AccountId: 011433970860
ContactId: a7fa1f8d-6d4d-4f6c-bc0a-6875c579430a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 708250 ms
Total Talk Time (AGENT): 223150 ms
Total Talk Time (CUSTOMER): 348934 ms
Interruptions: 4
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/19/a7fa1f8d-6d4d-4f6c-bc0a-6875c579430a_20250219T22:29_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is uh [PII] from provider office. I'm here for a claim.
[AGENT][NEUTRAL] [PII], I it would be my pleasure to assist you with claim information. What is the callback number, please?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. And what is the policy number, please?
[CUSTOMER][NEUTRAL] Yeah, it's 022 098-98.
[AGENT][NEUTRAL] Thank you, [PII] and the patient's name and date of birth, please?
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] The date of birth? [PII].
[AGENT][NEUTRAL] And you said policy number 2209898?
[CUSTOMER][NEUTRAL] In
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] That is not the patient's policy number.
[CUSTOMER][NEUTRAL] OK, OK. Sorry. It's uh 0.
[AGENT][NEUTRAL] It
[CUSTOMER][NEUTRAL] 2309898. Yeah.
[AGENT][NEUTRAL] OK, let me try that. Bear with me just one second.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Again, 223-098-998.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. And can you repeat [PII]'s date of birth, please?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Alright, thank you, and that is the correct policy number and I can help you with that claim status. What is the date of service?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It's uh
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] What is the bill amount, please, sir?
[CUSTOMER][NEUTRAL] Yes ma'am
[CUSTOMER][NEUTRAL] It's $2,082.52.
[AGENT][POSITIVE] Alright, thank you.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] I'm checking on that for you bear with me one moment. What is the facility name?
[CUSTOMER][NEUTRAL] It's FHMC Clinic. Yeah, yeah, it stands for Fountain Health Medical Center.
[AGENT][NEUTRAL] Is that Fountain Hills Medical Center?
[AGENT][NEUTRAL] All right. All right.
[AGENT][NEUTRAL] All right, thank you, [PII], I can help you with that claim status. We received the original claim on 12-6-23.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] And processed on 12-7-23, we did pay the maximum benefit payable of $325 to Fountain Hills Medical Center.
[CUSTOMER][NEUTRAL] OK, and the claim number?
[AGENT][NEUTRAL] Claim number is.
[AGENT][NEUTRAL] 338.
[AGENT][NEUTRAL] 9947.
[CUSTOMER][NEUTRAL] 47
[CUSTOMER][NEUTRAL] OK, and the charge amount is.
[CUSTOMER][NEUTRAL] The check number is 33, OK, just a moment.
[CUSTOMER][NEUTRAL] There's something wrong because you provide the information from the uh professional side uh institutional claim. We have also submitted the professional claim because we are emergency on ER and we built two claims. One is from professional side and one from facility side.
[CUSTOMER][NEUTRAL] Uh, the last payment we already received.
[AGENT][NEUTRAL] OK, so
[AGENT][NEUTRAL] Uh, did you receive that $75 payment?
[CUSTOMER][NEUTRAL] No, it's, uh, we'll see $325.
[AGENT][POSITIVE] Yes, sir, that's correct.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And that's the maximum benefit payable.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Maximum benefit payable. And what about for the other claim?
[AGENT][NEUTRAL] What was that bill amount?
[CUSTOMER][NEUTRAL] is $2,082.52.
[AGENT][NEUTRAL] I'm checking.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] you know.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] 2000 was that for CPT 99285 and 93,010?
[CUSTOMER][NEUTRAL] Mm, uh, allow me a minute.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh yeah, two procedure code 99285 and 93,010.
[AGENT][NEUTRAL] All right, yes, sir. I see that claim as well.
[AGENT][NEUTRAL] That claim we received on [PII] and processed on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No, uh
[CUSTOMER][NEUTRAL] At least
[AGENT][NEUTRAL] And that claim was denied.
[AGENT][NEUTRAL] As the benefit maximum for that data service has been met.
[CUSTOMER][NEUTRAL] We'll let you know
[CUSTOMER][POSITIVE] Maximum benefit has
[CUSTOMER][NEUTRAL] Be met. OK. But, uh, this is a different under different uh tax ID.
[CUSTOMER][NEUTRAL] Because we have two tax ID that the other one that you guys pay $325.20 is under a different tax ID and that one is also for a different tax ID.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That's right, they're different tax ID numbers, yes sir.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So this is a limited plan.
[AGENT][NEUTRAL] It is a limited plan, yes sir, that is correct.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] Sir, uh, this claim is under NSA processing. Can we, uh, open the, uh, can we request to open negotiation? No surprise act.
[AGENT][NEUTRAL] So with our policy there's no contractual involvement we did process and pay the maximum benefit payable to the facility. The professional fee claim is denied as benefits met for that date of service.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Benefit
[CUSTOMER][NEGATIVE] Benefits met for the state of service. So you guys only pay uh one claim, right? Not pay for the, not, not pay for the professional side.
[AGENT][POSITIVE] That's correct.
[AGENT][NEUTRAL] That's right, because if we had received the professional claim first.
[CUSTOMER][NEUTRAL] And also
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, well, we, we paid the facility first and we maxed out the benefits on the facility claim.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Facility claim. But my question is this is a the second one is for professional.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. And we cannot send uh uh uh send a request of our negotiation, right?
[AGENT][NEUTRAL] You can submit a claim, however, I mean an appeal, but the time frame for an appeal has lapsed. The appeal time frame is 180 days from the date of denial.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] 180 days [PII]. OK. Uh, so for the other debt you guys paid, uh, we also send a corrected claim.
[CUSTOMER][NEUTRAL] On
[AGENT][NEUTRAL] In [PII]. Mhm.
[CUSTOMER][NEUTRAL] [PII], yeah.
[AGENT][NEUTRAL] That was [PII] as a duplicate.
[CUSTOMER][NEUTRAL] And what's the status?
[CUSTOMER][NEUTRAL] That it too.
[CUSTOMER][NEUTRAL] Lick it. OK, uh, just hold a moment. I have some question. I first need to discuss with my supervisor.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm. Thank you. I just want 1 or 2 minute hold.
[AGENT][NEUTRAL] All right.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Yeah, thanks for.
[AGENT][POSITIVE] You're very welcome. Anything else I can help you with, [PII]?
[CUSTOMER][NEUTRAL] Uh, uh, this is
[CUSTOMER][NEUTRAL] Yes. Uh, actually, this is a facility claim and you, uh, and our fare health value is 9000 and, uh, because, uh, we also provide some CTs, uh, the two CT scan services as well as uh some lab tests.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, and for some drugs, you can also see that the lab test is 123444 lab services and 2 CT scan.
[AGENT][NEUTRAL] Yeah, so with this
[CUSTOMER][NEGATIVE] So that's not a uh if, if this is a, a limited plan, so uh we send this bill to patient cause this is too much loss, uh.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Uh, amount that you guys pay.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] So any decision to bill the patient would be up to the provider. We don't determine patient responsibility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so provider is authorized to send the bill, right?
[AGENT][NEUTRAL] That is completely up to the provider we can't um.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] Verify if you can bill or not that's up to the provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's up to the on the provider. OK. OK. That's, that's, that's for just confirmation from the insurance side because this is too much low uh uh payment that you uh that we received because this is an emergency room and we provide that as well as uh CT scan services, lab services, and we give the time to patients in emergency room.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] And if this is a limited plan and you guys not paid anymore, so rest of the balance will send the patient.
[AGENT][NEUTRAL] That's to be determined by the provider.
[CUSTOMER][NEUTRAL] Yes, sir, depending on the provider, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK. OK. Got it. Thank you. May I have your reference number?
[AGENT][NEUTRAL] Yes sir, it would be my name and today's date. I spell my name [PII]
[AGENT][NEUTRAL] First initial and my last name is [PII].
[CUSTOMER][NEUTRAL] [PII]. OK, got it. And to the date and the time for
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Package
[AGENT][NEUTRAL] It just you would use my name in today's date.
[CUSTOMER][NEUTRAL] Name and. OK, I will discuss with my doctor. Thank you.
[AGENT][POSITIVE] All right, well thank you [PII] for calling APL. I hope you have a wonderful day.
[CUSTOMER][POSITIVE] Mhm. Thank you, you too. Bye.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] OK.