AccountId: 011433970860
ContactId: 9470654e-68f6-4b3e-8369-73ff8a6602e2
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 603679 ms
Total Talk Time (AGENT): 270349 ms
Total Talk Time (CUSTOMER): 183746 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/18/9470654e-68f6-4b3e-8369-73ff8a6602e2_20250218T14:31_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII] calling from provider's office. Could you please help me with claim status?
[AGENT][POSITIVE] Sure, I'll be more than happy to help you with the claim status, [PII]. May I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Uh, sure. It's going to be [PII], and it's a direct line.
[AGENT][NEUTRAL] Wait a minute, hold on one second. [PII]?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yeah, right.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And may I have the member's policy number?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yeah, sir. Uh, by the way, could you please, uh, let me know your, your initials to the last name?
[AGENT][NEUTRAL] Yes, it's [PII].
[CUSTOMER][POSITIVE] Got it. Thank you.
[CUSTOMER][NEUTRAL] Yeah, the policy ID is 02462238 M as in Mary, L as in Lima, H.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Uh, sure. It's [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bill for the claim you like me to check on?
[CUSTOMER][NEUTRAL] Uh yeah, sure. It's uh [PII] and the bill charges are $2760.06.
[AGENT][NEUTRAL] So that was [PII] and the amount of $2760.06.
[CUSTOMER][NEUTRAL] Yes, right.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Alright, so I'm showing we received the claim on [PII].
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] The claim number is 33,530,360.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], we paid out on the claim to the provider a total of $750.
[CUSTOMER][NEUTRAL] OK, got it. Uh, well, could you please let me know what's the allowed amount on this claim?
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] The outpatient benefit is $750 per calendar day.
[CUSTOMER][NEUTRAL] OK, got it. Thank you so much. Uh, well, upon checking the contract, the provider's expected allowed amount is $2,757.37 and it leaves an underpayment of $250. So, could you please send the claim for a review?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] No, there's no need for review. The maximum for the benefit was applied $750 so we paid the $750 to the claim. If there's an outstanding balance, that would be up to you and the primary insurance to determine patient responsibility, but for this benefit, we applied the max, so there would be no need for review because we can't go over the max.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Uh, like, uh, upon checking the UOB, we have the bill charges at $750. So actually the bill charges are $2,76.06.
[AGENT][NEUTRAL] I understand what you're saying. What I'm explaining to you is the benefit amount. So our policy for primary has its own benefits. I'm sorry, secondary has its own benefits, just like primary has its own benefits. If the total is a million dollars, it does not matter. The benefit maximum is $750. So we can only apply the max.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] The maximum benefit. So no matter what the charge was, the maximum was $750 and that is what we paid.
[AGENT][NEUTRAL] There's nothing else to pay but the max.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, just a second.
[CUSTOMER][NEUTRAL] Uh, is, could you please let me know what's the patient's maximum benefit in terms of dollars per calendar is?
[AGENT][NEUTRAL] Say that one more time, it's going in and out.
[CUSTOMER][NEUTRAL] Uh, like, could you please let me know what's the patient's, uh, benefit amount for the calendar year?
[AGENT][NEUTRAL] For outpatient for this policy, it's not a calendar year benefit, it's a calendar day. So it's $750 that they have to use every day. So for this claim, we paid out the $750 for that date of service, [PII]. So they maxed out their benefits for that day with your claim.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] Just a second. So can we apply for underpayment?
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, so I can try to explain it to you a different way. So there's no need for an I can't tell you not to appeal a claim, but if the maximum, meaning all that we can pay has been paid, the appeal would be denied because we've already paid everything we can pay. We only have $750 each day that we can pay, and that full $750 was paid to your claim.
[CUSTOMER][NEUTRAL] OK, got it. Like we have a leftover balance, so can we bill it to the patient?
[AGENT][NEUTRAL] Again, we don't determine patient responsibility because we're not the major medical. So with the outstanding balance, it would be either you as the provider or their primary insurance that would determine patient responsibility.
[CUSTOMER][NEUTRAL] OK, got it. Like, if you don't mind, can I put you on hold for a brief moment?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Uh, well, so actually the primary left a patient responsibility of 1000. So, will secondary pay the patient responsibility completely?
[AGENT][NEUTRAL] Is there a supervisor maybe that I can explain this to?
[CUSTOMER][NEUTRAL] OK, got it. Uh, well, I would like to uh pay because our allowed amount is $2,757.30.
[AGENT][NEUTRAL] Right, but there's if
[AGENT][NEUTRAL] So if, if you have $750 to use for a day, and we, and I and I bill you $1000 you only have $750 to use.
[AGENT][NEUTRAL] It doesn't matter that I billed you $1000. So we paid you the $750 that is all we have. That's the maximum benefit that we can pay. We can't go over $750. So whether you bill $1 or $1 million we cannot go over $750 which is what we paid you.
[CUSTOMER][NEUTRAL] OK. So could you please let me know what's the timely filing limit because we are uh like at least we have to apple.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mhm. You have 180 days from the denial date, but this claim was not denied, it was paid on.
[CUSTOMER][NEUTRAL] OK, from processed it.
[AGENT][NEGATIVE] From the denial, you appeal denials.
[AGENT][NEUTRAL] You can't appeal a pay claim.
[CUSTOMER][NEUTRAL] OK. And what's the attention to?
[AGENT][NEUTRAL] Attention APL claims or appeal department. If you are you faxing it or how did you want to send it in?
[CUSTOMER][NEUTRAL] Uh, well, we would like to cancel the both like the mailing address and app as well.
[AGENT][NEUTRAL] Oh, it's the same. So it's [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][POSITIVE] OK, got it. Thank you so much.
[CUSTOMER][NEUTRAL] And uh well, could you please provide me the fax number?
[AGENT][NEUTRAL] Sure, it's [PII].
[CUSTOMER][NEUTRAL] [PII]. OK, just to confirm, it's [PII]. Am I correct?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][POSITIVE] OK, got it. Thank you so much. And by the way, could you please provide me the call reference?
[AGENT][NEUTRAL] Sure, so there's no call reference number, but you can use my name in today's date. So again, that's [PII].
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][POSITIVE] OK, got it. Uh, well, thank you so much for assisting with the claim details and have a great day. Bye for now.
[AGENT][POSITIVE] Thank you also. Thanks for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] 438-476.