AccountId: 011433970860
ContactId: 7e1097a3-fcf4-4cce-add3-0d274aaf6d1b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1037310 ms
Total Talk Time (AGENT): 308577 ms
Total Talk Time (CUSTOMER): 315020 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/24/7e1097a3-fcf4-4cce-add3-0d274aaf6d1b_20250124T19:52_UTC.wav
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[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from the provider's office see on a claim status.
[AGENT][NEUTRAL] OK, I can check in a claim for you, [PII]. Can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, [PII]. No extension direct line.
[AGENT][NEUTRAL] Thank you. And then do you have the policy number?
[CUSTOMER][NEUTRAL] Yeah, 1067611.
[AGENT][NEUTRAL] Thank you. And uh what was the name and date of birth for the insured?
[CUSTOMER][NEUTRAL] Member's name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] I'm sorry, what was the last name?
[CUSTOMER][NEUTRAL] [PII]. Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Got it, thank you for that. And what was the date of service for this client to?
[CUSTOMER][NEUTRAL] Be of service is [PII] and total charges are $3,045 even.
[AGENT][NEUTRAL] 3,045. OK, alright, thank you, one moment please.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That.
[AGENT][NEUTRAL] All right. Bear with me just a moment, [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so we did receive this claim, uh, we were unable to pay a benefit as the benefits are paid on a per occurrence basis and the maximum amount payable for this occurrence had been met.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] OK, may I know when was the claim issued?
[AGENT][NEUTRAL] Yes, one moment please.
[AGENT][NEUTRAL] OK, we received this claim [PII], and it was processed on [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, can I have the claim number?
[AGENT][NEUTRAL] Claim number is 3532718.
[CUSTOMER][NEUTRAL] So for this claim, the claim was denied as maximum benefits exhaustor right.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. May I know how the maximum benefits are existed, whether in terms of dollar amount or in terms of visits?
[AGENT][NEUTRAL] It's the dollar amount.
[CUSTOMER][NEUTRAL] OK. May I know the maximum amount that the patient can get?
[AGENT][NEUTRAL] Mhm. Maximum amount per occurrence for outpatient is $500.
[CUSTOMER][NEUTRAL] Per day, right?
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] $500 per day, right?
[AGENT][NEUTRAL] $500 per occurrence.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] But the for this date of service only one claim was filed.
[AGENT][NEUTRAL] What was that? I'm sorry.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So for this date of service only one claim was filed, right? This is the only claim we have filed.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] Um, that this provider has filed?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Um, I can check. Give me just a moment, and this was Galloway, right?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] $170.
[AGENT][NEUTRAL] OK, yeah, that was the only claim for this state of service from that provider.
[CUSTOMER][NEUTRAL] But you said maximum benefits has existed right.
[AGENT][NEUTRAL] Yes, per occurrence it has.
[AGENT][NEGATIVE] We did receive other claims from different providers for this state of service.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I was
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 35096
[CUSTOMER][NEUTRAL] I have 3 more claims. Can you pull information for that?
[AGENT][NEUTRAL] Were they for the same member or for a different member?
[CUSTOMER][NEUTRAL] For the same member another claim? Sorry, sorry, one moment. No, no.
[AGENT][NEUTRAL] This is for the same member?
[CUSTOMER][NEUTRAL] No different, ma'am?
[AGENT][NEUTRAL] OK, yes, one moment, I'll let you know when I'm ready for that next policy number.
[CUSTOMER][NEUTRAL] Yeah, next policy number is 02.
[AGENT][NEUTRAL] Um, give me just a moment, [PII]. I'm not quite ready. I'll let you know when I'm ready for that.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I'm gonna I I'm gonna.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, I'm ready for that next policy number.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 02
[CUSTOMER][NEUTRAL] 36892 ML 7.
[AGENT][NEUTRAL] Alright, thank you. And what was the name and date of birth? oh, hold on, I'm sorry. Uh, could you repeat the policy number, [PII]? I think I'm missing a digit.
[CUSTOMER][NEUTRAL] Yeah, 0236892. M as in Mary, L as in Lima, 7.
[AGENT][NEUTRAL] OK, so we are missing a digit. There should be another digit before the M. um, do you maybe have their, uh, OK.
[CUSTOMER][NEUTRAL] One moment, one moment, I will check.
[CUSTOMER][NEUTRAL] For some reason
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, please hold for a moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And so that's.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] It.
[CUSTOMER][NEUTRAL] Yeah, it's 02363892.
[AGENT][NEUTRAL] 3892. OK, that was the missing number. Give me just a moment.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] All right, what was the name and date of birth for this number?
[CUSTOMER][NEUTRAL] Member's name is [PII] or [PII].
[CUSTOMER][NEUTRAL] And date of birth is [PII].
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Alright thank you and then uh what was the date of service for this claim?
[CUSTOMER][NEUTRAL] Data services.
[CUSTOMER][NEUTRAL] [PII] and total charges are $4,189 even.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] Oh I.
[AGENT][NEUTRAL] Was this claim uh for the same provider [PII] or was this a different provider?
[CUSTOMER][NEUTRAL] Different provider?
[AGENT][NEUTRAL] What was the provider's name?
[CUSTOMER][NEUTRAL] Provider's name is [PII].
[AGENT][NEUTRAL] Um, could you give me the tax ID?
[CUSTOMER][NEUTRAL] Yeah. Tax ID is [PII].
[AGENT][NEUTRAL] OK, OK, we've got it as a gastro Health. Thank you for verifying that. All right, one moment. OK, so for this claim, [PII], we are missing um a copy of the EOB from primary insurance.
[CUSTOMER][NEUTRAL] So for that, the claim was denied, right?
[AGENT][NEUTRAL] Yes, as we were missing the primary EOB.
[CUSTOMER][NEUTRAL] OK. May I know when was the claim received?
[AGENT][NEUTRAL] Yes, this claim was received [PII], and it was processed, uh, [PII].
[CUSTOMER][NEUTRAL] OK, can I get the claim number?
[AGENT][NEUTRAL] Mhm, claim number is 354-7250.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you have received the UOB with the with the procedure code 43239?
[AGENT][NEUTRAL] Um, we're missing the primary EOB for this claim, so once we have the primary EOB, we'll be able to process it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I mean.
[CUSTOMER][NEUTRAL] Can you provide me the payer ID to submit the payment?
[AGENT][NEUTRAL] Yeah, payer ID is 60801.
[CUSTOMER][NEUTRAL] OK. And can you tell me the fax number?
[AGENT][NEUTRAL] Fax number is [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Is there any timely filing limit to submit the primary?
[AGENT][NEGATIVE] No, there is no timely filing limit.
[CUSTOMER][NEUTRAL] Alright.
[CUSTOMER][POSITIVE] Thank you, can we go for the next number?
[AGENT][NEUTRAL] Yes, you can go ahead and give me that uh policy number.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 02066097 M as in Mary, L as in Lima 7.
[AGENT][NEUTRAL] Alright, and then what was the name and date of birth for this number?
[CUSTOMER][NEUTRAL] Member's name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] What was the date of service for this claim, [PII]?
[CUSTOMER][NEUTRAL] Date of service is [PII] and total charges are $237 even $237.
[AGENT][NEUTRAL] OK, so the policy number you gave me terminated [PII]. If you'll give me one moment, I'll see if they had one that was active during that time.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, they did have a different policy number that was active at that time of service. Give me just a moment, I'll try to find that claim.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You.
[CUSTOMER][NEUTRAL] Um.
[AGENT][NEUTRAL] I'm sorry, just to that was [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, uh, I'm not showing that we've received this claim, [PII]. I can give you that correct policy number whenever you're ready.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It is 02
[CUSTOMER][NEUTRAL] Um, but
[AGENT][NEUTRAL] 46.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] 226 8.
[CUSTOMER][NEUTRAL] example.
[CUSTOMER][NEUTRAL] 802-462-268, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] No claim was found for the date of service.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] May I know the time funding limit to submit the claims?
[AGENT][NEGATIVE] There's no timely filing limit.
[CUSTOMER][NEUTRAL] Can you provide me the effective dates of the calls?
[AGENT][NEUTRAL] This policy's effective date was [PII] and it is currently active.
[CUSTOMER][NEUTRAL] Thank you. I have the last thing. Can you check status for it.
[AGENT][NEUTRAL] One moment please.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] OK, I'm ready for that next policy number.
[CUSTOMER][NEUTRAL] Yeah. 1484314 M as in Mary, L as in Lima, 8.
[AGENT][NEUTRAL] OK and the name and date of birth for this number?
[CUSTOMER][NEUTRAL] Name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] Alright, thank you for verifying that and what was the date of service for this one?
[CUSTOMER][NEUTRAL] Date of service is [PII].
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, total charges are $3480 even.
[AGENT][POSITIVE] OK, thank you one moment.
[AGENT][NEUTRAL] Alright, give me just a moment. [PII] looks like we received this claim more than once.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. So I did find that original claim. Uh, we were unable to pay a benefit as this policy provides no benefits for the treatment of conditions other than a sickness or an injury as defined by the policy.
[CUSTOMER][NEUTRAL] OK, so the bill CPTs are not covered by the patient's plan, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] May I know the received date?
[AGENT][NEUTRAL] Yes, one moment.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] This claim was received [PII].
[AGENT][NEUTRAL] And it was processed [PII].
[CUSTOMER][NEUTRAL] Can I have a claim number?
[AGENT][NEUTRAL] Claim number is 3526611.
[CUSTOMER][NEUTRAL] OK. Can you provide me the effective dates of the policy?
[AGENT][NEUTRAL] Effective date was [PII] and it is currently active.
[CUSTOMER][POSITIVE] Thank you for your assistance. Can I have a call reference number?
[AGENT][NEUTRAL] Reference number would just be my first name, last initial, and today's date and so my name is spelled [PII] Was there anything else I could help you with, [PII]?
[CUSTOMER][POSITIVE] No, thank you for your assistance. Have a great day.
[AGENT][POSITIVE] Alright, yeah, thanks for calling IPO you too bye bye.
[CUSTOMER][NEUTRAL] I see.
[CUSTOMER][NEUTRAL] Yeah.