AccountId: 011433970860
ContactId: 78a2c87b-a837-41d9-9306-30ab8fa12b38
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 694380 ms
Total Talk Time (AGENT): 191438 ms
Total Talk Time (CUSTOMER): 139376 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/18/78a2c87b-a837-41d9-9306-30ab8fa12b38_20250418T17:55_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yes, my name is [PII] calling from doctor's office and calling on direct client.
[AGENT][NEUTRAL] OK, [PII], um, may I please get your callback number, sir, just in case the call is disconnected.
[CUSTOMER][NEUTRAL] Yes, my direct phone number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Thank you, sir. And how can I help you today?
[CUSTOMER][NEUTRAL] Is a man going on a direct line?
[AGENT][NEUTRAL] OK, I can help you with the claim. Can I please get the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] His first name is [PII]. Date of birth is.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Yes sir.
[CUSTOMER][NEUTRAL] His birthday is uh [PII].
[AGENT][NEUTRAL] Thank you. And then what is the policy number, please?
[CUSTOMER][NEUTRAL] The policy number is
[CUSTOMER][NEUTRAL] 11.
[AGENT][POSITIVE] OK. Take your time.
[CUSTOMER][NEUTRAL] 0155.
[CUSTOMER][NEUTRAL] 1671.
[AGENT][NEUTRAL] OK, let me look up that policy real quick.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, thank you. And then what is the data service and the charge amount?
[CUSTOMER][NEUTRAL] Yeah, so date is [PII]. So the build amount on this claim is.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] This bill amount is $262 even.
[AGENT][NEUTRAL] OK, and then what are the charges after the primary insurance paid their part?
[CUSTOMER][NEUTRAL] Yeah, I'm checking it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] During the primary insurance process.
[CUSTOMER][NEUTRAL] Towards deductible amount.
[CUSTOMER][NEUTRAL] For $99.94 46 cents.
[AGENT][NEUTRAL] So that's what's left after the primary paid?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and then what is the name of the facility that you're calling from, sir?
[CUSTOMER][NEUTRAL] It's MESC Communities physicians.
[AGENT][NEUTRAL] OK, [PII], I'm gonna put you on a brief hold while I look up this claim and I'll be right back sir.
[CUSTOMER][POSITIVE] OK, take your time.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] 262.
[AGENT][POSITIVE] And benign.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] 358.
[AGENT][NEUTRAL] 36.
[AGENT][NEUTRAL] [PII], can you spell the name of the facility for me, please?
[AGENT][NEUTRAL] [PII], are you there?
[CUSTOMER][NEUTRAL] Yes, it is Michael Uniform, Sam, Charlie Community physicians.
[AGENT][POSITIVE] OK, thank you. I appreciate that, sir. A brief hold again. I'll be right back.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK [PII], I have the claim pulled up for you. The claim number is 3584036.
[AGENT][NEUTRAL] And the claim was received on.
[AGENT][NEUTRAL] [PII] and processed on [PII].
[AGENT][NEUTRAL] Are you there, [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and the claim was denied because the inpatient benefit for the calendar year has been maxed.
[CUSTOMER][NEUTRAL] Inpatient.
[CUSTOMER][NEUTRAL] Inpatient service, uh, benefits has been met.
[AGENT][NEUTRAL] Yeah, inpatient benefit for the calendar year has been maxed out.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Actually, I see this is not an inpatient services. This is an outpatient services.
[CUSTOMER][NEUTRAL] Alana.
[AGENT][NEUTRAL] On the claim, the procedure code is 99238.
[CUSTOMER][NEUTRAL] 99238
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Yeah, you're right.
[AGENT][NEUTRAL] OK, is there anything else I can help you with before we go?
[CUSTOMER][NEUTRAL] No, no, I'm not understanding that. It's a hos showing as an inspection or?
[CUSTOMER][NEUTRAL] Or also, it is showing as a hospital patient or observation discharge services, not uh you can uh you consider as an observation services and not as an inpatient. So can you able to send this claim back for the process?
[AGENT][POSITIVE] Yes, you can send it back.
[CUSTOMER][NEGATIVE] No, I'm asking you to send this claim back for a process as this is denied incorrectly.
[AGENT][NEUTRAL] Uh, you'll have to resubmit the claim if you feel like it's been denied incorrectly with the claim correction.
[AGENT][NEUTRAL] There's no time limit for that and you'll need a letter why it needs correction.
[CUSTOMER][NEUTRAL] Uh, you don't claim, send, uh, claim back for the process?
[AGENT][NEUTRAL] No sir, the claim has already been processed, so if you feel like it needs a correction, you'll need to send it in a letter why you feel like it needs to be corrected.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So we are suggesting to open this claim. Is that correct?
[AGENT][NEUTRAL] I'm sorry, sir. Can you repeat that question?
[CUSTOMER][NEUTRAL] What is the address we need to submit the bill?
[AGENT][NEUTRAL] Um, APL claims.
[CUSTOMER][NEUTRAL] Any problem that is to the claim?
[AGENT][NEUTRAL] APL claims [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that is in [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] What is the bill time frame or no time limit is stated.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] There that for correction. Now an appeal is 180 days from the date the claim was initially processed and you'll also need to send a letter why you want to appeal.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do you acceptable through fax?
[AGENT][NEUTRAL] Yes sir, let me give you the fax number.
[AGENT][NEUTRAL] That is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]. Attention to whom?
[AGENT][NEUTRAL] Appeals
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Do you have a call number for this inquiry?
[AGENT][NEUTRAL] Yes, sir. You can use my name [PII], in today's date.
[CUSTOMER][NEUTRAL] What's the, what's your last initial?
[AGENT][NEUTRAL] A
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][POSITIVE] OK, sure, that's all information for today. Thank you. Have a nice day.
[AGENT][POSITIVE] You too, [PII]. You have a wonderful weekend and thank you for calling APL.
[AGENT][NEUTRAL] Bye-bye, sir.
[CUSTOMER][POSITIVE] Thank you.