AccountId: 011433970860
ContactId: 98363bd2-535f-455f-a8a7-5bf3e5b13d16
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 785559 ms
Total Talk Time (AGENT): 241834 ms
Total Talk Time (CUSTOMER): 420462 ms
Interruptions: 2
Overall Sentiment: AGENT=0.9, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/12/98363bd2-535f-455f-a8a7-5bf3e5b13d16_20250312T15:18_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help? How can I help you? I'm so sorry. How can I help you?
[CUSTOMER][NEUTRAL] No problem. Yeah, hi, my name is [PII]. My name is [PII]
[AGENT][NEUTRAL] I'm sorry, I can't.
[CUSTOMER][NEUTRAL] Yeah, it's now I'm a.
[AGENT][NEUTRAL] Now you are.
[CUSTOMER][NEUTRAL] Uh, uh, yes, actually, my name is [PII] [PII].
[AGENT][POSITIVE] Yes, [PII], how can I help you today?
[CUSTOMER][NEUTRAL] Yeah, actually I need to know the uh claim status regarding the same patient with a different data service.
[AGENT][NEUTRAL] How many dates of service do you have for this member that you're needing to check claim status for?
[CUSTOMER][NEUTRAL] Uh, yeah, only, only 5 clamps with the same patient.
[AGENT][NEUTRAL] You have 5 days of service for the same patient.
[CUSTOMER][POSITIVE] Yeah, exactly, ma'am.
[AGENT][POSITIVE] Yes, [PII], I can help you with that. And what is your callback number?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] OK, thank you. So, [PII], you will use my name that I gave you along with today's date as your call reference number for each. Also in
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And could you please spell out your name for my documentation?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And like any information that I provide will be a verification of benefits and not a guarantee of payment and also if you need a copy of any of the exclamation of benefits, you can print those from our portal by going to [PII].
[CUSTOMER][POSITIVE] Yeah, it was a nice name.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] OK, and what is the patient's policy number please, [PII]?
[CUSTOMER][NEUTRAL] Yeah, the patient policy number is uh
[CUSTOMER][NEUTRAL] Yeah, here it is. Uh it is uh 02458526.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And give me just a couple of moments want to get the information pulled up please.
[CUSTOMER][NEUTRAL] Yeah, please.
[CUSTOMER][NEUTRAL] To
[AGENT][NEUTRAL] And again, any information provided will be a verification of benefits and not a guarantee of payment. What is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] The member's name is [PII] and date of birth was [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] But you know what.
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] And the first day of service and total build amount please.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes, the first date of service is uh [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the bill amount is $484.39.
[AGENT][POSITIVE] Thank you. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And you said the total bill amount is 484.39, is that correct?
[CUSTOMER][NEUTRAL] For
[CUSTOMER][POSITIVE] Exactly. Exactly, ma'am. Right. That was right.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, so we do not have a claim on file for this member for that data service and that total bill amount like.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Actually, yeah, actually I do have a claim here. Uh, can I provide the claim number?
[AGENT][NEUTRAL] Not
[AGENT][NEUTRAL] Yes, sir, but it's not for that bill's amount.
[CUSTOMER][NEUTRAL] Yeah it should be.
[AGENT][NEUTRAL] You can give me the claim number.
[CUSTOMER][NEUTRAL] Yeah, the claim number is 355941.
[AGENT][NEUTRAL] OK, that's not at 355. There should be 35.
[CUSTOMER][NEUTRAL] It's, yeah, it's 355-5941.
[AGENT][NEUTRAL] And that too.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes, sir, but again, that is not the billed amount on this claim.
[CUSTOMER][NEUTRAL] Yeah, actually, the total claim bill amount is $484.39 but the 99213 CBT balance is $142 even.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] The particular CBD 99213 uh balance was 1421 uh.
[AGENT][NEUTRAL] So you already have the claim numbers you're just needing to get additional information?
[CUSTOMER][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] Exactly, ma'am. Actually, the claim was initially processed by Aetna and Aetna, uh, Aetna provided the uh mm.
[AGENT][NEUTRAL] Yes, and on this policy.
[AGENT][NEGATIVE] This was denied because office visits are not covered by this policy. The members supplemental policy does not cover office visits.
[CUSTOMER][NEUTRAL] Oh, got it, ma'am. Actually, 99213 CBT which is we will with office visit code. That's why uh the offices are not covered, and that is the denial reason, right? Yes, thank you very much for the valuable information that will be very quickly and just give me a second here. I'm ready for the next data service. It is, um, yeah, ma'am. It is 2-18-2025.
[AGENT][POSITIVE] That is correct.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the next day.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] Mhm, and total bill amount?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] The total bill amount is $142 even.
[AGENT][NEUTRAL] 142.
[CUSTOMER][NEUTRAL] Yeah, ma'am.
[CUSTOMER][NEUTRAL] The claim number is 3,570,050.
[AGENT][NEUTRAL] And the claim number?
[AGENT][NEUTRAL] Say that one more time 357-0050. OK, yes sir, that claim was denied for the same reason.
[CUSTOMER][NEUTRAL] Yeah, that is uh 99213 CPT which we will do the evaluation management code uh office visit that is not covered under the patient plan, right, ma'am? Yes, yeah, just give me a second. I'm uh ready for the next data service.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It is 27-2025.
[AGENT][NEUTRAL] Mhm, total bill amount.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Total bill amount is $399.
[CUSTOMER][NEUTRAL] And uh yeah, 0 cents, $399 only.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And that was, and you already have the claim number on that as well?
[CUSTOMER][NEUTRAL] Yeah, ma'am. It is 3570019.
[AGENT][NEUTRAL] Yes, sir, it was denied for the same reason.
[CUSTOMER][NEUTRAL] The 99205.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] And office visits are not covered in the patient plan and this is also the same reason. Uh, these are all balances of patient responsibility, right?
[AGENT][NEUTRAL] We do not determine patient responsibility that would be up to the provider.
[CUSTOMER][POSITIVE] Uh yeah, thank you very much for that available information also and uh the next uh date of service is [PII].
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Total bill amount?
[CUSTOMER][NEUTRAL] And the total bill amount is uh $667.
[AGENT][NEUTRAL] 667.
[CUSTOMER][NEUTRAL] Even
[CUSTOMER][NEUTRAL] Yeah, ma'am. Actually, I don't have a claim number for this.
[CUSTOMER][NEUTRAL] I uh.
[CUSTOMER][NEUTRAL] I put on those.
[CUSTOMER][NEUTRAL] Well
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the claim number for this claim is 354.
[AGENT][NEUTRAL] 893.
[CUSTOMER][NEUTRAL] Mm, oh, just give me a second, ma'am. I'm sorry. I'm sorry for the interruption. Uh, the system was loading. Yeah, please, ma'am, please provide me that.
[AGENT][NEUTRAL] That's OK.
[AGENT][NEUTRAL] 354-893-9
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm it is received on.
[AGENT][NEGATIVE] This claim was also denied.
[AGENT][NEUTRAL] I'm sorry, what was your question?
[CUSTOMER][NEUTRAL] Yeah, the claim, when the claim was received on your end.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] It's received on [PII], processed and denied on [PII].
[CUSTOMER][NEUTRAL] Yeah, thank you. And could you please provide me the denied reason?
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] The denial reason on this claim states outpatient benefit for this calendar year has been met.
[CUSTOMER][NEUTRAL] We
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] That.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] For this calendar year, right?
[AGENT][POSITIVE] Yes, has been met.
[CUSTOMER][NEUTRAL] And could you please confirm me when the member was met with this benefits?
[CUSTOMER][NEUTRAL] Mother's Day
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][POSITIVE] Oh my goodness
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The claim was processed on [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So the outpatient benefits are not uh already exhausted for this patient, so that's where the 99283 CPT was not processed and paid, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][POSITIVE] Yeah, actually I'm um ready for the last, I mean last data service.
[CUSTOMER][NEUTRAL] They
[AGENT][NEUTRAL] OK, and the name of the service?
[CUSTOMER][NEUTRAL] And yeah, it is 1212 15 2024.
[AGENT][NEUTRAL] Mhm, total bill amount.
[CUSTOMER][NEUTRAL] Actually called
[CUSTOMER][NEUTRAL] Mm. It's $667 even.
[AGENT][NEUTRAL] Same build amount as the last claim.
[CUSTOMER][NEUTRAL] Yeah, exactly. But actually same as for the last one, I don't have a claim number.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Alright, I'm.
[CUSTOMER][NEGATIVE] 00 my God I didn't wanna be talking again.
[CUSTOMER][NEUTRAL] Uh, then they should be.
[AGENT][NEUTRAL] This claim was received on [PII].
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] And it was processed on [PII]. Claim number is 355-0331, and it was denied for the same reason. The outpatient benefit maximum for this calendar year has been met.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, they met on the same date.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Mm, yeah, ma'am. And the caller number, it is TYC and initially S as in [PII] and today's date. Is that it was right?
[AGENT][NEUTRAL] I'm not sure if you spelled my name correctly. It's [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] [PII]
[AGENT][POSITIVE] That is correct.
[CUSTOMER][POSITIVE] Yeah, ma'am. Thank you very much for the valuable information. That will be very quickly. I'm very happy for that. Have a nice day. Bye-bye.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] All right. Well, you're very welcome. Is there anything else I can help you with this morning?
[CUSTOMER][POSITIVE] No, ma'am. Thank you.
[AGENT][POSITIVE] OK, well then thank you for calling APL and I hope you have a nice day.
[CUSTOMER][NEUTRAL] Hm.