AccountId: 011433970860
ContactId: b3f05f08-61f7-4661-99ba-d9501f003da4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 597270 ms
Total Talk Time (AGENT): 197419 ms
Total Talk Time (CUSTOMER): 148388 ms
Interruptions: 1
Overall Sentiment: AGENT=0.1, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/27/b3f05f08-61f7-4661-99ba-d9501f003da4_20250127T15:25_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, I need to check on a claim, a medical claim status.
[AGENT][NEUTRAL] OK, you're calling from a provider's office?
[CUSTOMER][NEUTRAL] Yeah, facility, yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII], what's the policy number?
[CUSTOMER][NEUTRAL] 398789331.
[AGENT][NEUTRAL] Mm mm do you have a copy of the APLI?
[CUSTOMER][NEUTRAL] That's the social.
[AGENT][NEUTRAL] OK, give me that.
[CUSTOMER][NEUTRAL] No, they
[AGENT][NEUTRAL] Give me the social again.
[CUSTOMER][NEUTRAL] Go ahead, I'm sorry.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and what's a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, give me one moment while I search for the policy number.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] That's OK.
[AGENT][NEUTRAL] What's the patient's name?
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] And what type of claim are you submitting, dental or medical?
[CUSTOMER][NEUTRAL] Medical.
[AGENT][NEUTRAL] And [PII]'s date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, thank you. Do you wanna write down the policy number for future reference?
[CUSTOMER][NEUTRAL] OK, yes.
[AGENT][NEUTRAL] That number is 2506719.
[AGENT][NEUTRAL] And you stated that you're checking claim status?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yes, for, um, data service 103124.
[AGENT][NEUTRAL] What's the total charge?
[CUSTOMER][NEUTRAL] 3,306.88.
[AGENT][NEUTRAL] A professional or facility charge?
[CUSTOMER][NEUTRAL] I'm sorry?
[AGENT][NEUTRAL] Is it a professional or facility charge?
[CUSTOMER][NEUTRAL] Facility.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] You look at his history and I'll give you that information.
[AGENT][NEUTRAL] Is this in, let's see.
[AGENT][NEUTRAL] Is it an ER charge?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so I see several services related to the ER visit on [PII], but nothing matches the total charge that you provided.
[CUSTOMER][NEUTRAL] I have a
[CUSTOMER][NEUTRAL] Claim number, can you pull it out? OK, the claim number is 3552061.
[AGENT][NEUTRAL] OK. Yes.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, let's see.
[AGENT][NEUTRAL] OK, I see that.
[AGENT][NEUTRAL] OK, so this is the ER physician's charge, so this is a professional fee?
[AGENT][NEUTRAL] Is it two procedure codes on this claim?
[CUSTOMER][NEGATIVE] Hold on, no, we, no, that's not the professional, that's the ER and that's the not the professional.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That
[AGENT][NEUTRAL] You gave me claim number 3552061.
[CUSTOMER][NEUTRAL] 355, yeah, it's that's on the UB not the 1500 and it's the ER, yeah, there's 99283 and the 42,700.
[AGENT][NEUTRAL] Yeah, so this is the ER surgeon's charge, right?
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Now this is the facility.
[AGENT][NEUTRAL] OK, I'm looking at
[CUSTOMER][NEUTRAL] We bill for the ER the 99283.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And uh uh fortune.
[AGENT][NEUTRAL] Yeah, I'm
[AGENT][NEUTRAL] OK, yeah, I have the claim. It, it's on the CMS 1500 form. This is not on the UBL4 under the claim number that you gave me.
[AGENT][NEGATIVE] Now I do show the facility, the ER facility charge, but it's more than what you gave me. It's more than the bill amount that you gave me.
[AGENT][NEUTRAL] Uh, the facility charge was $21,512.
[CUSTOMER][NEUTRAL] Hold on a second.
[AGENT][NEUTRAL] But the, but the one we're talking about, the two codes are on the, the claim number that you gave me.
[CUSTOMER][NEUTRAL] Mm mm.
[AGENT][POSITIVE] Just wanna make sure I have the right, the right one.
[CUSTOMER][NEUTRAL] No, I have.
[CUSTOMER][NEUTRAL] Let me see if there's another claim for.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, let's see, 10:31.
[CUSTOMER][NEUTRAL] OK, we have the 10:31 for 3306.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] We have 112.
[AGENT][NEUTRAL] I I stand to be corrected. If it is a UVO4 with those two codes on there, the 99283.
[AGENT][NEUTRAL] And then the 42,700, it is a it is a hospital, a UVO4 form and OK, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] On this one.
[CUSTOMER][NEUTRAL] Now we did get a denial stating that the benefits were exhausted. Is this like a supplement?
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] It is, well, it's, it's actually a limited, a limited hospital mhm indemnity policy and the ER visit.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Limited plan.
[AGENT][NEUTRAL] Benefit under this policy, excuse me.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] A few more minutes.
[AGENT][NEUTRAL] Alright, so the emergency room benefit is $350 per day.
[AGENT][NEUTRAL] A max of 2 days per calendar year per covered person.
[AGENT][NEUTRAL] And so
[AGENT][NEUTRAL] So like another claim for this date of service was was processed.
[AGENT][NEGATIVE] Which exhausted the benefit.
[CUSTOMER][NEUTRAL] Another claim from another facility?
[AGENT][NEUTRAL] Let me pull up this claim.
[AGENT][NEUTRAL] What's the name of the hospital?
[CUSTOMER][NEUTRAL] University of Mississippi Medical Center.
[AGENT][NEUTRAL] Yeah, so this is from a different provider?
[AGENT][NEUTRAL] Same date of service?
[CUSTOMER][NEUTRAL] Um, so you're saying you have 2 charges on the same day from different providers?
[AGENT][NEUTRAL] I'm stating that the claim that the benefit was paid on is from a different provider.
[AGENT][NEUTRAL] Uh, that's the extent I can tell you I can't give any information regarding the other claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, I mean, I wasn't asking for that. I was just making sure that you, that's what you were saying that the reason why we didn't get the reason why we didn't get paid was because there was another ER charge and you are paid the other facility.
[AGENT][NEUTRAL] So I'm saying
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] There's another claim with that date of service and that benefit was paid on that claim from the other provider's office.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK, so this is patient responsibility.
[AGENT][NEUTRAL] We do not determine patients responsibilities, [PII].
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] Because, because the benefits were exhausted for this $300 per day, correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, can I get a call reference number?
[AGENT][NEUTRAL] You'll use my name in today's date as your reference, [PII]. Any other questions, [PII]?
[CUSTOMER][POSITIVE] No, that'll be all thank you have a great day.
[AGENT][POSITIVE] Alrighty, thanks for calling ATO. You too, bye bye.
[CUSTOMER][NEUTRAL] Bye bye.