AccountId: 011433970860
ContactId: 9440937c-dfdc-48d9-a658-dd30665e0321
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 352899 ms
Total Talk Time (AGENT): 120494 ms
Total Talk Time (CUSTOMER): 147502 ms
Interruptions: 2
Overall Sentiment: AGENT=1, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/23/9440937c-dfdc-48d9-a658-dd30665e0321_20250123T16:04_UTC.wav
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[AGENT][NEUTRAL] Calling APL, my name is [PII]. How may I assist you today?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from provider's office checking on claim status.
[AGENT][POSITIVE] I'd be happy to assist with claim status today, [PII], if I can get a good call number for you.
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And what is the policy number?
[CUSTOMER][NEUTRAL] Policy number. OK. Uh, the policy number is 01729147.
[AGENT][NEUTRAL] Patient's name and date of birth.
[CUSTOMER][NEUTRAL] Patient name is?
[CUSTOMER][NEUTRAL] [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that information and what is the date of service?
[CUSTOMER][NEUTRAL] It's [PII]. Total bill amount is $350 even.
[AGENT][NEUTRAL] And your tax ID.
[CUSTOMER][NEUTRAL] Uh yeah, sure. The tax ID is [PII].
[AGENT][NEUTRAL] OK, I'm showing that a payment was made in the amount of $25.
[CUSTOMER][NEUTRAL] I'm
[CUSTOMER][NEUTRAL] Actually, uh, we have, uh, flipped the amount of $60. Uh, so can you please provide me why only $25 are paid?
[AGENT][NEUTRAL] 25 is the maximum for office visits.
[CUSTOMER][NEUTRAL] OK, just a moment, let me note it down.
[CUSTOMER][NEUTRAL] Maximum allowed for office visit, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] So the remaining balance is?
[AGENT][NEUTRAL] I mean we don't determine patient responsibility.
[CUSTOMER][NEUTRAL] The remaining balance is patient responsibility?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is Max dollar me.
[AGENT][POSITIVE] For that visit, yes.
[CUSTOMER][NEUTRAL] OK. Uh,
[CUSTOMER][NEUTRAL] Can you please provide me uh the patient responsibility amount?
[AGENT][NEUTRAL] We don't determine that. That's for you to determine. All we're paying is $25. So if you want to subtract that from what they owe, then what we can't tell you.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Oh, OK, no problem. Can you provide me the policy name?
[AGENT][NEUTRAL] Policy name is Metlink Gap.
[CUSTOMER][NEUTRAL] Uh spell it, please?
[AGENT][NEUTRAL] M E D L I N K.
[AGENT][NEUTRAL] Gap GAP.
[CUSTOMER][NEUTRAL] GAP and can you please provide me the effective and term date?
[AGENT][NEUTRAL] Policy became affected on.
[AGENT][NEUTRAL] Uh, [PII] and it's still active.
[CUSTOMER][NEUTRAL] [PII] and still active. OK.
[CUSTOMER][NEUTRAL] I do have one more claim for the same patient.
[AGENT][NEUTRAL] Data service?
[CUSTOMER][NEUTRAL] Uh, just provide me, just provide me the claim number and card reference number for this one.
[AGENT][NEUTRAL] Um, the claim number is 352-711-5, and the reference number is just my name [PII], last initial S [PII], and the date and time of the call.
[CUSTOMER][NEUTRAL] OK, thank you for that. Um, the next date of service is gonna be [PII] with the total bill amount of $950 even.
[AGENT][NEUTRAL] I'm showing the same thing, a payment was made in the amount of $25.
[CUSTOMER][NEUTRAL] The same
[CUSTOMER][NEUTRAL] Uh, actually, uh, these are the ultrasound CPTs, uh, 76,830 and 76856. So can you please justify or provide me the detailed information regarding
[CUSTOMER][NEUTRAL] This one?
[AGENT][NEUTRAL] It was, it was completed in an office visit and the maximum payment for an office visit is $25.
[CUSTOMER][NEUTRAL] Ma'am, actually, this CPTs are billed are not office visits. These are the uh ultrasound CPTs, radiology.
[AGENT][NEUTRAL] OK, what's the place of service on the claim? Can you pull up the place of service and tell me what the place of service is?
[CUSTOMER][NEUTRAL] Uh, place of service.
[CUSTOMER][NEUTRAL] OK. The place of service is 11.
[AGENT][NEUTRAL] That's 11. What's 11? That's doctor's office, right?
[CUSTOMER][NEUTRAL] Yes, it's done in office but it's not an office with the service, OK.
[AGENT][NEUTRAL] OK. So we, we process, OK. Well, we processed it according to what was put on the claim. Place of service 11 is doctor's office. For their doctor's office, their benefit maximum is $25.
[CUSTOMER][NEUTRAL] OK, can you please provide me the amount paid, uh, CPT code wise?
[AGENT][NEGATIVE] $25 was paid to the 76,830 CPD. The other one denied for maxed out benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Max out at the maximum $1 has been paid.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] And policy name?
[AGENT][NEUTRAL] Same meddling gap.
[CUSTOMER][NEUTRAL] And effective in term date?
[AGENT][NEUTRAL] Same.
[CUSTOMER][NEUTRAL] OK, and claim number?
[AGENT][NEUTRAL] Claim number is 352.
[AGENT][NEUTRAL] 3825.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Call reference would be the same, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][POSITIVE] OK, [PII]. Uh thank you so much for your kind information and have a great day.
[AGENT][NEUTRAL] Was there anything else I can assist with today?
[CUSTOMER][POSITIVE] No, thank you so much for your kind information and have a great day. Bye for now.
[AGENT][POSITIVE] Thank you for calling APL. Have a good day.
[CUSTOMER][POSITIVE] Have a good day too. Bye.