AccountId: 011433970860
ContactId: c6213c26-45a5-4926-8685-cdc2c2acb54a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 600330 ms
Total Talk Time (AGENT): 130308 ms
Total Talk Time (CUSTOMER): 149795 ms
Interruptions: 0
Overall Sentiment: AGENT=-0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/11/c6213c26-45a5-4926-8685-cdc2c2acb54a_20250611T14:14_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], this is [PII] calling from provider's office regarding claim status.
[AGENT][NEUTRAL] OK, I can help you with claim status and I missed your name. What was that?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Sure, OK, you have a good callback number, [PII]?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And policy number for the patient?
[CUSTOMER][NEUTRAL] Policy number starting with 024.
[CUSTOMER][NEUTRAL] 281
[CUSTOMER][NEUTRAL] 73
[CUSTOMER][NEUTRAL] M as in Mike
[CUSTOMER][NEUTRAL] L as in Lima, #7.
[AGENT][NEUTRAL] Patient name and date of birth?
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And date of service and bill charges?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] With $78 even?
[CUSTOMER][NEUTRAL] Yeah yeah
[AGENT][NEUTRAL] Uh, that claim was received on 10-28-24, processed 10-30-2024.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] May I know the claim number?
[AGENT][NEUTRAL] The claim number is 352-3603.
[AGENT][NEGATIVE] And it looks like it was denied for
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Service not covered when performed in doctor's office?
[AGENT][NEUTRAL] And the second line item outpatient benefit for calendar year has been met.
[CUSTOMER][NEUTRAL] OK. May I know the patient plan?
[AGENT][NEUTRAL] Uh medling SFX.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] HMO or APO PPO?
[AGENT][NEUTRAL] Neither it's a secondary policy.
[CUSTOMER][NEUTRAL] You mean EPO, right?
[AGENT][NEUTRAL] It's not a PPO or EPO or HMO. It's just a secondary supplemental policy.
[CUSTOMER][NEUTRAL] Uh, then what can be done to process this claim?
[AGENT][NEUTRAL] This is a supplemental secondary policy, so we've processed it according to the policy.
[CUSTOMER][NEUTRAL] OK. Actually, I have, we have bill with the radiology code, I think, let me check.
[CUSTOMER][NEUTRAL] Yeah, actually, we have the radio record which is for specifically taking reviews from me.
[AGENT][NEUTRAL] I'm sorry, what?
[CUSTOMER][NEUTRAL] I mean knee joint, knee joint for taking 3 reviews for X-ray. This is a radiology code. We have only one line item with $78 even.
[AGENT][NEUTRAL] OK, yes, so it was performed in the doctor's office, correct? Places service 11?
[CUSTOMER][NEUTRAL] No, 22, 22, 22s.
[CUSTOMER][NEUTRAL] Let me check.
[CUSTOMER][NEUTRAL] Yeah, it signifies on-campus outpatient, right.
[CUSTOMER][POSITIVE] The service is also perfect.
[CUSTOMER][NEUTRAL] And 26 is a professional component modifier with the right side.
[AGENT][NEUTRAL] OK, yeah, there were 2, there's two denial reasons on here. One is the outpatient calendar year or the outpatient maximum has been met for the year, dollar amount.
[AGENT][NEUTRAL] And this was billed with place of service 11.
[AGENT][NEUTRAL] So
[CUSTOMER][NEUTRAL] No, actually, we have 22, not 11.
[AGENT][NEUTRAL] I'm I'm looking at the claim. I do you wanna resubmit a corrected claim?
[CUSTOMER][NEUTRAL] So we have to change the place of service and can submit a contract claim, right?
[AGENT][NEUTRAL] It was a claim for date of service.
[AGENT][NEUTRAL] [PII] for $78.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Weston Clinic
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, I
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Yeah, I'm looking at the HICA we received the CMS 1500 places service 11 CPT 73562 modifier 26 and RT.
[AGENT][NEUTRAL] This is how we received the claim.
[CUSTOMER][NEUTRAL] OK, let me check whether what we have sent. Just give me a moment on that.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, [PII], we have sent with places of 22 only. Could you please recheck again once if you don't mind, Cross.
[AGENT][NEUTRAL] Yeah, I, I'm looking at it right now. I've got it pulled up.
[AGENT][NEUTRAL] So if you want to submit a corrected claim, um, you can do that.
[CUSTOMER][NEUTRAL] So by changing the place of service we need to submit a correct claim by [PII] place of service.
[CUSTOMER][NEUTRAL] Right?
[AGENT][NEUTRAL] If that's what the where the services were rendered.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] But they've also met their outpatient dollar amount for the year, so if even if you submitted a corrected claim, it wouldn't be paid because they've maxed out their dollar amount.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] So this claim will not be processed as the patient made the dollar amount per year, per year, how much is the dollar amount for this patient?
[AGENT][NEUTRAL] 2500.
[CUSTOMER][NEUTRAL] OK. Like may I know the last date of service which has been met with the amount?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So, we can bill the patient for this, right?
[AGENT][NEUTRAL] We can't instruct on patient responsibility, we're a secondary policy.
[CUSTOMER][NEUTRAL] OK. Just give me a moment.
[CUSTOMER][NEUTRAL] Thank you for being on hold, [PII]. As for checking upon checking from my end, on [PII], we haven't received any payments and we haven't billed any claim.
[AGENT][NEUTRAL] It's for different providers.
[CUSTOMER][NEUTRAL] As you say, dollar amount has been made.
[AGENT][NEUTRAL] It was built by a different provider.
[CUSTOMER][NEUTRAL] Even for the different provider uh.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] Let me check again.
[AGENT][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Yes, I'm here. Just one moment, I'm on it checking.
[CUSTOMER][NEGATIVE] As for checking from my end for different providers, so I'm unable to find.
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] May I know the caller reference number?
[AGENT][NEUTRAL] My name is [PII] and today's date.
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][POSITIVE] Thank you, [PII], for providing me the information needed and have a great day.
[AGENT][NEUTRAL] I