AccountId: 011433970860
ContactId: 8a75a0b2-7b64-46e7-abdd-4bbff119119a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1262380 ms
Total Talk Time (AGENT): 509239 ms
Total Talk Time (CUSTOMER): 271766 ms
Interruptions: 2
Overall Sentiment: AGENT=1.2, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/26/8a75a0b2-7b64-46e7-abdd-4bbff119119a_20250226T13:39_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good Morning, thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Yeah, can you please spell your name for me?
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] OK just a
[CUSTOMER][POSITIVE] Yeah, thank you so much, [PII].
[AGENT][POSITIVE] You're very well.
[CUSTOMER][NEUTRAL] Yeah, this call is regarding the claim status.
[AGENT][POSITIVE] All right, I'll be happy to assist you. May I ask your name?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII].
[AGENT][POSITIVE] Thank you, [PII]. What is a good callback number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you, [PII] and the policy number for the patient, please.
[CUSTOMER][NEUTRAL] Yeah, just a second. It would be 01940423.
[AGENT][NEUTRAL] And [PII], what is the, the, I'm sorry, what is the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] So the patient's last name would be [PII] and the first name would be [PII] And the date of birth was on [PII].
[AGENT][POSITIVE] Thank you [PII]. What is the data service I can help you with that claim status.
[CUSTOMER][NEUTRAL] So, so the data service was on [PII].
[AGENT][NEUTRAL] And what is the billed amount, please, sir?
[CUSTOMER][NEUTRAL] Yeah, it would be $3740.21.
[AGENT][POSITIVE] Thank you. And finally, what is the facility name please, sir?
[CUSTOMER][NEUTRAL] It would be Advent Health Palm Coast Parkway.
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] I can help you with that claim status, [PII]. I'm showing that the claim was received on [PII].
[AGENT][NEUTRAL] And process. Yes, sir.
[CUSTOMER][NEUTRAL] Sorry, February?
[CUSTOMER][NEUTRAL] Can you repeat the receipt please?
[AGENT][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And processed on [PII].
[AGENT][NEUTRAL] And the claim was denied.
[AGENT][NEUTRAL] As the maximum amount payable for this occurrence has been met.
[CUSTOMER][NEUTRAL] Can you provide me the claim number?
[AGENT][NEUTRAL] The claim number is 355.
[AGENT][NEUTRAL] 9377.
[CUSTOMER][NEUTRAL] OK, can you repeat the dinner one?
[AGENT][NEUTRAL] The maximum amount payable for this occurrence has been met.
[AGENT][NEUTRAL] So Max benefits met.
[CUSTOMER][NEUTRAL] So you're saying that primary paid more than the secondary allowed?
[AGENT][NEUTRAL] No sir, I'm saying that the benefit amount on his policy for this service, the benefit has been met.
[AGENT][NEUTRAL] It was paid to another provider for that date for that occurrence.
[CUSTOMER][NEUTRAL] OK, what is the code uh
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] So can you please provide me the which code has been done?
[AGENT][NEUTRAL] So
[AGENT][NEUTRAL] All because the total charge for that amount on this claim.
[AGENT][NEGATIVE] Was denied
[CUSTOMER][NEUTRAL] So all the codes would be it.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] So you're saying that the maximum payable for this occurrence was met by the provider?
[AGENT][NEUTRAL] Was met by, um, we pay, we pay the claim the maximum benefit prior to receiving your claim. Therefore, no benefits remain payable.
[CUSTOMER][NEUTRAL] OK. So what was the maximum uh occurrence code was paid? Is it 3 or 4 any number?
[AGENT][NEUTRAL] So per occurrence, the outpatient benefit is 500, I'm sorry.
[AGENT][NEUTRAL] Is $250 per occurrence.
[CUSTOMER][NEUTRAL] You're saying per day?
[AGENT][NEUTRAL] Per occurrence is for the same related condition every 90 days.
[CUSTOMER][NEUTRAL] So you're saying that uh $250 for uh for one for a 90 days.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] So it has been already met.
[AGENT][POSITIVE] Yes, sir. That's correct.
[CUSTOMER][NEUTRAL] OK. When was the same goods has been billed for different data sources for the previous data services.
[AGENT][NEUTRAL] I'm sorry. Can you repeat that?
[CUSTOMER][NEUTRAL] OK, you said that uh for every 90 days, uh.
[CUSTOMER][NEUTRAL] $250 for one account will be paid, right? When it was uh last previously paid.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] It was paid on [PII], but it, we received that claim prior to receiving your claim.
[CUSTOMER][NEUTRAL] So it was, it was paid on [PII].
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] Can you provide the paid claim number?
[AGENT][NEUTRAL] No, sir. I'm not able to provide that. It was to a different provider.
[AGENT][NEUTRAL] Let me check. Hang on just a second. Let me check something.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Yes, it was paid to a different provider.
[CUSTOMER][NEUTRAL] Yeah just.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] I'm here.
[CUSTOMER][NEUTRAL] Yeah, you said that the claim was previously paid on [PII], right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] But we didn't receive any payments regarding this. Can you please take back for the process?
[AGENT][NEUTRAL] The payment was, excuse me, the maximum payment.
[AGENT][NEUTRAL] Paid out on a different claim, not yours, so there's no payment on this claim, just a denial that the maximum benefit for that occurrence has been met.
[AGENT][NEGATIVE] And for that occurrence, there's no benefits.
[AGENT][NEUTRAL] Available.
[CUSTOMER][NEGATIVE] But we didn't receive any payments for the claim which was paid on [PII].
[AGENT][POSITIVE] That's right. That claim maxed out that benefit.
[AGENT][NEUTRAL] Therefore, on this claim, there's no benefits payable.
[CUSTOMER][NEUTRAL] So, uh, so just to confirm that you have been said that the claim was paid on [PII] for the different provider.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] But uh this provider and that provider was different, right? So can you, so it was incorrectly denied.
[AGENT][NEUTRAL] No, sir, it was denied correctly because for the per occurrences for the same or related condition every 90 days, and we processed the claim prior to.
[CUSTOMER][NEUTRAL] Yeah, but the provider was different.
[AGENT][NEUTRAL] That's right, but that's the maximum benefit that we can pay per occurrence for that diagnosis.
[AGENT][NEUTRAL] And so therefore,
[AGENT][NEGATIVE] There were no benefits payable on this claim because it was already met, maxed out.
[CUSTOMER][NEUTRAL] Yeah, I got your reason, but the provider was different, right? You said that uh it was paid previously on [PII] and the provider was different, not AdventHealth Palm course.
[AGENT][POSITIVE] That's right.
[AGENT][NEGATIVE] But the, but there are no benefits.
[CUSTOMER][NEUTRAL] Yeah. So, I need to receive them.
[AGENT][NEGATIVE] There are no benefits payable because we've already maxed out the benefit for this diagnosis during the 90 days.
[CUSTOMER][NEUTRAL] Sorry, I got your point, but the provider was different, right?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Actually, it was for an ER visit.
[CUSTOMER][NEUTRAL] Yeah, so then send it back for review.
[AGENT][NEUTRAL] But we don't pay per provider as per the dollar amount.
[AGENT][NEUTRAL] That's why it's maxed out for the dollar amount.
[CUSTOMER][NEUTRAL] Sorry, can you repeat that?
[AGENT][NEUTRAL] It's maxed out due to the dollar amount to the dollar benefit amount.
[AGENT][NEUTRAL] Regarding
[CUSTOMER][NEUTRAL] So, but the provider was different, right?
[AGENT][NEUTRAL] Yes sir, but that's not um.
[AGENT][NEUTRAL] That doesn't, we pay the same for all providers up to that $250 per occurrence, and we process claims in order that we receive them. Now the claim the benefit was maxed out on a claim received prior to receiving this claim for data service [PII].
[AGENT][NEUTRAL] So for that diagnosis, we paid that other provider, and actually it was to AdventHealth Palm Coast, but for a different data service.
[AGENT][NEUTRAL] And it maxed out that diagnosis occurrence.
[CUSTOMER][NEUTRAL] OK, when was the previous date of service?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] On [PII].
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] And uh for the Advent Health Palm Coast Parkway, right?
[AGENT][POSITIVE] Yes sir, that's correct.
[CUSTOMER][NEUTRAL] OK, then, uh, provide me the claim number.
[AGENT][NEUTRAL] Uh, since it is the same tax ID number and provider that claim, I can provide that information for data service 1225, that claim number is 355.
[AGENT][NEUTRAL] 9360.
[CUSTOMER][NEUTRAL] And it was paid right, you?
[AGENT][POSITIVE] That's right. That maxed out the benefit for that occurrence, for that diagnosis.
[CUSTOMER][NEUTRAL] Can you provide me the allowed and the item?
[AGENT][NEUTRAL] We paid $250 which is the maximum benefit payable for that diagnosis every 90 days.
[CUSTOMER][NEUTRAL] OK, what's the payment method? Is it through EFT or?
[AGENT][NEUTRAL] It's single paper check.
[CUSTOMER][NEUTRAL] What's the check number?
[AGENT][NEUTRAL] 202.
[AGENT][NEUTRAL] 6004.
[AGENT][NEUTRAL] And that was for data service [PII].
[CUSTOMER][NEUTRAL] OK. What, uh, when is the pay date?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK. Is it a bulk check or also single?
[AGENT][NEUTRAL] Single check.
[CUSTOMER][NEUTRAL] $250 sir.
[AGENT][NEUTRAL] $250 yes, sir.
[CUSTOMER][POSITIVE] OK. And it was cleared.
[AGENT][POSITIVE] As still outstanding.
[CUSTOMER][NEUTRAL] OK. What's the pay to order?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] 055.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, just a second.
[CUSTOMER][NEUTRAL] Yeah, can you please provide me the account number of the PDF?
[AGENT][NEUTRAL] Um, for the pay claim, the patient account number is [PII] 110,600.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] Let me
[AGENT][NEUTRAL] 0075278.
[CUSTOMER][NEUTRAL] OK, yeah. Just to confirm, H for Hotel 11060000752781.
[AGENT][POSITIVE] Yes, sir, that is correct.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Can you please fax the, can you please fax the your video to us because we didn't see any your videos.
[AGENT][NEUTRAL] Now the EOBs are obtainable on our provider portal at [PII].
[CUSTOMER][NEUTRAL] That people.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Can you please spell, spell the portal once.
[AGENT][NEUTRAL] Yes, sir. It's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Oh yeah just
[AGENT][NEUTRAL] And if you don't have an account, I can assist you and you can have 24/7 access to claim status, EOBs, and claim submission.
[AGENT][NEUTRAL] Online
[CUSTOMER][NEUTRAL] because we just.
[CUSTOMER][NEUTRAL] Yeah, can you please fax the UB as it is only one AUB, right? I'll be providing the fax number.
[AGENT][NEUTRAL] Give me just one moment to get that prepared and then I'll get that fax number and fax it to you. And can I put it to your attention, [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] T E J A correct?
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] All right, if you'll give me just one moment please sir.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Hm
[AGENT][POSITIVE] And if you can create that account online it's much quicker to get those EOBs.
[AGENT][NEUTRAL] And claim status.
[CUSTOMER][NEUTRAL] Sure. Is it a self-registered?
[AGENT][NEUTRAL] It is, so what you'll do is you'll go in as a new user and you'll choose that you are a medical or dental provider.
[AGENT][NEUTRAL] Then to create the account you're gonna use the tax ID number and the patient's account number that I gave you the H.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] A patient account number, so you'll always use the patient account number inbox 3A on the UBO4 or inbox 26 on the CMS 1500.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, of course.
[AGENT][NEUTRAL] Depending on how, what what it's built on.
[AGENT][NEUTRAL] All right, [PII], I'm ready for that fax number.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So it would be 407303-0942.
[AGENT][NEUTRAL] And just to verify that fax number, I'm sending this EOP to 407303-0942.
[CUSTOMER][NEUTRAL] So, 407, right.
[AGENT][NEUTRAL] 407.
[CUSTOMER][NEUTRAL] And I need the both uh paid EUB, right? I need to pay DUB as well as the denied EUB as well.
[AGENT][NEUTRAL] OK, if you'll bear with me just one second, you said that 407303-0942?
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, give me just one moment. That paid EOB is on the way. Let me get this denied EOB for you. Bear with me just one second.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 3
[AGENT][POSITIVE] All right, take those are on the way for you.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] And you should be receiving them shortly.
[CUSTOMER][NEUTRAL] OK, so it will be received by the end of the day.
[AGENT][NEUTRAL] Can you repeat that?
[CUSTOMER][NEUTRAL] So what is the turn around time to receive the EU?
[AGENT][NEUTRAL] Well, uh, those are both on the way for you. It just depends on how long it takes to get from me to you.
[AGENT][NEUTRAL] But they're on the way.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hopefully within about 15 minutes or less.
[CUSTOMER][NEUTRAL] OK. So.
[CUSTOMER][NEUTRAL] OK. So just to confirm, uh, so the provider was same right? for the 4th day and the night, please.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] In two different dates of service call reference number is my name.
[CUSTOMER][NEUTRAL] Yeah, what's the call reference number?
[CUSTOMER][POSITIVE] Yeah, I've got it.
[AGENT][NEUTRAL] My name in today's date and I spell my name [PII].
[AGENT][POSITIVE] TJ, it was a pleasure to assist you with that claim status. Is there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, thank you so much for asking.
[AGENT][POSITIVE] Mm, I hope you have a wonderful day and thank you for calling APL.
[CUSTOMER][POSITIVE] Yeah, Mr. [PII], thank you so much.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Mhm. Yeah, bye bye.