AccountId: 011433970860
ContactId: ac39f83f-bcbe-459b-9b6f-1f5d45cceb0a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 580530 ms
Total Talk Time (AGENT): 170313 ms
Total Talk Time (CUSTOMER): 258408 ms
Interruptions: 2
Overall Sentiment: AGENT=0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/11/ac39f83f-bcbe-459b-9b6f-1f5d45cceb0a_20250311T19:58_UTC.wav
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[AGENT][NEUTRAL] For calling APL, my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] Hello. This is [PII], and I'm calling from provider's office for the claim information.
[AGENT][POSITIVE] I'd be happy to assist with claim status today, [PII] if I can get a good call back number for you.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And what is the policy number?
[CUSTOMER][NEUTRAL] It's 1,702,710.
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] It's [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that information. Please be advised the verification of coverage is not a guarantee of payment.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] I do show the policy is currently active and what is the date of service for the claim?
[CUSTOMER][NEUTRAL] A minute, a moment. Can I get the effective date once?
[AGENT][NEUTRAL] Effective date is excuse me, [PII].
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][POSITIVE] And still like this.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][NEUTRAL] And uh
[CUSTOMER][NEUTRAL] Yeah. So the date of service is [PII] for the billed amount of
[CUSTOMER][NEUTRAL] Yeah, uh, $320.
[AGENT][NEUTRAL] And what's the tax ID?
[CUSTOMER][NEUTRAL] Tax ID is [PII].
[AGENT][NEUTRAL] Thank you for that information. I'm showing the claim was denied because the.
[AGENT][NEUTRAL] Outpatient Max had already been met.
[CUSTOMER][POSITIVE] But I can check that uh Prime has already paid the claim.
[AGENT][NEUTRAL] I'm showing that um his outpatient benefits were maxed out by the time we received the claim.
[CUSTOMER][NEUTRAL] So you didn't receive the claim timely?
[AGENT][NEUTRAL] I didn't say that.
[AGENT][NEUTRAL] I'm showing that the outpatient maximum their benefit was already maxed out when we received the claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] But I can see that uh Prime has already paid the claim and if they had, it needs to be get paid and uh this
[CUSTOMER][NEGATIVE] Yeah, it is denying it incorrectly because it is already paid for.
[AGENT][NEUTRAL] OK. You can file an appeal.
[CUSTOMER][NEUTRAL] Uh, you cannot send the claim back for the reprocessing.
[AGENT][NEUTRAL] No, you'll need to file an appeal. According to us, we process the claim correctly. If you don't agree with that, you can always file an appeal. Thank you.
[CUSTOMER][NEUTRAL] OK. Can you provide me the fax number?
[AGENT][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] And it is the exit, uh, right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEGATIVE] It is bad as the moment.
[CUSTOMER][NEUTRAL] So, can you also verify how many rentals are allowed for E 0470?
[AGENT][NEUTRAL] You said what now?
[CUSTOMER][NEUTRAL] How many rentals are allowed for the CPT code is 0470?
[AGENT][NEUTRAL] It's their benefit max is 4000 per year.
[AGENT][NEUTRAL] $4000 per year.
[CUSTOMER][NEUTRAL] So it is
[CUSTOMER][NEUTRAL] So it is already met.
[AGENT][NEUTRAL] They already met the $4000 maximum for outpatient services which includes DME.
[CUSTOMER][NEUTRAL] A moment.
[CUSTOMER][NEUTRAL] Uh, uh, but I can see the future claims are paid.
[AGENT][NEUTRAL] What do you mean by you can see future claims are paid. I, I don't understand. I'm sorry.
[CUSTOMER][NEUTRAL] Uh, uh, actually, I'm saying that for the same CPD codes, the future claims are processed and paid. If it should make that amount, it not be paying for the future one, but I can see it's paying for the future ones.
[AGENT][NEUTRAL] OK, well then you'll need to file an appeal if we if you think we processed it wrong.
[CUSTOMER][NEUTRAL] OK. Can I go with another date of service?
[AGENT][NEUTRAL] What's the date of service?
[CUSTOMER][NEUTRAL] That is [PII].
[CUSTOMER][NEUTRAL] For the bill amount of uh I mean.
[CUSTOMER][NEUTRAL] Yeah, $1000.
[AGENT][NEUTRAL] What's the tax ID?
[CUSTOMER][NEUTRAL] Same, [PII].
[CUSTOMER][NEUTRAL] And I can see that previously was denied us the medical records and it was also sent the medical records. Previously, the call was made and it was sent back for the claim for review.
[CUSTOMER][NEUTRAL] Can you check what is that of uh the processes, but I can, can't see any of the results.
[CUSTOMER][NEUTRAL] I the
[AGENT][NEUTRAL] I'm not showing we received any other claims.
[AGENT][NEUTRAL] Or any updated claims?
[CUSTOMER][NEUTRAL] No, I just said that it was denied as a medical record, but we do already submitted the medical records on our mailing address. And, and on [PII], the claim was sent back for the reprocessing.
[AGENT][NEUTRAL] OK, I'm not showing that we received medical records.
[CUSTOMER][NEUTRAL] But it was already stated that
[CUSTOMER][NEUTRAL] Uh,
[CUSTOMER][NEUTRAL] It was already sent back for the review, but can I know the the uh status of that uh reprocessed claim?
[AGENT][NEUTRAL] I'm showing they pay 147.79.
[CUSTOMER][NEUTRAL] So you need the medical records, right?
[AGENT][NEUTRAL] I'm not showing we received any medical records.
[CUSTOMER][NEUTRAL] So you need that, right?
[AGENT][NEUTRAL] OK, what claims are you showing?
[AGENT][NEUTRAL] I'm showing we need an explanation of benefits. I'm not showing we asked for medical records. I'm showing we asked for the explanation of benefits from the primary insurance.
[CUSTOMER][NEUTRAL] A moment. But if it would be required, the explanation of benefits, it would be paying for the all claim because I can see that only one line item is paid.
[CUSTOMER][NEUTRAL] If it, if it is denying for this reason, then all it should be not paid for any of the CPT code, but I'm showing it is paid for only one.
[AGENT][NEUTRAL] OK, we asked for the explanation of benefits for.
[AGENT][NEUTRAL] Uh, let's see which lines that we ask for.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For the
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] E 0562.
[AGENT][NEUTRAL] 84604.
[AGENT][NEUTRAL] 87034.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And I'm not seeing where it was sent in, in 87035. I'm not seeing where it was sent in, so if you wanna send that in so we can review the claim, you can do that.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK. And then we can submit that on fax. Can you provide me the fax number where we can send the?
[AGENT][NEUTRAL] 877.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 365.
[AGENT][NEUTRAL] 942 3.
[CUSTOMER][NEUTRAL] Got it. Thank you. And can I get the call reference number and the claim number?
[CUSTOMER][NEUTRAL] is this what SD?
[AGENT][NEUTRAL] Reference number is just my name [PII] last initial [PII], and the date and time of the call and the claim number is 34704.
[CUSTOMER][NEUTRAL] Just a moment, just a moment, just a moment. [PII], and your name is [PII], right? OK. And can I get the claim number, right? No, go ahead.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] 347.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 0492.
[CUSTOMER][NEUTRAL] And can I go with the previous claim number as well for the date of service of [PII]?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] It's 3503228.
[CUSTOMER][NEUTRAL] 350
[CUSTOMER][NEUTRAL] to get
[AGENT][NEUTRAL] 322 8.
[CUSTOMER][NEUTRAL] OK, got it.
[CUSTOMER][POSITIVE] 8. OK, thank you.
[AGENT][POSITIVE] Thank you for calling APO. Have a good day.