AccountId: 011433970860
ContactId: a7e626a9-742a-4ff5-9ae9-055b041bc752
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 935770 ms
Total Talk Time (AGENT): 250085 ms
Total Talk Time (CUSTOMER): 291130 ms
Interruptions: 6
Overall Sentiment: AGENT=0.2, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/05/a7e626a9-742a-4ff5-9ae9-055b041bc752_20250505T19:09_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling American Public Life. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi [PII], my name is [PII] calling for Georgia Emergency Group LLC to check on a claim status. Please be informed that this call is may be recorded and monitored for quality and training purposes. May I know if we can help with the patient's information or provider's information?
[AGENT][NEUTRAL] Could you spell your name for me, please?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] And may I please have a callback number?
[CUSTOMER][NEUTRAL] OK, it's [PII]. It's a direct line without extension.
[AGENT][NEUTRAL] And may I have the policy number?
[CUSTOMER][NEUTRAL] It's 02558821.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Does that fit?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Date of birth [PII].
[AGENT][NEUTRAL] And you're calling in for status. May I please have the date of service and total bill?
[CUSTOMER][NEUTRAL] Yeah, I'm I'm calling for appeal status.
[AGENT][NEUTRAL] May I have the date of service and total bill?
[CUSTOMER][NEUTRAL] Um, the the.
[CUSTOMER][NEUTRAL] [PII] total charges $1280 even.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And I'm pulling that information up for you now.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] So it does look like we did receive that in on 24 of 25.
[AGENT][NEUTRAL] It was processed on 211 of 25.
[AGENT][NEUTRAL] The claim number is 356.
[AGENT][NEUTRAL] 1864, that claim denied as a duplicate of the previous claim that would that actually denied that the per calendar day max had been met.
[CUSTOMER][NEUTRAL] Actually we're sending uh appeal.
[CUSTOMER][NEUTRAL] And do you consider it's a claim that's why you denied a duplicate because we submitted an appeal.
[AGENT][NEUTRAL] OK, so looking at the claim that we received it in February, that claim denied as a duplicate because the previous claim actually was reviewed and processed correctly. So that claim denied as a duplicate because the maximum amount that we could pay out had already been met.
[CUSTOMER][NEUTRAL] With the medical reports.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, but.
[CUSTOMER][NEUTRAL] It just, as you can see, we submitted an appeal with the medical records, OK? And you consider as a claim, and that's where you're denying that a duplicate claim?
[AGENT][NEGATIVE] So the first time we received it was in December and that claim denied that the maximum had been met. So then we received it again. It was reviewed and it was processed that it denied correctly, so it denied as a duplicate because it was reviewed and denied correctly.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Then yes.
[CUSTOMER][NEUTRAL] All right. Just give me a moment. I have specific questions for you.
[AGENT][NEUTRAL] OK, how may I assist you?
[CUSTOMER][NEUTRAL] Just give me a moment.
[AGENT][NEUTRAL] And is there anything else that I can assist you with today, [PII]?
[CUSTOMER][NEUTRAL] OK, uh, OK, so, sorry for waiting you, uh, [PII], as you can see, we submitted an appeal and are you processed as a claim?
[AGENT][NEUTRAL] When we receive any item in it's going to be processed as a claim even if an appeal come in it's gonna have a claim number so it denied.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] And do you have a bill on file?
[CUSTOMER][NEUTRAL] OK. May I take your.
[AGENT][NEUTRAL] We received on [PII].
[CUSTOMER][NEUTRAL] Yes, [PII], I know that. I just wanted to know, do you have a bill on file?
[AGENT][NEUTRAL] Let me pull the image up so I can make sure that I'm advising you this correctly.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So you're asking if we have an appeal on file. Am I correct?
[CUSTOMER][POSITIVE] Correct, yes.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Hey.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So the information that we received, it shows an appeal for the date of service that was received on [PII].
[CUSTOMER][NEUTRAL] Alright, so you have a bill on file correct?
[AGENT][NEUTRAL] That's what I'm continuing to say. We do have it on [PII]. We received it and it was processed.
[CUSTOMER][NEUTRAL] And you said that is.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] And it's upheld and the original claim has been denied as correct, correct? That's the appeal the decision.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And is there anything else that I can assist you with today, [PII]?
[AGENT][NEUTRAL] Are you still there?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh yes, I need a pill.
[CUSTOMER][NEUTRAL] Uh, appeal control number appeals control number.
[AGENT][NEUTRAL] We don't do a a PO control number. I gave you the claim number of that was that was processed. Do you need that claim number again?
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] All right. And uh do you have a pay date?
[CUSTOMER][NEUTRAL] The decision date means.
[CUSTOMER][NEUTRAL] And the bill was up here.
[AGENT][NEUTRAL] That will be the date that I gave you, which was done on [PII].
[CUSTOMER][NEUTRAL] Got it and I have some specific questions. Just a moment.
[CUSTOMER][NEUTRAL] Oh, got it.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] May I know what are the allowed service amount per time per frame?
[AGENT][NEUTRAL] The benefit amount that will be paid out for that date of service?
[AGENT][NEUTRAL] Is that what you're needing?
[CUSTOMER][NEUTRAL] OK, did, uh, so the original claim has been denied for.
[CUSTOMER][NEUTRAL] Existing benefit exists right as per visit or as per dollar amount.
[AGENT][NEUTRAL] There's a dollar amount that the member has and we had already paid that on our previous claim for that date of service. So there's no other amount that could be paid out.
[CUSTOMER][NEUTRAL] Alright, may I know when was the last service built?
[AGENT][NEUTRAL] I can't advise you of that payment claim.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, I know the family filing to submit currently.
[AGENT][NEGATIVE] We have no timely filing.
[CUSTOMER][NEUTRAL] Mailing address to submit here.
[AGENT][NEUTRAL] Now you do understand that I'm that I'm telling you for that date of service there's no more money that could be paid out.
[CUSTOMER][NEUTRAL] OK, and just from a need for a documentation and as you can see, you didn't understand it properly so the original claim also has been denied right for the maximum benefits exist, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, so that exists with the.
[CUSTOMER][NEUTRAL] Visiting as per visit or as per dollar?
[AGENT][NEUTRAL] Is per date, so for that date of service, that maximum amount has been paid out.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh as you can see the CPD code 99284 is showing me outstanding for $1280.
[CUSTOMER][NEUTRAL] May I know what happened with this CPD code?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] What was the CPT code again?
[CUSTOMER][NEUTRAL] 99284.
[CUSTOMER][NEUTRAL] that
[AGENT][NEUTRAL] OK, so that's the same claim that you asked me for information on and that's the 1024 24 with 99284.
[AGENT][NEUTRAL] So I've already advised on both of those claims.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK, uh, I need your mailing to submit cartage them. It's just from the documentation.
[AGENT][NEUTRAL] The mailing address would be [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] The timely filing for appeal?
[AGENT][NEGATIVE] We have no timely filing.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mailing address for you?
[AGENT][NEUTRAL] I just gave you the mailing address.
[CUSTOMER][NEUTRAL] It's uh for credit claim and a bill is the same.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Is there any attention for you?
[AGENT][NEUTRAL] No attention. You can, if you would like, you're more than welcome to put appeals department.
[CUSTOMER][NEUTRAL] the
[CUSTOMER][NEUTRAL] Alright, is there any specific form for you?
[AGENT][NEUTRAL] No specific form.
[CUSTOMER][NEGATIVE] I denied you'll be required for corrected claim and appeal.
[AGENT][NEUTRAL] OK, could you repeat that question again?
[CUSTOMER][NEUTRAL] Denied you'll be required for appeal and corrected claim.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][NEUTRAL] I just want to confirm the claim number which is once again.
[CUSTOMER][NEUTRAL] You said 3561864, correct?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And.
[CUSTOMER][POSITIVE] Yeah, yeah, you will try again for once.
[CUSTOMER][NEUTRAL] may I know what is the allowed service amount for time frame?
[AGENT][NEUTRAL] For this member, verification of coverage does not guarantee the payment of the claim. This member does have up to $50 that we will pay out if there is an amount that is left over, that is considered patient's responsibility.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] And you, you also don't know when was the last service built, right?
[AGENT][NEUTRAL] I can't disclose that information since you did not submit that bill.
[CUSTOMER][NEUTRAL] But I
[CUSTOMER][NEUTRAL] I need your call reference number.
[AGENT][NEUTRAL] The call reference would be my first name [PII], which is spelled [PII] last [PII] and today's date. Is there anything else that I can assist you with today?
[CUSTOMER][POSITIVE] No. Thank you, [PII]. Thank you for your assistance. Have a great day ahead.
[AGENT][POSITIVE] OK, well, I do wanna thank you. You're welcome. Thank you for calling American Public Life. Same to you. Bye bye.