 was applied, so it can't be applied again for that day.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, for that CVD code, I'm right?
[AGENT][NEUTRAL] No, not for the CPT code for the date of service.
[CUSTOMER][NEUTRAL] For the data services, OK, I understand that. Uh, uh, OK, the dollar value already has been exhausted. I'm right, you're sending that information.
[AGENT][NEUTRAL] Right, the dollar amount and the number of visits or the date of service.
[CUSTOMER][NEUTRAL] OK, number of visit it, uh, and the dollar value is $50 you're saying that?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, the total dollar value of member for yearly.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEGATIVE] It doesn't work like that. This is a hospital indemnity policy, so it's benefits with a dollar amount that's paid for those benefits. So for physician office, it's 4 times per year at $50.
[CUSTOMER][NEGATIVE] OK. The dollar value is only $50 and can use for 50 or 4 times, I'm right? And this, and the $50 already exhausted, you're saying that for the CPT code for only previous data, sir, for this data service only.
[AGENT][NEUTRAL] Right, not for the CPT code for the date of service, yes.
[CUSTOMER][NEUTRAL] OK, I understand that for data service. OK, I understand that. The dollar value is $50 and can use 4 times in a, in a year or it is?
[AGENT][NEUTRAL] Yes, in a year. Mhm.
[CUSTOMER][NEUTRAL] In a year, OK, I understand that.
[CUSTOMER][NEUTRAL] OK, I understand that that information I needed. Uh, can you just verify the correctly can you find limit? What will be the correct find limit for that?
[AGENT][NEUTRAL] Um, there's no timely filing limit as long as the policy was active on the data service, um.
[AGENT][NEUTRAL] You can file at any time.
[CUSTOMER][NEUTRAL] OK, I understand that. And also just need to confirm, just give me a minute. I need to confirm the meeting address soar came, uh, that's going to be.
[CUSTOMER][NEUTRAL] [PII]. That's the mailing address for correct claim.
[AGENT][NEUTRAL] Can you say the city again?
[CUSTOMER][NEUTRAL] Yeah, sure. It is [PII].
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Yeah, sure, just.
[AGENT][NEUTRAL] Let me double check that.
[CUSTOMER][NEUTRAL] And the state is going to be [PII].
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] The city is [PII]
[AGENT][NEUTRAL] So PO
[CUSTOMER][NEUTRAL] OK, that is going to be [PII], yeah, go ahead, sorry for the interruption.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, I understand that.
[CUSTOMER][NEUTRAL] OK, thank you for pointing that information. I needed. That's it. Uh, can you just point the call reference number for this details?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name, which is [PII] First initials and my last name is [PII], and then today's date.
[CUSTOMER][POSITIVE] OK, thank you for pointing that information I needed. Thank you for helping me, [PII]. That's it. And have a great day ahead.
[AGENT][POSITIVE] Thank you Za you also and thanks for calling APL. Bye-bye.
[CUSTOMER][POSITIVE] Thank you bye bye.