AccountId: 011433970860
ContactId: 9e2b092d-2187-40a2-b2d6-0b19f2983d88
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1473239 ms
Total Talk Time (AGENT): 350568 ms
Total Talk Time (CUSTOMER): 537655 ms
Interruptions: 4
Overall Sentiment: AGENT=0.2, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/10/9e2b092d-2187-40a2-b2d6-0b19f2983d88_20250310T21:24_UTC.wav
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[AGENT][POSITIVE] Thank you for calling
[AGENT][NEUTRAL] Sure, can I help you?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. We're calling from provider's office to check in on claims.
[AGENT][NEUTRAL] OK, [PII], I can help you with the claim status. Can I please get your callback number?
[CUSTOMER][NEUTRAL] Yeah, sure. I'll callback number is [PII]. It's a direct line.
[AGENT][POSITIVE] Thank you, sir. And then what is.
[CUSTOMER][NEUTRAL] And by the way, I didn't catch your name. And can I get your name?
[AGENT][NEUTRAL] My name is [PII]
[CUSTOMER][POSITIVE] Perfect. Mhm.
[AGENT][NEUTRAL] OK. Um, [PII], what is the insured's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] Yeah, sure. Actually, so we are looking for the dependent claims, so the insurance is different. So can I provide the
[CUSTOMER][NEUTRAL] Patient information.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. So the patient's ID is [PII] [PII] [PII].
[CUSTOMER][NEUTRAL] [PII]. And the patient's name is [PII], and the date of birth is [PII].
[AGENT][NEUTRAL] OK. All right, [PII], I'm gonna put you on a brief hold. I'm gonna transfer you on over to IMA now so that they can assist you with this claim.
[AGENT][NEUTRAL] Let me give you that phone number just in case the call.
[CUSTOMER][NEUTRAL] And before that, can I get.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Let me give you the phone number just in case the call is disconnected, it's [PII].
[AGENT][NEUTRAL] [PII] and you will choose option one.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah, actually, [PII], I'm actually just called that number, spoke with one of the weapons that you, so they said that member have two different carriers. So this claims handled by different payer or different carrier. So that is why they, I mean, the answer the call to that department and get the claims for the department. So mhm.
[AGENT][NEUTRAL] Oh
[AGENT][POSITIVE] Got you.
[AGENT][NEUTRAL] OK do you have Miss [PII] social security number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And just give me one moment. OK. So the social security number of the number is [PII].
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, let me see if I can find that policy with the social security number real quick.
[CUSTOMER][NEUTRAL] What
[AGENT][NEUTRAL] And what is the member's name?
[CUSTOMER][NEUTRAL] Mhm. So the patient's name is?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, what's the mem.
[CUSTOMER][NEUTRAL] And the insured's name is [PII].
[AGENT][POSITIVE] OK. Thank you so much.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And let's see, this is a medical claim?
[CUSTOMER][NEUTRAL] Yeah, it's.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, let me look and see if I can find.
[CUSTOMER][NEUTRAL] I'll be a guy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You are
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, I am not finding [PII] on [PII]'s claim uh policies.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So, [PII] is not covered under [PII]'s policies.
[CUSTOMER][NEUTRAL] Mhm. And I also, upon checking my end, so we found that so the under the under the policy, so the is covered because and this is dependent I spouse.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, so, on [PII]'s policy, she's not on there and his policies lapsed in [PII].
[AGENT][NEGATIVE] And he does not have any active policies with us.
[CUSTOMER][NEUTRAL] OK. And just confirm that, so the and to policy effective on termination date?
[AGENT][NEUTRAL] Yes, the effective date was [PII].
[AGENT][NEUTRAL] And the policy lapsed on [PII], so he only had it for a month.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just give me one moment.
[AGENT][NEUTRAL] And [PII] is, is not on the policy.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure. And just give me one moment.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][POSITIVE] Yeah I can.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] And [PII], what is the name of the provider's office you're calling from?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure, so just let the name uh
[CUSTOMER][NEUTRAL] Community Medical Associates.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][POSITIVE] OK thank you.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] And upon checking my, yeah, actually, we received the claim for the another claim with the claim number. So could you please confirm that whether the status of the claim? Can you provide the, the another claim number for the same patient?
[AGENT][NEUTRAL] Yes, you can give me the claim number and I can pull that up and see if there's anything that I can find on them.
[CUSTOMER][NEUTRAL] OK, sure. So I think we have the claim number is 348.
[CUSTOMER][NEUTRAL] 6642
[CUSTOMER][NEUTRAL] Under the claim number, so the data service falls on [PII].
[AGENT][NEUTRAL] And what is the charge amount?
[CUSTOMER][NEUTRAL] Yeah, sure, so the total charge amount of the claim is $22 even it's $22.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, let me see if I can find anything on them.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold while I research this and I'll be right back.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, thank you for holding for me, [PII]. So I did find the claim, um, 3486642. The claim was paid $22.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, with check number 1,867,040.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] OK and I see.
[AGENT][NEUTRAL] The check was issued.
[CUSTOMER][NEUTRAL] A
[CUSTOMER][NEUTRAL] I'm sorry, I, I we employ in the claim number. Mhm mhm.
[AGENT][NEUTRAL] Yes, the check was issued.
[CUSTOMER][NEUTRAL] OK, listen. So, uh, actually, why I'm providing the claim number to you means so we have received the payment for the patient for the related data service, right? [PII].
[CUSTOMER][NEUTRAL] So our initially we discussing one claim, right? So that claim also falls under the same data service, [PII] with the charge amount of $26 even.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] Mhm. So that is the reason I providing the claim number.
[AGENT][NEUTRAL] OK. So,
[CUSTOMER][NEUTRAL] Mhm. So could you please provide the information about the data service [PII]?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] With the charge amount of $26.
[AGENT][NEUTRAL] So you know that you got this.
[AGENT][NEUTRAL] OK. All right, let me look real quick.
[AGENT][NEUTRAL] OK, I'm gonna put you on hold while I research this further. It's gonna be a brief hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, looking on the data service of [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I do find the claim. It is the claim number that you gave me and the, and that's the only claim on this state of service for her and the claim was paid.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Check number 186.
[CUSTOMER][NEUTRAL] OK, I'll, OK, I, no, I need the claim status for the charge amount of $26.
[AGENT][NEUTRAL] I don't have $26 on file.
[CUSTOMER][NEUTRAL] Mhm. OK, sure. Could you please provide the claim mailing address to some to the claims because you mentioned that, so there is no claim on file apart from the, the charge amount of $22. So you don't have any other claims for the status of [PII]. So could you please provide the claim mailing address?
[AGENT][NEUTRAL] Yes, it's [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] That's in [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And just confirm that, so the mailing address is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm. And is there any electronic payer ID?
[AGENT][NEUTRAL] Payer ID is 60801.
[CUSTOMER][NEUTRAL] 60801, right? And just confirm that so the member ID is same, right? D as in Delta.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] The, let me give you the policy number that you have, that they have with us. It's 2466.
[CUSTOMER][NEUTRAL] Can I
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 099.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. 246-6.
[CUSTOMER][NEUTRAL] I mean, 024 or just 24?
[AGENT][NEUTRAL] 246-6099.
[CUSTOMER][NEUTRAL] OK, so the member ID is 2466099, right?
[AGENT][NEUTRAL] Yes, and it's not under [PII], it's [PII].
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] However, under the [PII] policy, so the dependent is covered, right? [PII], because one of the claim was paid right, previously providing the paid claim number to you. That claim is built under the [PII], yeah, OK.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, [PII]'s on their effective [PII].
[CUSTOMER][NEUTRAL] And you mentioned,
[CUSTOMER][NEUTRAL] Sorry? Uh, OK, so [PII] is effective from
[AGENT][NEUTRAL] He
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] To current, yes.
[CUSTOMER][NEUTRAL] Still active?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And may I know the timely filing limit to submitted the claims?
[AGENT][NEUTRAL] We do not have one.
[CUSTOMER][NEUTRAL] Sorry, you don't have the time to limited information.
[AGENT][NEUTRAL] No, we don't have one.
[AGENT][NEGATIVE] We don't have a timely filing limit.
[CUSTOMER][NEUTRAL] So we can submit the claims.
[AGENT][NEUTRAL] Yes, you can submit them at any time as long as the policy was active during the date of service.
[CUSTOMER][NEUTRAL] OK, we can submit the
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, sure. Perfect. And thank you for the information. Actually, I have to with you one more detail so it was the same patient. So could you please check whether that claim was received or not?
[AGENT][NEUTRAL] What is the date of service?
[CUSTOMER][NEUTRAL] Mhm, sure, um.
[CUSTOMER][NEUTRAL] Just give me 1 2nd.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] And actually I have the claim number, so can I put the claim number?
[AGENT][NEUTRAL] Yes, but I still need the data service and charge amount please.
[CUSTOMER][NEUTRAL] OK, sure. So the date of service falls on [PII].
[CUSTOMER][NEUTRAL] And the total charge amount is $362 even.
[AGENT][NEUTRAL] OK, and then what is the claim number?
[CUSTOMER][NEUTRAL] Yeah, sure. So the claim number is 3526485.
[AGENT][NEUTRAL] OK, I'm gonna put you on a hold while I look up this claim for you and I'll be right back.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Hm
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, thank you very much uh this claim 3526485 was denied because the benefit maximum was met and also veiny puncture is not covered under the patient's policy.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And so for the CPT code 99214 was I mean, partially paid, right?
[CUSTOMER][POSITIVE] With the maximum benefit.
[AGENT][NEUTRAL] No.
[AGENT][NEUTRAL] No.
[AGENT][NEGATIVE] It was not paid
[AGENT][NEGATIVE] It was denied because the maximum benefit for the outpatient sickness writer was exhausted for the calendar year.
[CUSTOMER][NEUTRAL] Outpatient visit has been exhausted the current year for the patient plan, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm. May I know how many visits allowed for the current year for office visits?
[AGENT][NEUTRAL] Let me look
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's not they get 4 visits a year that pay $75.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And could you please provide the order amount for the CPT code 99214?
[AGENT][NEUTRAL] Uh, I just gave it to you.
[CUSTOMER][NEUTRAL] OK. And so the remaining balance goes to patient's responsibility, right? Since the patient's plan has been exhausted, right?
[AGENT][NEGATIVE] I can't give patient responsibility.
[CUSTOMER][NEUTRAL] And also you can confirm, mhm.
[CUSTOMER][NEUTRAL] No, you previously mentioned that the CPT code 36415 is not covered under the member's plan. So it should be processed, I mean, the remaining balance is the member responsibility date because the member's plan does not have these houses, I mean, does not allow these houses right under the patient's policy. So since, so the member taking the services, so they are the responsible, right?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] No, I can't give patient responsibility that's determined by the provider.
[CUSTOMER][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] OK, sure. And just confirm that is there any patient responsibility on the claim?
[AGENT][NEUTRAL] I can't give patient responsibility that's determined by the provider.
[CUSTOMER][NEUTRAL] Yeah, I'm gently asking to you, is there any patients responsibility on the claim? No, right?
[AGENT][NEUTRAL] And again, I can't give you patient responsibility, that's determined by the provider.
[CUSTOMER][NEUTRAL] OK, sure. I understand that. And so upon checking my end, so we didn't the exact year before the claims. So could you please send the copy of the EOB to our fax number?
[AGENT][POSITIVE] Absolutely. What's your fax number?
[CUSTOMER][POSITIVE] OK, perfect. Thank you. So our fax number is gonna be 732.
[CUSTOMER][NEUTRAL] 289
[CUSTOMER][NEUTRAL] 9254. And you can put attention my name, [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Alright, I'm gonna put you on a quick hold, [PII] while I get that ready for you and I'll be right back.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding for me [PII]. I got that fax on its way to you now.
[CUSTOMER][NEUTRAL] Mhm. And may I know how long it will receive our end?
[AGENT][NEUTRAL] You just gotta give it time to get to you. I've sent it.
[CUSTOMER][NEUTRAL] Yeah, so it will take 1 or 2 business days from today.
[AGENT][POSITIVE] It should be there today, yes.
[CUSTOMER][NEUTRAL] It will take one business day, right?
[AGENT][NEUTRAL] Yes, it'll be there today.
[CUSTOMER][POSITIVE] OK, sir. Thank you. And
[CUSTOMER][NEUTRAL] Yeah, OK, sure. Thank you, sir. Thank you for assisting me for today and that's all for today. And is there any call reference number for this call?
[AGENT][POSITIVE] Yes, you can use my name and today's date and you're very welcome [PII]. I hope you have a great rest of your day. Thank you for calling APL.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And may I know your last name for?
[AGENT][NEUTRAL] A
[CUSTOMER][NEUTRAL] And it was, should I mention that so the insured name is [PII]?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] OK. Thank you, sir. Thank you for assisting me and have a wonderful day. Stay safe. Bye-bye.
[AGENT][NEUTRAL] Bye bye, [PII].