AccountId: 011433970860
ContactId: ab08b4a4-b30d-4d1b-9d8f-63e35626eef5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 623869 ms
Total Talk Time (AGENT): 178654 ms
Total Talk Time (CUSTOMER): 208546 ms
Interruptions: 5
Overall Sentiment: AGENT=-0.1, CUSTOMER=-0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/15/ab08b4a4-b30d-4d1b-9d8f-63e35626eef5_20250515T21:03_UTC.wav
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[AGENT][POSITIVE] Thank you for calling APL.
[AGENT][NEUTRAL] [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, can you please spell out your name for me?
[AGENT][NEUTRAL] Yes, my name is [PII] And what is your name?
[CUSTOMER][NEUTRAL] Hi, [PII], I'm [PII] calling on behalf of providers office Imperial Health LLP. I want to discuss a claim with you if you can help me with that, that claim.
[AGENT][NEUTRAL] OK, uh, [PII], I can help you with claim. Um, can you please give me your callback number, sir, just in case the call is disconnected?
[CUSTOMER][NEUTRAL] Um, can you please give me your call back?
[CUSTOMER][NEUTRAL] It's [PII] [PII].
[AGENT][NEUTRAL] Thank you. And then what is the patient's name, date of birth, and policy number?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Patient's name, it's gonna be
[CUSTOMER][NEUTRAL] [PII] and date of birth is [PII].
[CUSTOMER][NEUTRAL] And uh should I provide the member ID first? 01633180.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] OK, let me pull that policy up real quick.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] All right. May I have the date of service and the charge amount?
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes, the date of service and the charge amount?
[CUSTOMER][NEUTRAL] Oh, data service, data service. Just give me a moment for that.
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][NEUTRAL] The service for this is of uh [PII] and total charge amount is $623.40.
[AGENT][NEUTRAL] OK, and that's 62,240.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and what's the name of the facility you're calling from?
[CUSTOMER][NEUTRAL] The name of
[CUSTOMER][NEUTRAL] I'm calling from uh Imperial Health LLP.
[AGENT][NEUTRAL] OK, I'm gonna put you on a quick hold, [PII], while I look up this claim for us and I will be right back, sir.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Sure.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding for me, [PII]. I do have the um
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] Claim ready for you, the claim number.
[AGENT][NEUTRAL] Is 354-1001.
[AGENT][NEUTRAL] The claim was denied because the maximum benefit for the outpatient sickness rider has been exhausted for the calendar year.
[CUSTOMER][NEUTRAL] So, may I know what is this outpatient sickness benefit which have been exhausted because we have built the CPT 99204, which is an ENM code as a new patient.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] So I show that we have two procedure codes. 99.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 204 and 93,000 and the claims specialist looked at it and said that the benefit was exhausted for the calendar year.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] For both the CBT.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So may I know these are the office visits and one is uh EKG. So may I know uh why it was, uh, how much is allowed and how much is met and which provider has built the services if you can tell me.
[CUSTOMER][NEUTRAL] Because it is an office visit, so you're saying that office, office visit is allowed only 5 times per calendar year.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So it is a uh new patient office, is it?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Correct, you're right, and um looking and, and this is just to verify benefits it's not a guarantee of payment. They get the 5 visits per year that pay $100 and they had used those up.
[CUSTOMER][POSITIVE] correct.
[CUSTOMER][NEUTRAL] So we.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] And then get the 5.
[AGENT][NEGATIVE] And there was no more available.
[CUSTOMER][NEUTRAL] So that the 5 is allowed and they used, so they were uh built by Imperial Health only.
[AGENT][NEGATIVE] They exhausted it.
[AGENT][NEUTRAL] No, you're not the only provider and I can't give that information out.
[CUSTOMER][NEUTRAL] May I know you can give this information, right?
[AGENT][NEUTRAL] No. No, sir.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Look, because on, in this year we have built only the single CPD 99204 and 9300.
[CUSTOMER][NEGATIVE] So why this has been denied uh all the benefit existed because we have not built the CBD in the previous month. So it has been for all the 4, all the 5 has been built by different provider, right?
[AGENT][NEUTRAL] Because you're not the only provider that has sent in claims, but I can't give out that information.
[CUSTOMER][NEUTRAL] I got you, I got your point that you're not able to give that.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] So is there anything else I can help you with before we go, [PII]?
[CUSTOMER][NEUTRAL] Yeah, actually, I want to know that uh you said that only 5 are allowed and $100 an hour and they have been made. So they, uh, all the 5 have been billed by different provider, am I right?
[AGENT][NEUTRAL] All 5 have been exhaust right, all 5 have been exhausted for the calendar year.
[CUSTOMER][NEUTRAL] I'm not asking about the names of the provider.
[CUSTOMER][NEUTRAL] I have been
[CUSTOMER][NEUTRAL] So it is going to be the patient responsibility?
[AGENT][NEUTRAL] We don't give patient responsibility we let the provider determine that.
[CUSTOMER][NEGATIVE] It is not qualification disponsibility.
[AGENT][NEUTRAL] I'm sorry, can you repeat the question?
[CUSTOMER][NEUTRAL] You're saying that it is as per provider, right?
[AGENT][NEUTRAL] Yes, it's determined by the provider.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Go to find determined by the provider.
[CUSTOMER][NEUTRAL] So, uh, 5 units per calendar year, right? So in [PII], only 5 units are, uh, in [PII], only 4 units were allowed.
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] It starts over again in [PII].
[AGENT][NEGATIVE] And they've exhausted their benefits.
[CUSTOMER][NEUTRAL] Oh, I got it, but I don't want to.
[AGENT][NEGATIVE] They don't carry over.
[CUSTOMER][NEUTRAL] No, I'm asking, I'm asking about the [PII] only.
[CUSTOMER][NEUTRAL] You said that in [PII], it was a lot 5, right?
[AGENT][NEUTRAL] The claim has been denied because the calendar year benefits for the outpatient has been exhausted.
[CUSTOMER][NEUTRAL] You mean the ENM code one, right?
[AGENT][NEGATIVE] The benefit for the year has been exhausted.
[CUSTOMER][NEUTRAL] For I that I know that you said that benefit for the year of exhausted for our patient, you said that they've been exhausted. So you're saying that for particular for office visit they have been uh exhausted because we are billed as a new patient, 99204. CPD is this.
[AGENT][NEUTRAL] If you want to appeal the claim I can give you that information or if you wanna correct the claim I can give you that information also but as of now it is denied because the benefit has been exhausted.
[CUSTOMER][NEUTRAL] Can we build this claim to patients?
[AGENT][NEUTRAL] We do not give patient responsibility that's determined by the provider.
[CUSTOMER][NEUTRAL] Sure. Thank you. Can you please provide me the uh call reference number?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Yes, sir. You can use my name, [PII], and today's date.
[CUSTOMER][POSITIVE] Thank you.