AccountId: 011433970860
ContactId: c854b0f1-eac6-4970-9a80-c4aad44e7053
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 573919 ms
Total Talk Time (AGENT): 149959 ms
Total Talk Time (CUSTOMER): 251760 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/06/c854b0f1-eac6-4970-9a80-c4aad44e7053_20250606T17:07_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL speaking. May I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] and I'm calling for a provider to check on additional information about the claim that has been denied. Please note this call will be monitored and recorded for quality and training purposes. How was your day?
[AGENT][NEUTRAL] OK, um, sorry, hold on one second.
[AGENT][NEUTRAL] And your name is again?
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, and go, what is that policy number, please?
[CUSTOMER][NEUTRAL] Member ID number is 01893470.
[AGENT][NEUTRAL] OK, thank you. And do you have a callback number in case the call drops?
[CUSTOMER][NEUTRAL] [PII]. It's a direct line with no extension.
[AGENT][NEUTRAL] OK, thank you. And the patient's name, date of birth?
[CUSTOMER][NEUTRAL] Patient's first name is [PII]. Last name [PII]. Date of birth, [PII].
[AGENT][NEUTRAL] OK, and what was the date of service and amount of the charge?
[CUSTOMER][NEUTRAL] [PII] and the bill amount is uh
[CUSTOMER][NEUTRAL] Yes, just a moment, please. The amount is $240 I think, so just a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, can I take a look at.
[CUSTOMER][NEUTRAL] The date of service is [PII] and the bill amount is $240 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And the name of the provider's office?
[CUSTOMER][NEUTRAL] The facility name is, it's Progressive Medical Management.
[AGENT][NEUTRAL] OK, I'm sure that claim process as office visits are not covered for the policy.
[CUSTOMER][NEUTRAL] So office visits are not covered under the member's plan, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Thank you. May I know the member's plan name, please?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]. Thank you. And the uh claim number of this claim is 360.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 1051.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Thank you. And this claim is uh last processed on, it is on [PII].
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh [PII]. Thank you. And before moving to the last line, could you please spell your name for me?
[AGENT][NEUTRAL] Sure, [PII].
[CUSTOMER][NEUTRAL] Can I have the call reference number before moving to the next line?
[AGENT][NEUTRAL] You may use my name in today's date.
[CUSTOMER][POSITIVE] Thank you. And uh
[AGENT][NEUTRAL] The next claim is it for the same patient or a different patient?
[CUSTOMER][NEUTRAL] Different patient as well as the different.
[AGENT][NEUTRAL] OK. One moment, please.
[CUSTOMER][NEUTRAL] Provider
[CUSTOMER][POSITIVE] Please take your time. How do you pronounce your name, if you, if you don't mind?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] That's nice.
[AGENT][POSITIVE] Mhm. Thank you.
[AGENT][NEUTRAL] For the service.
[AGENT][NEUTRAL] 2
[AGENT][NEUTRAL] OK. And what is the next policy number?
[CUSTOMER][NEUTRAL] The member ID number is 945131.
[AGENT][NEUTRAL] OK. Uh, patient's name, date of birth?
[CUSTOMER][NEUTRAL] Patient's first name is [PII]. Last name [PII]. Date of birth [PII].
[AGENT][NEUTRAL] OK, data service amount of the charge.
[CUSTOMER][NEUTRAL] Uh, data services.
[CUSTOMER][NEUTRAL] It's December, [PII] of [PII]. And the total bill amount, uh, the total charge amount is, it is, just a moment. It is
[CUSTOMER][NEUTRAL] I think it is $325 even.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] The name of this provider?
[CUSTOMER][NEUTRAL] Uh, the name of the provider, uh, facility is, it's foot, ankle, and leg specialist of.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] So [PII] mhm.
[AGENT][NEUTRAL] OK, I show on this claim, we paid $25 which is the max benefit payable.
[CUSTOMER][NEUTRAL] You
[CUSTOMER][NEUTRAL] Uh, we have submitted an appeal on [PII].
[CUSTOMER][NEUTRAL] Under the mailing address [PII]. May I know the status of that appeal?
[AGENT][NEUTRAL] Well,
[AGENT][NEUTRAL] Uh, it shows a P. It shows a claim being received again and it was processed as a duplicate.
[CUSTOMER][NEUTRAL] So a pill is, uh, it's like a duplicate one, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] And that was denied on.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Is there any case number?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Oh, well,
[CUSTOMER][NEUTRAL] What about the uh status of the code?
[AGENT][NEUTRAL] OK, what is the code?
[CUSTOMER][NEUTRAL] Uh, sorry, it's 99204 and the code 73,630 with modifa of LT. Both were denied and.
[AGENT][NEUTRAL] Well
[CUSTOMER][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] The 99204 initially paid 25, the other code processed as, give me a moment.
[AGENT][NEUTRAL] Is the benefits of Max for the calendar year.
[CUSTOMER][NEUTRAL] But the frequency is exceeded or the unit is exceeded for that code?
[AGENT][NEUTRAL] I'm sorry, say that again.
[CUSTOMER][NEUTRAL] Whether the maxis unit or the frequency.
[AGENT][NEUTRAL] I guess you say unit because they or a frequency I'm sorry because they have up to 4 visits per year and they've already maxed it with that payment of the claim.
[CUSTOMER][NEUTRAL] May I know when it was, when the last frequency was exceeded?
[AGENT][NEUTRAL] The claim that you're inquired about now.
[AGENT][NEUTRAL] Where we pay the $25 that match the benefit for the year.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] $23. So in the, so,
[CUSTOMER][NEUTRAL] The co-pay that was sent by the primary is $50. You have made the $25 made payment of $25 right? So benefit has been reached.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thank you. So the remaining $25 will be patient responsibility our providers right now.
[AGENT][NEUTRAL] We can't give patient responsibility. We can only verify how the claim was processed.
[CUSTOMER][NEUTRAL] So the, so the remaining amount will be the provider's rate of, right?
[AGENT][NEUTRAL] I can't say either way. I can only verify how the claim was processed.
[CUSTOMER][NEUTRAL] But we cannot bill the patient.
[AGENT][NEUTRAL] I did not say that. I am not saying that. I'm saying that you need to contact the patient because we pay $25 and with that payment, it matched their benefits. We can only verify claim status. We cannot give patient responsibility or tell you as a provider to write it off.
[CUSTOMER][NEUTRAL] OK, thank you. The claim number of this claim is 3591803.
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Thank you. And
[CUSTOMER][NEUTRAL] This claim is last processed on
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] No, this was process. Well, yes, sorry, [PII].
[CUSTOMER][NEUTRAL] And just call spelling of your name and the today's date is a call reference as well as well.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thank you. Well, thank you, [PII], for assisting me today, kindly. Have a great day.
[AGENT][POSITIVE] You're welcome. You too, Glad one. Thank you for calling APL. bye.
[CUSTOMER][NEUTRAL] Bye.