AccountId: 011433970860
ContactId: 8644f302-469a-41ca-afa8-efe3eed5b59f
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 480950 ms
Total Talk Time (AGENT): 216971 ms
Total Talk Time (CUSTOMER): 132858 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/19/8644f302-469a-41ca-afa8-efe3eed5b59f_20250619T12:40_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Good morning, [PII]. This is [PII], and I'm calling for Olive Branch Emergency physicians LLC. I verify that you'll be on this call is made for additional information about the denial. Please note the call will be monitored and recorded for quality and training purposes. My name is spelled as [PII] and my initial to the last name is [PII].
[AGENT][NEUTRAL] OK, may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Sure. It's [PII]. That's a direct line.
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Sure. The member ID 01838977.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure, this is for [PII] and the date of birth is on [PII].
[AGENT][NEUTRAL] Thank you for that. And all the information provided is a verification of benefits, not a guarantee of payment.
[AGENT][NEUTRAL] And may I have the date of service and the total bill for the claim or the claim number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure. The date of service, I can provide you with the claim number. It's 3609573.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, what's the the data what's the data service on here because this one was denied as a duplicate, so I need to find the original.
[CUSTOMER][NEUTRAL] OK, this is for [PII] for $1,926 even.
[AGENT][NEUTRAL] OK, hold on one second.
[AGENT][NEUTRAL] Oh, wait a minute. Do you mind if I place you on just a brief hold? We've received this several times. Um, hold on one moment, OK?
[CUSTOMER][POSITIVE] Sure, take your time.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Alright, now wait a minute.
[AGENT][NEUTRAL] The first one, the second one, OK, this is the same. So really it's
[AGENT][NEUTRAL] 3552635 is what you want 358063982.
[AGENT][NEUTRAL] 3609573 is the dupe so what does
[AGENT][NEUTRAL] Oh, wait, I gotta get the code. DMO1 RE.
[AGENT][NEUTRAL] DM 0180.
[AGENT][NEUTRAL] And get a sip of water patient 200 per occurrence. OK, so the first one is 60,560.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Yes, I'm here.
[AGENT][NEUTRAL] Alright, thank you so much for holding. I apologize for that wait. So we received the claim 3 times. Um, the first two claims were denied for the same reason. So the first claim we received um was [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Claim number 3552635.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Um, on [PII], the claim was denied because the maximum amount payable for the occurrence has been met.
[AGENT][NEUTRAL] So basically, the policy will pay up to $200 for outpatient expenses per occurrence. Occurrence is anything with the same or related issue. So every time they go for their knee, that's one occurrence. If they go for their shoulder, that's then another occurrence. So this is saying for this occurrence, we pay the whole 200 prior to your claim coming in, so we couldn't pay out anymore.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So it is already paid for the different day of service. Is that right?
[AGENT][NEUTRAL] No, no, no, it's the same day of service. It's on November.
[CUSTOMER][NEUTRAL] So they allowed them then.
[AGENT][NEUTRAL] I'm sorry, go ahead.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] You can repeat that. No problem.
[AGENT][NEUTRAL] Thank you. So I was saying, it's all for the same date of service, [PII]. What this is saying is we paid out on a claim prior to the prior to your claim coming in, but it was still the same date of service. So when your claim came in, we couldn't pay out because we had already paid what was filed earlier.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] A provider filed a claim before yours and it was paid. So when yours came in, we couldn't pay yours because we already paid it on the other claim.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, so what do you mean on the, on the other claim?
[AGENT][NEUTRAL] Let me see if this claim is yours. Hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And what is the name of your provider's office? I'm in a different screen.
[CUSTOMER][NEUTRAL] Mm. This is under all of Branch emergency physicians LLC.
[AGENT][NEUTRAL] OK, so like you're in the hospital, there's radiology that was done, there could be other testing that was done, those other claims came in before your claim came in for the hospital. So we paid what we pay as they come in.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So we paid the claims that came in before yours, so there's no more money to use for your claim.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK. That's that. Thank you. And the most recent claim was tinnitus a duplicate, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Perfect. And may I know the address for the reconsideration?
[AGENT][NEUTRAL] Sure. Our address is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Zip code is [PII].
[CUSTOMER][NEUTRAL] [PII]. Perfect. And for the time you're filing is it 180 days?
[AGENT][NEUTRAL] Yes, 180 days from denial if you're filing an appeal.
[CUSTOMER][POSITIVE] Perfect. So, so the payment was made for the different tax ID, right?
[AGENT][NEUTRAL] No, it's a completely different provider.
[AGENT][NEUTRAL] That had that did services that same day.
[CUSTOMER][NEUTRAL] OK, other provider.
[CUSTOMER][POSITIVE] Perfect thank you and may I know the reference number for this call?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. And again, that's [PII], first initial and my last name is [PII].
[CUSTOMER][POSITIVE] Perfect, [PII]. I think that's all for me and thank you so much for your assistance. Have a great day. Take care. Bye.
[AGENT][POSITIVE] You're welcome. Thanks for calling APL. Bye-bye.