AccountId: 011433970860
ContactId: 95ed4a77-503a-4000-ae7e-03541310e582
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 608340 ms
Total Talk Time (AGENT): 347296 ms
Total Talk Time (CUSTOMER): 121341 ms
Interruptions: 0
Overall Sentiment: AGENT=0.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/16/95ed4a77-503a-4000-ae7e-03541310e582_20250616T17:36_UTC.wav
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[AGENT][NEUTRAL] Thank you for contacting ATM. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] This is [PII]. I'm with Retina specialist of Alabama. I'm calling for the status of some claims.
[AGENT][NEUTRAL] I can help with the home status, uh, and what is that policy number please that we're looking at.
[CUSTOMER][NEUTRAL] Member ID is 251-9724.
[AGENT][NEUTRAL] Thank you and the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] Thank you so much. Is there a callback number I can have in the event we're disconnected?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you. What is the first uh data services?
[CUSTOMER][NEUTRAL] 1229 23.
[AGENT][POSITIVE] I appreciate that and what was the service that we're looking for the build amount?
[CUSTOMER][NEUTRAL] $786.
[AGENT][POSITIVE] Thank you so much. I'm just checking it now.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] The first point.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] I told you.
[AGENT][NEGATIVE] a little bit slow
[AGENT][NEUTRAL] So on this
[AGENT][NEUTRAL] OK, your claim on this one is going to be 36.
[AGENT][NEUTRAL] 11
[AGENT][NEUTRAL] 5
[CUSTOMER][NEUTRAL] I'm sorry, I, I can't hear anything you're saying for some reason.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK. Are you able to hear me now? Is that just a little bit better?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, your claim number is 36.
[AGENT][NEUTRAL] 11591.
[CUSTOMER][NEUTRAL] 361-151-7
[AGENT][NEUTRAL] Um, 361-15.
[AGENT][NEUTRAL] 91.
[CUSTOMER][NEUTRAL] 91 OK.
[AGENT][NEUTRAL] OK, we do not cover the office visit copay on this, the $105 office visit copay. We don't cover that. Uh, now for the other services, uh, the CPT code 9213467028J 9035.
[AGENT][NEUTRAL] The explanation of benefits that was submitted did not show a deductible, co-payment, or co-insurance.
[AGENT][NEGATIVE] So the office visit was not covered and the other other services looked like there was no deductible, co-payment or co-insurance for us to pay.
[CUSTOMER][NEUTRAL] OK, let me look at that real quick um.
[CUSTOMER][NEUTRAL] OK, um.
[CUSTOMER][NEUTRAL] So.
[CUSTOMER][NEUTRAL] I'm showing the primary it'll be is showing a.
[CUSTOMER][NEUTRAL] PR 3 amount of 4585.
[AGENT][NEUTRAL] Yeah, I think that's for the uh office visit co-payments. Let me just check here really quickly because that's, that's the thing that isn't covered everything else on here, see if we can get this really quickly.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Um, yeah, but these policies, yes ma'am.
[CUSTOMER][NEUTRAL] All right, and it
[CUSTOMER][NEUTRAL] Is there a way we can get a copy of that EOB? I tried to pull it up on the provider portal and I couldn't get it to pull up.
[AGENT][NEUTRAL] Sure. What's your fax number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]. OK, we'll go.
[AGENT][NEUTRAL] And um I will um let's see what we have here on the explanation of benefits. So as I mentioned before, the office visit co-pay is not covered, but on the EOB that we that we received, um.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so this would have been for uh health easy explanation benefits.
[AGENT][NEUTRAL] And so what they did was uh.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] They, uh, they paid the allowed amount for, uh, the three CPT codes, uh, that were that were services, uh, the 92134, the 67028, the J 9035. They paid those the the 4585 is for the office visit, which is not covered. So I will go ahead and send the EOB to you for that. Now you mentioned that there were multiple dates of service that we needed to look for the.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Um, what is the next data service that you needed to look at?
[CUSTOMER][NEUTRAL] Uh, there's one more, it's 4:29 24.
[CUSTOMER][NEUTRAL] And it may be the same situation.
[AGENT][NEUTRAL] Um, OK, so what we have on this, your, your excellent, excuse me, your, your um.
[AGENT][NEUTRAL] Claim number
[AGENT][NEUTRAL] On there
[AGENT][NEUTRAL] It's 36
[AGENT][NEUTRAL] 11603.
[AGENT][NEUTRAL] Um, this was for, uh, the, um,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] CPT code 92134.
[AGENT][NEUTRAL] 67028
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Now, I'm showing that a check went out on this, so let me just see what what we have on this. The check number would have been a single paper check.
[AGENT][NEUTRAL] It's within uh the check number is 204.
[AGENT][NEUTRAL] 946 7.
[AGENT][NEUTRAL] And we are showing that went to retinal specialists of Alabama.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]. Does that sound right to you?
[CUSTOMER][NEUTRAL] Uh, yes, let me check that to make sure, but um.
[AGENT][NEUTRAL] Because that was just processed on the [PII] of this month.
[AGENT][NEUTRAL] So it's on its way to
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So that was on um.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]. That's right. So that check is on its way to you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, it's uh.
[CUSTOMER][NEUTRAL] OK, and how much was the amount of that check?
[AGENT][NEUTRAL] That is uh $50.
[CUSTOMER][NEUTRAL] OK, OK, all right, and.
[CUSTOMER][NEUTRAL] Let's see 830525 yes that is correct, so we should be receiving that then so.
[AGENT][POSITIVE] Just anytime. Yeah, that's correct.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] And and can you send a um EOB fax and the EOB for that one just in case we don't receive it.
[AGENT][NEUTRAL] Uh, yes, I can see what is available, uh, for me to print out. I would be glad to, and I can send it to [PII]. Is that correct?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, and now this is the only one that we need to look at?
[CUSTOMER][NEUTRAL] Yes, um, and, and is there a reason I can't pull them up on the portal?
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] I'm not really sure. Let me just check.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] So what we did was we um the, the claim for this one.
[AGENT][NEUTRAL] His policy was in effect from [PII]. It's now considered.
[AGENT][NEUTRAL] See me, I'm sorry, let me just check here again. I apologize. It's, it's showing it's being lapsed. Now that doesn't mean that it's um.
[AGENT][NEUTRAL] That his coverage is lapsed when they renew as a group, uh, they get a new policy number and whenever that happens, um, they get, uh, you know, they get a new policy number, but the old one is lapsed. So the claim number, uh, both of these claim numbers.
[AGENT][NEUTRAL] Uh, the one from, um, uh, [PII] and the one that just was processed, uh, that is on an old policy number and that policy number.
[AGENT][NEUTRAL] Um, actually lapsed, uh, it's not the policy number that you gave me. It's, uh, it lapsed, this is lapsed as a group, and I mean just this policy and the number. I don't, I don't mean your current coverage.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That policy lapsed as as um.
[AGENT][NEUTRAL] Uh, [PII]. Now the policy number that you gave me is the most current, and that one is from [PII] to the current time. But the thing is, is that the bill, the dates of service that we have are from that old policy. It's lapsed and the and the computer system will not recognize a lapsed policy.
[AGENT][POSITIVE] And that is why you're not able to get it. So I will be very glad to send those those EOBs to you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Um, as I mentioned before, that other one is coming to you at the same time, I would give it about, um, 8 to 10 business days or so. Uh, now if you haven't received it by then, let's go ahead and check it and see what's going on with it, but I would give it at least that long.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][POSITIVE] OK, thank you so much for um sending the EOBs to me through a fax so.
[AGENT][POSITIVE] Absolutely, absolutely. Anything else at all that I can help with?
[CUSTOMER][NEUTRAL] Uh, just a reference number if you have one.
[AGENT][NEUTRAL] Yes, my name is [PII]. The first letter of my last name is [PII]. We're gonna use that today's date as our reference.
[CUSTOMER][POSITIVE] All right, thank you so much y'all have a good day.
[AGENT][POSITIVE] Mhm thanks for contacting ATR