AccountId: 011433970860
ContactId: a9c6e4f2-672b-4a11-b026-739e0ed2c255
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 649669 ms
Total Talk Time (AGENT): 219102 ms
Total Talk Time (CUSTOMER): 251212 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/13/a9c6e4f2-672b-4a11-b026-739e0ed2c255_20250513T14:22_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], and very good morning. This is [PII]. I have a small clarification on the claim. Can you please help me on this?
[AGENT][POSITIVE] Absolutely I can look at that claim for you. uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And then do you have that policy number?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] And the policy number is
[CUSTOMER][NEUTRAL] 02521709.
[AGENT][NEUTRAL] OK, and what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] Mhm. [PII], [PII], date of birth.
[AGENT][NEUTRAL] Got it, thank you for verifying that and what was the uh or do you have that claim number, [PII]?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, once again.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] No, I don't have a claim number. Sorry, sorry, uh.
[AGENT][NEUTRAL] Oh, that's OK. Sure, what was the date of service, please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, that was [PII]?
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] It
[CUSTOMER][POSITIVE] Correct. Yes.
[AGENT][POSITIVE] OK, and then yes that build them out please.
[CUSTOMER][NEUTRAL] Uh, one second. Bill amount $1,466 even.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK thank you one moment please.
[CUSTOMER][NEUTRAL] One second, your name, please?
[AGENT][NEUTRAL] It's [PII]
[CUSTOMER][POSITIVE] Oh thank you.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] [PII], do you have the uh tax ID for this provider?
[CUSTOMER][NEUTRAL] Uh-huh, yes.
[AGENT][NEUTRAL] Would you mind giving that to me?
[CUSTOMER][NEUTRAL] 570
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah, yeah. [PII].
[AGENT][POSITIVE] OK, thank you one moment.
[AGENT][NEUTRAL] OK, so we did receive this kind pull. It looks like we are missing a copy of the primary EOB.
[CUSTOMER][NEUTRAL] OK. When you received the claim?
[AGENT][NEUTRAL] This claim was received [PII].
[AGENT][NEUTRAL] And it processed on [PII].
[CUSTOMER][NEUTRAL] OK. And the claim was
[CUSTOMER][NEUTRAL] Date for primary EP. One second, just a moment.
[AGENT][NEUTRAL] Missing the primary EOB, yes.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] OK. And your mailing address, I do have here is. Once again, let me confirm. That is uh [PII], correct?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] What is your pay ID?
[AGENT][NEUTRAL] That is 60801 and I've also got a fax number as well if you'd like [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, once again, let me get this. And the effective date is [PII]. Correct? Select you.
[AGENT][NEUTRAL] Mhm.
[AGENT][POSITIVE] That's, that's correct.
[CUSTOMER][NEUTRAL] And the timing filing is 365 days from date of service.
[AGENT][NEGATIVE] There is no timely filing limit.
[AGENT][NEUTRAL] That there is no timely filing limit for missing claim information.
[CUSTOMER][NEUTRAL] OK. One second.
[CUSTOMER][NEUTRAL] OK. Oh,
[CUSTOMER][NEUTRAL] What is the claim number?
[AGENT][NEUTRAL] That is 358-522-5.
[CUSTOMER][NEUTRAL] OK. Can I have the reference number?
[AGENT][NEUTRAL] That would just be my first name, last initial, and today's date, uh, so my last initial is [PII] and was there anything else I could help you with?
[CUSTOMER][NEUTRAL] What is the last
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] So sweet of you. I have one more patient, uh, [PII]. Can you please help me on this? Sorry for that.
[AGENT][NEUTRAL] That's OK. This was for a different member?
[CUSTOMER][NEUTRAL] Yeah, yeah, yeah, yes.
[AGENT][NEUTRAL] OK, yes, one moment please, I'll let you know and I'm ready for that policy number.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yeah, one second, just a moment.
[CUSTOMER][POSITIVE] That's so nice and sweet of you. Just a moment.
[CUSTOMER][NEUTRAL] OK. And the member ID?
[AGENT][POSITIVE] Yes, I'm ready, go ahead.
[CUSTOMER][NEUTRAL] I do have here is uh 02521722.
[AGENT][NEUTRAL] OK, and then, uh, the name and date of birth phone number please.
[CUSTOMER][NEUTRAL] Yeah, sure, [PII]. Patient name is [PII], [PII].
[AGENT][NEUTRAL] Thank you, um, and then what was the date address for this claim?
[CUSTOMER][NEUTRAL] Uh, data services [PII]. Total bill amount I do have it is uh one second, 60.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] $1,628. Let me tell you what happened in this claim, OK? When you're ready.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure, yes, go ahead.
[CUSTOMER][NEUTRAL] Yeah. The claim must be denied for the maximum benefit excesses for the dollar amount. I, uh, it has been denied because it has been paid for the previous, uh, data service on the CPT code. Upon we received as the previous representative has uh send the claim back, but unfortunately, the call got disconnected. Can you please complete and send the claim back because it was for the, as we received, once again, as we received a response from the coding department.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] As the previous uh claim number and the CPT code as for other service and data service. Thank you.
[AGENT][NEUTRAL] OK, so I'm so sorry just so that I understand correctly, are you needing, um, you're needing a copy of the EOB?
[CUSTOMER][NEUTRAL] No, no, no, no, not the EOB. I do have the UOB in front of me. Uh, I need you to send the claim back for uh reprocessing. That's it. Thank you.
[AGENT][NEUTRAL] Oh, OK, so I, you would have to resubmit that information, [PII]. I'm not, I'm not able to do that.
[AGENT][NEUTRAL] Um, in this case, uh, as it has denied it for an appeal, um, and so I can't, do you have that claim number, [PII]?
[CUSTOMER][NEUTRAL] Yeah, there are other cases.
[CUSTOMER][NEUTRAL] Yeah. Yeah, yeah, yeah, once.
[CUSTOMER][NEUTRAL] Yes, yes, I do have the claim number. That's why I said the claim has been submitted multiple times, I think 4 to 5 times, uh, [PII]. That's why we are receiving the same denial on this. We can't able to appeal this claim. The claim number is 3581069, correct?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Uh, give me just a moment, let me verify that.
[AGENT][NEUTRAL] OK, yes, that does appear to be the original claim, so I will say if we just receive the same claim information of course it will just continue denying as this was the reason. So if you were to submit an appeal, um, the only difference with that is of course it would be that same information along with a letter that is stating that it is for an appeal. Now the timely filing for that is going to be uh within 180 days of the original process date.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] No no, [PII].
[CUSTOMER][NEUTRAL] OK, one second, one second. Already, I we have resub again along with the letter of the paper. Our coding department suggesting the payer to reprocess the claim one day for one time courtesy. For just for one time, you can send the claim back for review, not for reprocess for review.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] We are unable to do that, [PII], especially if we've received it multiple times and it has been denied, um, and I'm not showing that we've received any formal appeal, so it does, uh, if you were wanting to appeal it, um, then we would have to have that letter.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, no, no. I will, I will send an appeal. Yeah, yeah, I will send an appeal. Once you get the reprocessing, if you get the same denial as for the concern, you can send the claim back. OK? Thank you. Just give me one second. And when was the claim received date? [PII], correct?
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] That's
[AGENT][NEUTRAL] No sir, so the original claim that was [PII].
[AGENT][NEUTRAL] And that process date was [PII].
[AGENT][NEUTRAL] And that was the original claim, the one that you gave me.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And uh it will take, how long it will take not the review for this 17 to 14 business days, correct?
[AGENT][NEUTRAL] Could you repeat that? I'm sorry.
[CUSTOMER][NEUTRAL] Uh, it will take 7 to 14 business days for you, correct?
[AGENT][NEUTRAL] Um, once we received claim information, it can take about, yes, up to 14 business days for that process.
[CUSTOMER][NEUTRAL] Can I have the reference number?
[AGENT][NEUTRAL] Uh, it would be the same as the other one. my first name, last initial, and today's date.
[CUSTOMER][NEUTRAL] OK. Just give me one minute and the claim process is the same. The claim was denied for uh
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Maximum benefit exhaustion for the dollar amount, correct?
[AGENT][NEUTRAL] That's correct. However, the claim was received [PII]. It was processed on [PII].
[CUSTOMER][NEGATIVE] Maximum benefits excessive for dollar amount, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Mhm. What is the maximum dollar amount for the patient?
[AGENT][NEUTRAL] Sure, give me just a moment, let me get that.
[AGENT][NEUTRAL] So this policy, the outpatient benefits, it pays on a per calendar day basis, so there is no yearly maximum, simply a daily maximum, and that is $200 max per calendar day.
[CUSTOMER][POSITIVE] Thank you and bye-bye.
[AGENT][POSITIVE] All right thank you bye bye.