AccountId: 011433970860
ContactId: a75ab1c2-637c-4c3e-9920-4df2de11336c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 570440 ms
Total Talk Time (AGENT): 311611 ms
Total Talk Time (CUSTOMER): 107458 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/2025/03/17/a75ab1c2-637c-4c3e-9920-4df2de11336c_20250317T18:23_UTC.wav
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[AGENT][NEUTRAL] Contacting with you. My name is [PII]. How may I help you?
[AGENT][POSITIVE] Hello, thank you for contacting ATL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, calling from provider's office to check on claim status.
[AGENT][NEUTRAL] OK, I can certainly help with team status. What's that policy number, please?
[CUSTOMER][NEUTRAL] Yes, before you proceed, I'll let you know this call will be recorded for internal quality training purpose. And the member ID number is 02221656.
[AGENT][NEUTRAL] OK, I'm sorry. What
[AGENT][NEUTRAL] I'm sorry, what is the policy number again? 80.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No, it's 02221656. 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] The end of August and date of birth is [PII].
[AGENT][NEUTRAL] Thank you. Is there a callback number that I can have in the event that we're disconnected?
[CUSTOMER][NEUTRAL] [PII] with the extension of [PII].
[AGENT][NEUTRAL] Thank you and uh [PII] what uh policy, what data service are we looking for for her?
[CUSTOMER][NEUTRAL] [PII] and the amount is $619 even.
[AGENT][NEUTRAL] I'm sorry, you said [PII].
[CUSTOMER][NEUTRAL] [PII]. And bill amount is 619.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 619. OK, thank you.
[AGENT][NEUTRAL] OK. So just checking.
[AGENT][NEUTRAL] Excuse me just one moment, please.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, it looks like uh this was paid, um.
[AGENT][NEUTRAL] Looks like we received your, your claim and that uh claim number is 3534049.
[AGENT][NEUTRAL] It looks like that was paid, uh, let's see.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Sorry, I'm just checking here.
[CUSTOMER][POSITIVE] Yeah, actually claim got enough for the primary UB.
[AGENT][NEUTRAL] Yes, yeah, we, we originally, yeah, we originally did that for the primary EOB and but then it was, it looks like it was sent in again and it was paid. Um, now there, there was a check for $419.12 that was sent in. Uh, it's just that, uh, that is the most of the benefits that that would be available uh for this uh for that calendar year.
[CUSTOMER][NEUTRAL] So you already, yeah.
[AGENT][NEUTRAL] Um, yes, we did receive it. We did receive the EOB, uh, for that, and we did go ahead and pay that.
[AGENT][NEUTRAL] I can give you the check number if you like, um.
[CUSTOMER][NEUTRAL] OK. So after sending the primary you will be, uh, again, we got the payment on
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mm, so could you please at least pay the amount?
[AGENT][NEUTRAL] OK, it looks like the paid amount was $419.12 and that was the most that was that, uh, that was the remaining benefits that was on this policy. So, the policy has uh uh outpatient benefits of um
[AGENT][NEUTRAL] Excuse me, $3500 per calendar year. That's just a verification of the benefits, not a guarantee of payment, but, uh, the remaining benefits that uh we had at that available time was $419.12.
[CUSTOMER][NEUTRAL] Yeah, actually, we resend the primary UB again on [PII].
[CUSTOMER][NEUTRAL] Because for uh sorry.
[AGENT][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] Oh, please go ahead. Uh-huh.
[CUSTOMER][NEUTRAL] Yeah. Were the primary will be.
[CUSTOMER][NEUTRAL] On [PII].
[CUSTOMER][NEUTRAL] What's the status of status of after that?
[AGENT][NEUTRAL] Uh, yes, uh, that was denied as being a duplicate. Um, we had already processed this claim. It was denied as a duplicate. We had already processed the claim.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] Uh, the claim had already been processed once before and, and an amount paid. And so, uh, the, the second EOB that you submitted was denied as a duplicate.
[CUSTOMER][NEUTRAL] OK. So, uh, is there any patient responsibility?
[AGENT][NEUTRAL] Well, it would be anything that's above our contractual arrange uh uh obligation. So the check that was sent out, uh, is on [PII], uh, is the only amount that we will pay. It's, it's the most that they have the benefits for that calendar year. So anything above and beyond that is going to be something that you'd want to talk to the, the insured about, but that our contractual obligation was met with that check, and that's the most that we would pay.
[AGENT][NEUTRAL] But I can't actually tell you that it's a patient responsibility that they may have another uh insurance, but that's the most that this policy will pay.
[CUSTOMER][NEUTRAL] OK, so, OK, so the plane got enough for the CVD.
[AGENT][NEUTRAL] Uh, the second claim that you sent in was denied because it was a duplicate of the first one that was submitted.
[AGENT][NEUTRAL] And the
[CUSTOMER][NEUTRAL] Sorry, could you please repeat again?
[AGENT][NEUTRAL] I beg your pardon?
[CUSTOMER][NEGATIVE] Because I didn't understand what you're saying. After sending the second, uh, UB, uh, after sending the UB on [PII], it got a stating as duplicate, right?
[AGENT][NEGATIVE] Uh, well, it's not it's not eligibility. It just, it's, uh, you send it in twice and all the benefits had already been paid out, but there, there was no there were no more benefits to pay out, so we, we denied it as being a duplicate.
[AGENT][NEUTRAL] See the the claim's already been paid.
[AGENT][NEUTRAL] And uh there, there is a check. I can give you the check number. I can tell you when uh when it was sent out, but, but uh that's the only this, this data of service for these uh for these procedure codes has been paid.
[AGENT][NEUTRAL] And so if there's any remaining amount, um, that it's, I, I don't know.
[CUSTOMER][NEUTRAL] It's a discounted, uh, it's a discounted rate.
[AGENT][NEUTRAL] No, it's no, it's not discounted. The patient has uh benefits, outpatient benefits of $3500 per calendar year.
[AGENT][NEUTRAL] And at the time and of course that's $3500 per calendar year and that's just a verification, not a guarantee of payment but that entire amount.
[CUSTOMER][NEUTRAL] 35.
[AGENT][NEUTRAL] had been met with the except with the exception of that $419.12 once we made that payment of $419.12 her entire benefit for that calendar year was was maxed out. So she used all of her benefits. So we paid $419.12 because that's the only amount that that's the remaining amount that she had available. After that, all of her benefits were maxed out.
[AGENT][NEUTRAL] So it's not a discounted plan. It's, it's not a, it's not a discount, um, it's not a discount on our part. It's just that she used all of her benefits. So there's a certain amount of benefits each year and once those are used, then, um, then we're not, we don't pay out any more than that. So our contractual obligation was met.
[AGENT][NEUTRAL] For that calendar year with this check.
[AGENT][NEUTRAL] I can send you a copy of the check, um, if you like, but, uh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That's, that's the most that we will pay on uh for that calendar year for [PII].
[CUSTOMER][NEUTRAL] OK. So, claim got enough for the max benefit.
[AGENT][NEUTRAL] Well, it's, yeah, the second claim that you sent, uh, it looks like you sent the EOB again or somebody sent the EOB again, and that was a duplicate because it, it had already been, um, it had already been processed and paid.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Is there any other data service that we need to look for for this individual?
[CUSTOMER][POSITIVE] No, thank you so much. Could you please find the call reference number?
[AGENT][NEUTRAL] My name is [PII]. The first letter of my last name is [PII], and we're gonna use that today's date as our reference.
[CUSTOMER][NEUTRAL] Sorry, could you please repeat again?
[AGENT][NEUTRAL] Yes, my name is [PII], and we're gonna use that in today's date, which is, uh, [PII] as our reference.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] OK, thank you for contacting AP I have a good.