AccountId: 011433970860
ContactId: 8ae6ce60-2dc3-44c7-94fc-c322cf6af6eb
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1074640 ms
Total Talk Time (AGENT): 261030 ms
Total Talk Time (CUSTOMER): 404158 ms
Interruptions: 4
Overall Sentiment: AGENT=0.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/10/8ae6ce60-2dc3-44c7-94fc-c322cf6af6eb_20250210T16:46_UTC.wav
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[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] That that one I get it.
[CUSTOMER][NEUTRAL] Hi, uh, my name is [PII] calling from Cleveland Clinic Foundation to check the claim status.
[AGENT][NEUTRAL] OK. What's your name?
[CUSTOMER][NEUTRAL] A
[CUSTOMER][NEUTRAL] My name is [PII] first name is [PII]. Would you please spell your name?
[AGENT][NEUTRAL] Mhm, it's [PII]
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] First initial of my last name is [PII], and you'll use my name and today's date as a reference for today's call [PII] and what's the policy number?
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK, thank you. It's uh yeah, it's uh D as in Delta number 43301359.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, do you have a copy of the medical ID card? Uh, the APL number will start with a 0.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Well the they have the agent.
[CUSTOMER][NEUTRAL] So which one do you need?
[AGENT][NEUTRAL] It's a policy certificate number that begins with a 0.
[CUSTOMER][NEUTRAL] It's 008126.
[AGENT][NEUTRAL] No, 0, no, it's about 7 or 8 digits long.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No, I don't have one. I don't have a member ID only.
[AGENT][NEUTRAL] Spell the patient's first and last name?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] The patient's first name is [PII] and last name is [PII]. It's first name is [PII] and second name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] OK, what's a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Uh, it's [PII] and the extension number is [PII]. Yeah.
[AGENT][NEUTRAL] Give me just a
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] Yeah, you're welcome.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Give me one moment.
[CUSTOMER][POSITIVE] Yeah, sure, take your time.
[AGENT][NEUTRAL] A few more, few more minutes.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] What state does [PII] reside? Where does he live?
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] Where does [PII] live? What state?
[CUSTOMER][NEUTRAL] [PII] Ohgao.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Is this a medical claim?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] And you gave me a date of birth that you say [PII]?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mm, no, [PII].
[AGENT][NEUTRAL] Oh, [PII], not [PII]. OK, [PII]. OK.
[CUSTOMER][NEUTRAL] No, it's
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yes, yeah.
[AGENT][NEUTRAL] And what's the date of service?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] And how much is it for?
[CUSTOMER][NEUTRAL] $272 even.
[AGENT][NEUTRAL] OK, so the claim, the policy number, let me know when you're ready.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] It's 2089583.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's the policy number.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And I do show that this claim was received.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] On [PII], processed [PII].
[CUSTOMER][NEUTRAL] I know.
[AGENT][NEUTRAL] 23
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And it was denied as not covered under the patient's policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And I have the claim number. Let me know when you're ready.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] It's um 333.
[AGENT][NEUTRAL] 5458.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And you can also check your status on our online at [PII].
[CUSTOMER][POSITIVE] awesome.
[AGENT][NEUTRAL] And any other questions, [PII], I can assist with today?
[CUSTOMER][NEUTRAL] Yes, but, uh, we have, uh, received the payment from the same CPT previously. Can I, can I provide with that, uh, claim number?
[AGENT][NEUTRAL] What's what's the claim number?
[CUSTOMER][NEUTRAL] Yeah. It's 333-251-0.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I think that
[CUSTOMER][NEUTRAL] I'm sorry, it's 332-3452.
[AGENT][NEUTRAL] Give me that one more time.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] What is the, the claim number?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] It's 3323452.
[AGENT][NEUTRAL] And what's the procedure code on the claim?
[CUSTOMER][NEUTRAL] It's 99213.
[CUSTOMER][NEUTRAL] I know that I.
[CUSTOMER][POSITIVE] you take your time.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] And what's the place of service on the claim? Is it outpatient? What's that number? Inbo number 24?
[AGENT][NEUTRAL] [PII], are you there?
[CUSTOMER][NEUTRAL] Yes, I'm here about the claim we submitted the place of service is 19.
[AGENT][NEGATIVE] That's outpatient, so the previous claim should not have been paid uh under claim 3323452 because it's outpatient. Outpatient is not covered under this policy.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Which one is self-patient?
[AGENT][NEUTRAL] The codes are the same for each claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] So the previous claim should not have been paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Did you have any other questions?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] No, yeah, that's it. Can I get a call reference number?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] My name in today's date.
[CUSTOMER][POSITIVE] Yeah, thank you so much for asking me. Have a great day. Bye-bye.
[AGENT][POSITIVE] You're welcome thanks for calling APL have a good day.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][NEUTRAL] Thank you for calling APL, this is [PII]. How may I help you?
[AGENT][NEUTRAL] Hey [PII], this is [PII]. How are you?
[CUSTOMER][NEUTRAL] Fine, how are you?
[AGENT][NEUTRAL] Yeah, I have a real quick question. Uh, let's see, the policy number is 208.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 9583.
[AGENT][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] And for claim number 332.
[AGENT][NEUTRAL] 3452.
[AGENT][NEUTRAL] And then claim number 3335458.
[AGENT][NEUTRAL] Um, both of the place of service is 19, which I believe is like a, uh, office visit in an outpatient campus or something like that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Should it be paid under the um outpatient sickness or no? Because one person paid it and the other person denied it.
[CUSTOMER][NEUTRAL] Let me take a look.
[CUSTOMER][NEUTRAL] You said the other claim number was 3321543?
[AGENT][NEUTRAL] Uh, 3323452, and then 3335458.
[AGENT][NEUTRAL] Hold on a second.
[AGENT][NEUTRAL] 332.
[AGENT][NEUTRAL] Yeah, 3452.
[CUSTOMER][NEUTRAL] So it looks like what they usually do is, let me see on that date, let me see if we got the.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Facility one on that one.
[CUSTOMER][NEUTRAL] Yeah, cause what they usually do sometimes is they build the facility and the physician fee separately and it is a clinic. So let me pull up the um facility one on this [PII] and look at it and see if that was the case.
[AGENT][NEUTRAL] Uh-huh. Right.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] Yeah, it's a rev code 510 so we did pay the facility claim for the 7923, but it looks like somebody went in there and denied the actual professional fee as a non-covered place of service when they should have not, they should have just processed it as the max has been met for the data service.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Let me see.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So that one, that's, that one was processed incorrectly on that 791.
[AGENT][NEUTRAL] No, ending in 5458.
[CUSTOMER][NEUTRAL] Mhm, yup, cause I'm, I'm looking.
[AGENT][NEGATIVE] OK, should have denied his Max M. OK.
[CUSTOMER][NEUTRAL] Yeah, because we pay the facility bill, um, yeah, so that's what they, they bill the professional fees separate, yep.
[AGENT][NEUTRAL] Got it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Cause then I have both claims side by side. It's the same physician, so yeah, they usually bill them separate for some reason. I don't know why, but yeah.
[AGENT][NEUTRAL] OK. And you consider it, um, is it, was it paid because the inpatient was paid?
[CUSTOMER][NEUTRAL] A clinic
[CUSTOMER][NEUTRAL] We consider it as clinic because the repcode 510 from the facility bill. And had we not had the facility bill to let us know that it was in a clinic, then it would have been a non-covered place of service.
[AGENT][NEUTRAL] Uh-huh uh-huh.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] Got it. Got it.
[CUSTOMER][NEGATIVE] Yeah, but since we had that before, that claim was denied that was processed incorrectly.
[AGENT][NEUTRAL] Got it. OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] All right. Very good.
[CUSTOMER][NEUTRAL] So that would need to be reprocessed.
[AGENT][NEUTRAL] changing the diagno, I mean the remark code.
[CUSTOMER][POSITIVE] Mhm. Yup. And the benefits.
[AGENT][NEUTRAL] So just a hub hub request?
[CUSTOMER][NEUTRAL] Uh, do y'all send it? Do y'all still, y'all don't, do y'all send error?
[AGENT][NEUTRAL] Oh.
[AGENT][NEGATIVE] I don't think we're supposed to. I don't think so, but I don't know how to get it to y'all.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I, I'll send it. I'll send it. cause she, yeah, that's gonna need to be corrected.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. So what would you do? Change the, um, the, the.
[CUSTOMER][NEUTRAL] I'll send it.
[CUSTOMER][NEUTRAL] The benefit, they need to put it under the correct benefit because we would go ahead and consider it based off the UB.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] They should have just put it under the outpatient benefit max and that that data for data service has been met for that date.
[AGENT][NEUTRAL] Right
[AGENT][NEUTRAL] Right. Right. OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yep.
[AGENT][NEUTRAL] All right.
[AGENT][NEUTRAL] Tubing, so it'll be just so I'll know like under the benefit, is it the outpatient sick benefit?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah, mhm, the outpatient seat.
[AGENT][NEUTRAL] OK, instead of not covered. OK.
[CUSTOMER][NEUTRAL] Mhm. Wait, let me see what this, yeah, it, it will be under the outpatient sick benefit.
[AGENT][NEUTRAL] Roger that.
[AGENT][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] All right, got it.
[CUSTOMER][NEUTRAL] Yep.
[CUSTOMER][POSITIVE] Alrighty.
[AGENT][NEUTRAL] There is mud.
[AGENT][NEUTRAL] Now
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Oh, OK. All righty. Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] Bye.