AccountId: 011433970860
ContactId: 894a3347-a40d-4546-9cd0-e8f795153f9a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 529969 ms
Total Talk Time (AGENT): 126862 ms
Total Talk Time (CUSTOMER): 195796 ms
Interruptions: 0
Overall Sentiment: AGENT=1.7, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/05/894a3347-a40d-4546-9cd0-e8f795153f9a_20250305T20:34_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] Hi, this is [PII], and I'm calling for BHS physician Network to check on additional information about the claim that has been denied. Please note this call will be monitored and recorded for quality and training purposes. I have already checked correspondence and however, I just need the denial clarification.
[AGENT][POSITIVE] OK, well, I'll be more than happy to assist you with the denial, and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that. And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Yes, and before that, you said your name is [PII], right?
[AGENT][NEUTRAL] Yes, [PII]
[CUSTOMER][NEUTRAL] All right. Got it, [PII]. And the ID number's policy number is D as in Delta 43,302,090.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] OK, and do you have a copy of the member's ID card available?
[CUSTOMER][NEUTRAL] Mm, let me check. Give me a moment.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, on the card, do you see anywhere that says in hospitals or outpatient policy certification number?
[CUSTOMER][NEUTRAL] Give me a moment.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Um, no, there's nothing like that.
[AGENT][NEUTRAL] OK, on the card, what's the member's first and last name?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yes, member's name is [PII].
[AGENT][NEUTRAL] OK, you said you received the denied claim. What is the claim number?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes, the claim number is.
[CUSTOMER][NEUTRAL] 356-639-0
[AGENT][POSITIVE] Thank you. Hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] And can you verify the member's date of birth?
[CUSTOMER][NEUTRAL] Yes, ma'am. This date of birth is.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment, and I'm pulling the claim now. Hold on one moment.
[CUSTOMER][POSITIVE] Sure, take your time.
[AGENT][NEUTRAL] You said the claim number is 356-6390?
[CUSTOMER][NEUTRAL] 356-6390. That's correct?
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, so I'm showing the claim was paid a total of $75 and you said you had questions about the denial reasons.
[CUSTOMER][NEGATIVE] Yes, for the particular uh CPT code 93,000 has been denied.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see.
[AGENT][NEUTRAL] Um, because the maximum benefit payable for the data service has been met.
[CUSTOMER][NEUTRAL] OK, maximum.
[CUSTOMER][NEUTRAL] Benefits.
[CUSTOMER][NEUTRAL] And what was the maximum benefit limit?
[AGENT][NEUTRAL] I'm looking that up for you now, hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] different
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] 872943.
[AGENT][NEUTRAL] So I'm just waiting for it to come up here.
[CUSTOMER][POSITIVE] Sure, take your time. No problem.
[AGENT][NEUTRAL] So the benefit is 75 up to $75 with a max of 5 visits per calendar year.
[CUSTOMER][NEUTRAL] OK. So $75 is the maximum benefits payable and only 5 visits per calendar year is allowable, right?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Um, OK.
[CUSTOMER][NEUTRAL] Just give me a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And also, [PII], can you just let me know that uh as you said that the 5 per uh sorry, 5 visits per calendar year is allowable. So can you just help me out with the date that when the visit has been exhausted.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] OK, so that, so what this is saying is, it's $75 per day, basically per visit. So the code 99215 was paid the $75. So because [PII] is the same date of service as [PII], we can't apply it twice.
[AGENT][NEUTRAL] So it's the same claim.
[CUSTOMER][NEUTRAL] Yes, and
[CUSTOMER][NEUTRAL] Yes, I got it. I got your point. And, and you said 75 per day is allowed, right?
[AGENT][NEUTRAL] Right, 75 per visit per date of service, yes.
[CUSTOMER][NEUTRAL] OK, 75 per date of services.
[CUSTOMER][NEUTRAL] All right, got it now. Just give me a moment.
[CUSTOMER][NEUTRAL] OK, I got your point. And just to summarize this call, as you said that only $75 per day of service.
[CUSTOMER][NEUTRAL] It's there, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. And for this date of service which I provide you, uh, it's already has been exhausted. Uh, you paid it in 99215, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] All right then. Got it. No problem.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And uh just for the documentation purposes, can you let me know the correct claim filing limit?
[AGENT][NEUTRAL] Um, there's no, um, filing limit for a corrected claim, only an appeal.
[CUSTOMER][NEUTRAL] All right, no problem there. Um, can you check out with the call reference number?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name and today's date. The first initial to my last name is [PII].
[CUSTOMER][NEUTRAL] OK, and today's date, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] All right, and I got it. Thank you so much for your help.
[AGENT][POSITIVE] You're very welcome. Was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] Uh, no, that's all.
[AGENT][POSITIVE] Alright, well thanks for calling APL. Have a great day.
[CUSTOMER][NEUTRAL] Bye now.
[AGENT][NEUTRAL] Bye bye.