AccountId: 011433970860
ContactId: a47e3be2-6b31-404b-9cbf-937e77cdd188
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 732440 ms
Total Talk Time (AGENT): 371544 ms
Total Talk Time (CUSTOMER): 168232 ms
Interruptions: 0
Overall Sentiment: AGENT=0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/01/a47e3be2-6b31-404b-9cbf-937e77cdd188_20250401T14:49_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] For contacting ATO. My name is [PII]. How may I help you?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII], and initial is M like me calling from provider's office for claiming information.
[AGENT][NEUTRAL] I can help with the claim, [PII]. What is the policy number, please?
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] It's going to be 02430719 M as in Mike L as in Lima number 8.
[AGENT][NEUTRAL] Thank you. And the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] And the patient's name is [PII].
[CUSTOMER][NEUTRAL] Banco. Date of birth is [PII].
[AGENT][POSITIVE] I appreciate that if there's a callback number I could have in the event we're disconnected?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you. And the date of service for Ada?
[CUSTOMER][NEUTRAL] It's number [PII].
[AGENT][NEUTRAL] OK, I'm sorry. Uh, no, the, um, do you mind repeating that again, please? I apologize.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] [PII]. OK.
[AGENT][NEUTRAL] Thank you. And is there a bill amount that I should look for?
[CUSTOMER][NEUTRAL] It's for $16,600 even.
[AGENT][NEUTRAL] OK, thank you. Um, your claim number for this is 355.
[AGENT][NEUTRAL] 322-6 is it um
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] 355326, right?
[AGENT][NEUTRAL] Yeah, 3553226.
[AGENT][NEUTRAL] And it looks like we received your claim.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] On the [PII].
[AGENT][NEUTRAL] and we processed it January, that is correct, and we processed it on the [PII].
[CUSTOMER][NEUTRAL] January.
[AGENT][NEUTRAL] Now,
[CUSTOMER][NEUTRAL] No, the received date is January on which date?
[AGENT][NEUTRAL] OK, the, the date that we received your, your claim?
[AGENT][NEUTRAL] This is uh claim 3553226. The date that we received your, your claim was in [PII].
[AGENT][NEUTRAL] That's the date that we actually received it. Oh, the [PII]. We received it on the [PII].
[CUSTOMER][NEUTRAL] On which day?
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And then we process it on the [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Now the, now the policy only covers uh only covers um inpatient or outpatient hospital settings. It doesn't cover anything within the physician's office. So we were unable to pay that claim.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEGATIVE] Because it doesn't, it's just not covered um on this policy.
[CUSTOMER][NEUTRAL] May I know why it was not covered?
[AGENT][NEUTRAL] OK, so the, the policy doesn't cover anything that's in the physician's office. It only covers things that were in the hospital. So, for example, um, if it were inpatient hospital uh or outpatient hospital, uh, those are the things that are covered, inpatient or outpatient hospital. Um, nothing within a physician's office is covered, not the office visit, not the treatment within the physician's office, not the, the, anything at all. So that is why that was, um, not covered.
[CUSTOMER][NEUTRAL] So this is all the as for the patient's policy.
[AGENT][NEUTRAL] Yes, as per, as per the patient's policy, uh, these services are not covered.
[CUSTOMER][NEUTRAL] May I know the patient's policy?
[AGENT][NEUTRAL] Yes, this is a secondary or gap insurance.
[AGENT][NEUTRAL] It went into effect on [PII], and it is active.
[AGENT][NEUTRAL] Is there anything else at all that I can help with?
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] May I know the, could you please send us a copy of your the fax?
[AGENT][NEUTRAL] Yes, and what is that fax number?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII] and the attention is [PII].
[AGENT][NEUTRAL] [PII]. OK.
[AGENT][POSITIVE] I can certainly do that. Is there anything else at all I can help with?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, I do have 3 more claims with the same patient.
[AGENT][NEUTRAL] OK, certainly, and what is the um the next data service right now?
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] It's going to be.
[CUSTOMER][NEUTRAL] It is [PII], so [PII].
[AGENT][NEUTRAL] And is there a particular bill amount?
[CUSTOMER][NEUTRAL] And the bill amount is $16,600 even.
[AGENT][NEUTRAL] OK, looks like your claim number.
[AGENT][NEUTRAL] 355.
[AGENT][NEUTRAL] 3
[AGENT][NEUTRAL] 224.
[AGENT][NEUTRAL] And it looks like.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] It looks like we received that claim on the [PII] and we processed it.
[AGENT][NEUTRAL] On the [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And this is the same sort of uh claim. Uh, it looks like this is treatment within the physician's office, but it was not covered.
[CUSTOMER][NEUTRAL] OK, and for this one also please send us a copy of your.
[AGENT][POSITIVE] Yes, I can certainly do that.
[CUSTOMER][POSITIVE] And I'm ready with the next one.
[AGENT][NEUTRAL] And what is the next date of service?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] With the bill amount.
[CUSTOMER][NEUTRAL] $17,600 even.
[AGENT][NEUTRAL] OK, thank you. And you said it was, I'm sorry, you said what, what is the date again? It's uh
[CUSTOMER][NEUTRAL] It's uh [PII].
[AGENT][POSITIVE] Oh, great. Yes, of course. Thank you.
[AGENT][NEUTRAL] The
[AGENT][NEUTRAL] Claim number for this one.
[AGENT][NEUTRAL] It's 355-9161.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 355-9161 and it looks like this was uh received on um.
[AGENT][NEUTRAL] Uh, let's see what we have here.
[AGENT][NEUTRAL] On the um
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] We received this on the [PII] and we processed it on the uh.
[AGENT][NEUTRAL] On [PII].
[AGENT][NEUTRAL] [PII], and this is exactly the same thing.
[AGENT][NEUTRAL] Where the policy doesn't, uh, doesn't cover.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Is the claim number is 3559161, right?
[AGENT][NEUTRAL] 355-9161, that is correct.
[CUSTOMER][POSITIVE] And I'm ready with the last one.
[AGENT][NEUTRAL] OK, and what is that date of service?
[CUSTOMER][NEUTRAL] It's going to be [PII].
[AGENT][POSITIVE] Thank you, and the build amount?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] The bill amount is $17,600 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So the claim number for this one is 355.
[AGENT][NEUTRAL] 3220.
[AGENT][NEUTRAL] And on this one,
[AGENT][NEUTRAL] We received that on the [PII].
[AGENT][NEGATIVE] [PII] and we processed it on the [PII]. And again, this is because this is treatment within the physician's office, it's not gonna be covered.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] I can send those EOBs to you.
[CUSTOMER][NEUTRAL] Uh, could you repeat it?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, uh, so for this one.
[CUSTOMER][NEUTRAL] So as for the patient policy, these services are not covered because
[AGENT][NEUTRAL] The policy only covers, it's, it's just like we, we talked about before, it only covers uh treatment within a hospital setting. So nothing within a physician's office.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, [PII]
[CUSTOMER][NEUTRAL] I'm just noting it down. Because the treatment.
[AGENT][NEUTRAL] It
[AGENT][NEGATIVE] It, it doesn't, it doesn't cover treatment within the physician's office. It doesn't cover the office visit co-pay and it doesn't cover treatment. The, the only thing.
[AGENT][NEUTRAL] The only thing that this covers.
[AGENT][NEUTRAL] Is treatment within an inpatient hospital setting or an outpatient hospital setting. So the physician's office is not covered.
[CUSTOMER][NEUTRAL] So physicists are not covered, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Offices are not covered under the patients benefit plan.
[AGENT][POSITIVE] That's right.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] Actually for this one, so.
[CUSTOMER][NEUTRAL] Uh, for this one that you said the claim was issued on [PII], right? So we have submitted uh the claim on again on.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Right. And we, and we denied it as a duplicate.
[AGENT][NEUTRAL] But yes, it looks like uh all of these claims have been sent back in and they've been denied as duplicate because we're, it still is not going to be covered, no, no matter what we do. I mean, you can certainly, you feel free to send it in again, but I mean, it's just the, the policy doesn't cover these, um these sorts of, of charges.
[CUSTOMER][NEUTRAL] To
[AGENT][NEUTRAL] So I, I do see where it was sent in again. Um, it looks like there's a claim number 3570074, but um it's just not going to be covered under these policies.
[AGENT][NEUTRAL] Now, if you wish to send an appeal, you can certainly do that. Um, I can give you our address, but, uh, again, the, the policy doesn't, uh, clearly states that it doesn't cover those. It's just, it's just the um inpatient or outpatient. But, but if you'd like to send it in the appeal for any of these, you certainly can.
[AGENT][NEUTRAL] Is there anything
[CUSTOMER][NEUTRAL] OK, may I know the mailing address or the.
[AGENT][NEUTRAL] Yes, it's, it's [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And that is in [PII].
[CUSTOMER][NEUTRAL] And the ZIP code?
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][NEUTRAL] OK, it is [PII] [PII].
[AGENT][NEUTRAL] 895-0, that's correct, but you, you need to send it in when you're sending it in, uh, [PII], you need to send it in as an appeal, otherwise it will be denied as a duplicate again. You need to send it in as an appeal.
[CUSTOMER][NEUTRAL] OK, may I know the timely filing limit?
[AGENT][NEGATIVE] Uh, there's, there's no timely filing.
[CUSTOMER][NEUTRAL] That was.
[CUSTOMER][NEUTRAL] And the call number?
[AGENT][NEUTRAL] My name is [PII]. The first letter of my last name is [PII]. We'll use that in today's date as a reference. Is there anything else at all I can help with?
[CUSTOMER][NEUTRAL] No, that's all for the day.
[AGENT][NEUTRAL] OK, thank you for contacting API.