AccountId: 011433970860
ContactId: a6716a46-c159-4110-ab73-be38242865f1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1198689 ms
Total Talk Time (AGENT): 340071 ms
Total Talk Time (CUSTOMER): 193283 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/17/a6716a46-c159-4110-ab73-be38242865f1_20250117T16:31_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling ATL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from the provider service checking on a claim status.
[AGENT][NEUTRAL] Sure, I can assist you with the claim status and may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yeah [PII].
[AGENT][NEUTRAL] Oh it's [PII], I'm sorry, can you repeat the last four?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]. OK, thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Yeah, sure. One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The patient's policy number is 02024698M as in Mary L as in Lima 7.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Member's name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] Thank you. What's the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] D of services in [PII] and total charges of $2,031 even 203.
[AGENT][NEUTRAL] OK, thank you. Let me see if I can find this claim for you and for future you can check claim status online through our website at [PII] and that's just optional. And let me go ahead and see if I can find this claim and you said it was for [PII], correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] OK, let me pull this ERP. Let me see if this is your claim.
[AGENT][NEUTRAL] OK, here we come. OK, looks like we processed the claim on [PII].
[AGENT][NEUTRAL] And the claim was denied. Um, the reason for this denial is that let's see.
[AGENT][NEUTRAL] Mm OK.
[AGENT][NEUTRAL] Looks like the insurance, primary insurance provides full benefits and it looks like it's a duplicate of previously submitted expense. Let me see if I have another claim. OK, yeah, I do have a different one. Let me give you the original denial, one moment.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEGATIVE] OK, the original denial was on [PII] and the denial reason on this one is the max.
[CUSTOMER][NEUTRAL] [PII], right.
[AGENT][NEUTRAL] [PII]. Yes. Mhm.
[AGENT][NEUTRAL] And the original denial indicates that the maximum benefit for the date of service has been met.
[CUSTOMER][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] May I know how the man the benefits were existed in whether in terms of visits or in terms of dollar amount?
[AGENT][POSITIVE] Dollar value.
[AGENT][NEUTRAL] Policy has a calendar day benefit of $500 so it's a daily benefit of $500.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Sorry, patient has?
[AGENT][NEUTRAL] The benefit maximum for outpatient service is $500 per day.
[CUSTOMER][NEUTRAL] But we have built only one claim for the date of service right.
[AGENT][NEUTRAL] Correct, but we have received many claims for that day. So when we receive this claim, the maximum benefit payable for the date of service has been met.
[CUSTOMER][NEUTRAL] OK. Can I have the claim number?
[AGENT][NEUTRAL] Mhm. Sure.
[AGENT][NEUTRAL] The claim number is.
[AGENT][NEUTRAL] 342-765-2
[CUSTOMER][NEUTRAL] Uh.
[CUSTOMER][NEUTRAL] A little.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Mhm. Sure.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Thank you. I have 3 more claims. Can you put information for.
[AGENT][NEUTRAL] Is it different members or the same number?
[CUSTOMER][NEUTRAL] Different members.
[AGENT][NEUTRAL] OK, I'll have to do a note on each one before I move forward to the next one, OK?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][POSITIVE] Thank
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, and what's the next policy number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 023 04876.
[AGENT][NEUTRAL] OK bear with me let me.
[AGENT][NEUTRAL] All that information.
[AGENT][NEUTRAL] May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Member's name is [PII] and date of birth is.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And may I have um the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Date of service is [PII] and total charges are $3,045 even.
[AGENT][NEUTRAL] OK, let me see if I can find this claim, and that was [PII], correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me pull the original 11 moment.
[AGENT][NEUTRAL] OK, I'm waiting on the ERP.
[AGENT][NEUTRAL] OK, so uh we processed the claim originally on [PII] and we send a benefit amount of $240.94 to the provider.
[CUSTOMER][NEUTRAL] OK, so what the primary leftover the balance is 4 $28.40 right?
[AGENT][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] You repeat what you said.
[CUSTOMER][NEUTRAL] Yeah, but the price.
[CUSTOMER][NEUTRAL] Yeah, but the pri Aetna process as primary and left over the patient patient responsibility is for $28.40 right? You have paid only $240.94. May I know the reason for that?
[AGENT][NEUTRAL] OK, the reason for that payment is in on the remarks codes, which indicates with the check, the maximum payable for the date of service has been met.
[CUSTOMER][NEUTRAL] OK, may I know the maximum amount that has to be paid for the date of service?
[AGENT][NEUTRAL] OK, let me get that for you one moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, so this one had a calendar day benefit of 350.
[CUSTOMER][NEUTRAL] But you have paid only 24, right?
[AGENT][NEUTRAL] Correct, because that was the remaining with the payment of that check, the maximum payable for the date of service has been met. So the 240.94 was the remaining for that date of service and that's what we pay.
[CUSTOMER][NEUTRAL] OK, so the remaining $110 paid to another claim, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] With for another provider or the same provider?
[AGENT][NEUTRAL] More than likely if you don't see it, it's because it's another provider.
[CUSTOMER][POSITIVE] Thank you. Can we go for the next member?
[AGENT][NEUTRAL] Let me make a note on this one, and you don't need any other information on this one.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Yeah I'm waiting on the system, bear with me.
[CUSTOMER][POSITIVE] No problem.
[AGENT][NEUTRAL] Alright, what is the next policy number?
[CUSTOMER][NEUTRAL] 01139250.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Patient's name is [PII].
[CUSTOMER][NEUTRAL] And date of birth is
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. And what is the day of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Date of service is [PII] and total charges are $953 even.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] That was [PII].
[AGENT][NEUTRAL] Duplicate, let me pull the original 11 moment.
[AGENT][NEUTRAL] It's gonna be a minute, OK.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so the original one was processed [PII] and we send a benefit amount of $25 and this was for um procedure 99204.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, so the procedure code 46,600 was not paid. May I know the reason for that?
[AGENT][NEUTRAL] OK, the reason for that denial is because the maximum benefit amount for treatment provider during the office visit has been exhausted. $25 is the maximum we pay on this policy.
[CUSTOMER][NEUTRAL] So we can bill the patient for the remaining amount, right?
[AGENT][NEUTRAL] It's up to the provider's discretion. Mhm.
[CUSTOMER][NEUTRAL] Thank you. Can we go for the last number?
[AGENT][NEUTRAL] OK, one moment, let me make a note on this one.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] What's the next policy number?
[CUSTOMER][NEUTRAL] 02255799 M as in Mary, L as in Lima 8.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Patient's name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] OK. And may I have the date of service and the amount of the claims?
[CUSTOMER][NEUTRAL] Data service is [PII] and total charges of $237 even.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, let me see if I can find this one. That was [PII], correct.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That's for 2:37 or 257?
[CUSTOMER][NEUTRAL] 237.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] 244611.
[AGENT][NEUTRAL] OK, we processed the claim [PII] and the claim was denied, indicating office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] 558
[CUSTOMER][NEUTRAL] So we can build the patient, right?
[AGENT][NEUTRAL] It's up to the provider's discretion.
[CUSTOMER][NEUTRAL] Thank you. Can you spell your name for my documentation?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Sure, my name is [PII]. That's [PII]. Last initial is [PII].
[CUSTOMER][NEUTRAL] Thank you. Can I have the caller reference number for all the claims?
[AGENT][NEUTRAL] We don't have reference numbers you can use my name in today's date.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] You need the spelling or any other information?
[AGENT][NEUTRAL] Mr. [PII].
[CUSTOMER][POSITIVE] Oh, thank you for your assistance. Have a great day, sir.
[AGENT][POSITIVE] OK. You as well thank you for calling APL. bye-bye, Mr. [PII].