AccountId: 011433970860
ContactId: 89327da7-deed-49a4-bef2-ce9c0b6d3aa7
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1185109 ms
Total Talk Time (AGENT): 347975 ms
Total Talk Time (CUSTOMER): 351387 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/08/89327da7-deed-49a4-bef2-ce9c0b6d3aa7_20250108T19:54_UTC.wav
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[AGENT][POSITIVE] And thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from provider's office to check the claim status.
[AGENT][NEUTRAL] I'm sure, [PII] I can assist you with claim status. Um, first, could I get a good callback number?
[CUSTOMER][NEUTRAL] Uh, sure, it is [PII] and it is a direct line.
[AGENT][NEUTRAL] Thank you. Now, I need the policy number, please.
[CUSTOMER][NEUTRAL] Uh yes, sir, just a moment.
[CUSTOMER][NEUTRAL] It is 02370324 M for Mike L for Lima 8.
[AGENT][NEUTRAL] Thank you. Now, please verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Uh yes, uh, just a moment.
[CUSTOMER][NEUTRAL] The first name is [PII] and the last name is uh [PII] and [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. Now I need the date of service and bill charges for the claim.
[CUSTOMER][NEUTRAL] It is [PII]. Total charge amount is $150 even.
[AGENT][NEUTRAL] OK, one moment, please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, yes, we received this claim on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim was processed on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim number is 3,493,480.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the claim denied because according to the diagnosis, this was for a screening and under this policy, um, screenings are not covered.
[CUSTOMER][NEUTRAL] Uh, may I know the reason for not go because the primary is processed.
[AGENT][NEUTRAL] Yeah, under this policy, it denied because the diagnosis code. The diagnosis code according to the claim is for uh screening. And under this policy, services are not covered unless they're related to an illness or an injury. And according to this claim, um, there was no illness or an injury.
[CUSTOMER][NEUTRAL] And applied to deductible rate.
[CUSTOMER][NEUTRAL] Uh, for this one we need to submit a character claim or we need to be the patient.
[AGENT][NEUTRAL] You can submit a corrected claim if there's another diagnosis code, you can resubmit the claim with the diagnosis code.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] you were saying the claim was denied due to uh the diagnosis called in inconsistent with uh.
[CUSTOMER][NEUTRAL] Injury, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] And what is the time limit for submission?
[AGENT][NEUTRAL] There's no timely filing limit?
[CUSTOMER][NEUTRAL] Thank you. Can I move to another place?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Is it for the same member?
[CUSTOMER][NEUTRAL] Uh, no, for the next one there is a different one.
[AGENT][NEUTRAL] How many do you have?
[CUSTOMER][NEUTRAL] I have 4 more.
[AGENT][NEUTRAL] Um, I can assist you with 2 more. What's the next policy number, please?
[CUSTOMER][NEUTRAL] Yes, uh, just a moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] For the next one.
[CUSTOMER][NEUTRAL] Just a moment. It is 980773.
[AGENT][NEUTRAL] And please verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Uh yes, it is, uh,
[CUSTOMER][NEUTRAL] [PII] and the last name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. Now, I need the date of service and bill charges for the claim.
[CUSTOMER][NEUTRAL] Uh yes, it is [PII]. Total charge amount is $616 even.
[AGENT][NEUTRAL] OK, one moment, please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] You said the total bill charges was $616?
[CUSTOMER][POSITIVE] That's correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, we received that claim on [PII].
[AGENT][NEUTRAL] The claim processed on [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the claim number is 3495506.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And this claim paid out for $50 even.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And it was a
[CUSTOMER][NEUTRAL] It is paid for $50 right?
[AGENT][NEUTRAL] Yes, $50. It was a single check and I have the check number here.
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] And what is the number?
[AGENT][NEUTRAL] The check number is 189.
[AGENT][NEUTRAL] 279. I'm sorry, it's 1869.
[AGENT][NEUTRAL] 279.
[CUSTOMER][NEUTRAL] Thank you and when it was it shouldn't clear.
[AGENT][POSITIVE] Um, I'm showing that the check was issued on [PII] and it's still outstanding.
[CUSTOMER][NEUTRAL] It is 821-2024, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] And may I know the reason uh why uh the claim is still in.
[CUSTOMER][NEUTRAL] Not cash.
[AGENT][NEGATIVE] The provider haven't cashed it yet. We mailed it to the provider's address on the claim. They still have not cashed it. It's still outstanding.
[CUSTOMER][NEUTRAL] And what address do you have sent?
[AGENT][NEUTRAL] I'm sorry, what's your question, please?
[CUSTOMER][NEUTRAL] Uh, can you please, uh, provide me that, uh, check and address?
[AGENT][NEUTRAL] Yes, the address it was issued to was Elite Imaging LLC.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Dallas, Texas.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] And can you please provide me the client pay date? It is [PII], right?
[AGENT][NEUTRAL] Yes, that's when the claim was paid.
[CUSTOMER][POSITIVE] Thank you. Can I move to another one for the last.
[AGENT][NEUTRAL] Yes, one moment please.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] For this one, can you please send me the copy of your fax?
[AGENT][NEUTRAL] Yes, I can fax you the ELB. Let me pull up my fax system.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, and to whose attention?
[CUSTOMER][NEUTRAL] Uh, it's my name, [PII].
[AGENT][NEUTRAL] OK. And your fax number, please?
[CUSTOMER][NEUTRAL] Uh, it is [PII].
[AGENT][NEUTRAL] OK. That's attention [PII] [PII].
[CUSTOMER][POSITIVE] That's correct.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes
[AGENT][POSITIVE] OK, I'm ready for the next policy number.
[CUSTOMER][NEUTRAL] Uh yes. Uh, it is 60801.
[AGENT][NEUTRAL] No, that's our payer ID. That's not a policy number.
[CUSTOMER][NEUTRAL] Oh, just a moment.
[CUSTOMER][NEUTRAL] Just a moment, I'll provide that information.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The woman
[CUSTOMER][NEUTRAL] Still loading here.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yes, it is showing it is uh 02408794 M for Mike L for Lima 8.
[AGENT][NEUTRAL] And thank you. Now, please verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Uh yes, uh it is uh [PII].
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Thank you. Now I need the date of service and bill charges on the client.
[CUSTOMER][NEUTRAL] Uh, yes, so it is uh [PII]. Total charge amount is uh $1206 even.
[AGENT][NEUTRAL] OK, and I'm still waiting on my system one moment please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, we received this claim on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim processed on [PII].
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] The claim number is 3499907.
[AGENT][NEUTRAL] And the claim denied because under this policy, we cover up to $1750 per calendar year.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] And that benefit maxed out on [PII].
[CUSTOMER][NEUTRAL] You're saying a member already made the maximum benefits for the calendar year, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Uh you were saying the member was last on [PII], [PII], right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] For this one, can we be the patient, right?
[AGENT][POSITIVE] Yes, you can build the patient.
[CUSTOMER][NEUTRAL] Uh, is there any call reference number?
[AGENT][NEUTRAL] Yes, for the reference number, you can use my name and today's date. My name is [PII]. Um it's spelled [PII] My last initial is [PII] and today's date. Is there anything else that I can assist you with?
[CUSTOMER][NEUTRAL] Uh, I have 2 more. Is there any chance, can you please complete that thing?
[AGENT][NEUTRAL] I can help you with 2 more. What's the next policy number?
[CUSTOMER][POSITIVE] Thank you so much, uh, just a moment.
[CUSTOMER][NEUTRAL] For the next one, it is 02388965 M for Mike, L for Lima 8.
[AGENT][NEUTRAL] Thank you. Now, please verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Uh yes, sir, just a moment.
[CUSTOMER][NEUTRAL] The first name is [PII] and the last name is uh [PII] and the date of birth is uh.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, thank you. Now, I need the date of service and bill charges for the claim.
[CUSTOMER][NEUTRAL] Yes, so.
[CUSTOMER][NEUTRAL] Data service is 86-2024 and total charge amount is $1,883 even.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, for this one I want to know the specific CPT code only.
[AGENT][NEUTRAL] OK, for which CPT code?
[CUSTOMER][NEUTRAL] Uh, it is for just a moment.
[CUSTOMER][NEUTRAL] It is a
[CUSTOMER][NEUTRAL] The CBD code is 76,700.
[AGENT][NEUTRAL] OK, yes. That denied because under this policy, we cover up to, let's see.
[AGENT][NEUTRAL] We cover up to $200 per day and that benefit was maxed out and that's why that code denied and the other code also.
[AGENT][NEUTRAL] Denied for the same reason daily benefit maximum was reached.
[CUSTOMER][NEUTRAL] You're saying a daily maximum benefits right teacher, right?
[AGENT][NEUTRAL] Yes, yes, sir.
[CUSTOMER][NEUTRAL] And it is for $200 right?
[AGENT][NEUTRAL] Yes, 200 per day.
[CUSTOMER][NEUTRAL] Uh, for this one, can we be the patient, right?
[AGENT][NEUTRAL] Yes, sir, you can bill the patient.
[CUSTOMER][NEUTRAL] And what is the claim received and denied and claim number?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] The claim number is 35046887.
[CUSTOMER][NEUTRAL] Oh sorry, can you please repeat that claim number?
[AGENT][NEUTRAL] 35046887.
[CUSTOMER][NEUTRAL] Like, and what is the denied it?
[AGENT][NEUTRAL] Well, we received the claim on [PII], and the claim was denied on [PII].
[CUSTOMER][POSITIVE] Thank you. Can I move to the last one today?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes. What's the policy number?
[CUSTOMER][NEUTRAL] Yes, so just a moment, it is still loading.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Yes, for this one the member ID is 02166543 M for [PII] [PII].
[AGENT][NEUTRAL] Thank you. Please verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Uh, the first name is, uh, it's that. Last name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] And the date of service and bill charges on the claim, please.
[CUSTOMER][NEUTRAL] Uh yes, uh, just a moment. It is 812024. Total charge amount is $1950 even.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, I'm not showing that claim on file.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] It is for 812024 and total charge amount is 1,99 sorry it is 1950.
[AGENT][NEUTRAL] Right, I'm not showing any claim on file with that date of service.
[CUSTOMER][NEUTRAL] Uh yes, sir, just a moment.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Actually it's showing in my system the primary.
[CUSTOMER][NEUTRAL] Uh, for this one is showing the primary was denied due to services not covered under plan, uh.
[AGENT][NEUTRAL] What's the um claim number?
[CUSTOMER][NEUTRAL] Uh, I have a primary claim number. Can I provide you that?
[AGENT][NEUTRAL] OK. We wouldn't have that. So yeah, they, you never did file a claim with us, so.
[AGENT][NEUTRAL] That's why we're not showing it on file. You said that the claim that you have is from the primary insurance company, right?
[CUSTOMER][NEGATIVE] Yes, uh, I want to know the one question about this. The primary was denied, uh, due to.
[CUSTOMER][NEUTRAL] Not covered services. Can we transfer these charges to this insurance I need to bill the patient?
[AGENT][NEUTRAL] Um, no, you would need to bill the patient because if the primary didn't, um, cover it, then we'll also deny it.
[CUSTOMER][NEUTRAL] OK. Uh, it's showing the primary was denied to services not covered under plan.
[AGENT][NEGATIVE] Right, then, yeah, if the primary doesn't um cover a charge, then that's an automatic denial with us.
[CUSTOMER][POSITIVE] Oh thank you. Uh, that's it for today and thank you so much for your assistance. Have a great day. Bye for now.
[AGENT][NEUTRAL] You do the same, [PII]. Thank you for calling APL. Mm bye.
[CUSTOMER][NEUTRAL] Bye.