AccountId: 011433970860
ContactId: c8c2baae-d18a-4747-999d-3f3343f1b244
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 3392080 ms
Total Talk Time (AGENT): 1052889 ms
Total Talk Time (CUSTOMER): 1177898 ms
Interruptions: 7
Overall Sentiment: AGENT=0.4, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/c8c2baae-d18a-4747-999d-3f3343f1b244_20250109T17:28_UTC.wav
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[AGENT][POSITIVE] Thank you for calling. This is Ape Angel. How can I help you?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] This is [PII]. We are calling from service to checking on planes.
[AGENT][NEUTRAL] What is your callback number [PII]?
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] What is your callback number?
[CUSTOMER][NEUTRAL] Yeah, sure, I'll call back number is [PII], no extension.
[AGENT][NEUTRAL] Thank you, what is the policy number?
[CUSTOMER][NEUTRAL] OK, so the number ID is 025.
[CUSTOMER][NEUTRAL] 446 84.
[AGENT][NEUTRAL] OK, let me repeat that to you. I have that as 02544684. Thank you.
[AGENT][NEUTRAL] Verify the patient's name.
[AGENT][NEUTRAL] And date of birth?
[CUSTOMER][NEUTRAL] Sure, so, mhm. So the business name is [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you for the verification process. I have that number pulled up. Again, you're calling for claim status. I can assist you now. You can also check claim status by visiting our secure portal at [PII], and on that website is where you will obtain an EOB as well. What is that date of service and the total charge amount please?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm mhm.
[CUSTOMER][NEUTRAL] Sure. And the data service falls on [PII] and the total bill amount is $691 even.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Can you verify the procedure codes billed for the service dates for the member?
[CUSTOMER][NEUTRAL] Yeah, sure, so we have the procedure code under the claim 99214 and the other CPT code is 76,810.
[AGENT][POSITIVE] OK. Thank you very much for the information, [PII]. One moment, please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It shows that the claim was received on [PII] and processed on [PII].
[AGENT][NEUTRAL] It shows that we made a maximum payment of $50 with a single paper check.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] The payment is $50.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] So and so the
[CUSTOMER][NEUTRAL] Pay was paid with 50 $50.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm. And before that we need to know the allotment of the claim. So could you please provide the amount of amount of the claim.
[AGENT][NEUTRAL] The allowed amount for the policy for this claim was $50 for the office visit procedure code 999214.
[CUSTOMER][NEUTRAL] And I'm, I'm a little bit, I mean your voice is getting in and out so for the CPT code.
[CUSTOMER][NEUTRAL] 99214.
[CUSTOMER][NEUTRAL] I know the amount of $50.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Just the $50 or maybe 2 cents.
[AGENT][NEUTRAL] $50 is the allowed amount and the paid amount.
[CUSTOMER][NEUTRAL] OK, and may I know the other CPT code amount and paid amount.
[AGENT][NEGATIVE] Per the policy, we paid $50 max for the visit and that was for the procedure code 99214. We did not make a payment on 76816.
[CUSTOMER][NEUTRAL] May I know why you didn't make a payment for the CBD17816?
[AGENT][NEUTRAL] Because the allowed amount, the maximum allowed amount was paid for procedure code 99214.
[CUSTOMER][NEUTRAL] Mhm. Maximum allowed amount is $50 and you guys possibly $50 until the CPT code 99214, is that right?
[AGENT][NEUTRAL] We paid $50 for 99214, that is correct.
[CUSTOMER][NEUTRAL] Because
[CUSTOMER][NEUTRAL] Mhm. And you mentioned that so the number of complaint is $50 and may I know as per your policy or as per your
[AGENT][NEUTRAL] It's for the patient's policy.
[CUSTOMER][NEUTRAL] Uh, OK, so as for the patient passing, so under the claim, the maximum allowed amount is $50 and you guys pass the allowed amount under the CPT code 99214, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Mhm. And you mentioned that so the CPT code 76816, no, no, I mean didn't make any payment under the CPT code and is there any specific reason for
[CUSTOMER][NEUTRAL] The CPT code 76816 is not payment. Did you have any exact information or specific reason for that? Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] The specific reason again, is because we made the maximum payment of $50 on procedure code 99214, and this is for the patient's plan.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, and I really need to know, so the maximum amount of the paid amount for $50 is for only the CPD code [PII] or the old claim.
[AGENT][NEUTRAL] The allowed amount is $50 max for an office visit, for a sick visit, which this was for a sick visit. We pay the $50 max for procedure code 99214. That is the maximum that we will pay.
[AGENT][NEUTRAL] For this particular claim.
[CUSTOMER][NEUTRAL] Mhm. So for office visits, so the maximum allowed amount of uh $50 right.
[AGENT][NEUTRAL] Correct, and that was paid for procedure code 99214.
[CUSTOMER][NEUTRAL] Mhm and you stated that so only 6 offices is all like that you mentioned, right? May I know that what is that?
[AGENT][NEUTRAL] I'm sorry, I'm sorry, I mentioned what? If you could repeat what I mentioned.
[CUSTOMER][NEUTRAL] Information?
[CUSTOMER][NEUTRAL] Yes, and you mentioned that so.
[CUSTOMER][NEUTRAL] Receipt or this is only covered under the patient plan like that you mentioned right something.
[AGENT][NEUTRAL] I mentioned that per the patient's policy, the maximum that we will pay is $50 for an office visit.
[CUSTOMER][POSITIVE] OK, got it. And so thank you for the information, and you mentioned that the payment was paid with the $50. And may I know the mode of payment?
[AGENT][NEUTRAL] You're welcome. It was a single paper check.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, and may I know the check number?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] 202-075-5
[CUSTOMER][NEUTRAL] Mm and just confirm that the number is 2020755.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Mhm and may I know when it was issued?
[AGENT][NEUTRAL] The check was issued on [PII].
[CUSTOMER][NEUTRAL] OK, and may I know whether the check this.
[CUSTOMER][NEUTRAL] Cash or not.
[AGENT][POSITIVE] Currently the check shows outstanding.
[CUSTOMER][NEUTRAL] OK, thank you. And could you please confirm the date order and let me check.
[AGENT][NEUTRAL] The pay to address, is that correct? You want me to verify?
[CUSTOMER][NEUTRAL] Yes, we need to verify the paper address.
[AGENT][NEUTRAL] OK, yes. The check was mailed to Community Medical Associates, [PII].
[CUSTOMER][NEUTRAL] OK, perfect. And so, and is there uh is there a chance to send the copy of the year with your fax number?
[AGENT][NEUTRAL] In order to get a copy of the UOB, you can visit the website that I provided at the beginning of the call, and that is [PII]. You can also check claim status there as well.
[CUSTOMER][NEUTRAL] OK, so the, the portal name is [PII]?
[AGENT][POSITIVE] Yes, correct.
[CUSTOMER][NEUTRAL] OK, thank you for the information. And actually, I have to do one more claim for the same patient, so can I forward the next claim?
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What is the date of service and the total charge amount?
[CUSTOMER][NEUTRAL] Mhm sure and the details of call on.
[CUSTOMER][NEUTRAL] [PII] and the total charge amount is $26 even.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That was [PII]. Is that correct?
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and the total charges again please?
[CUSTOMER][NEUTRAL] $26 even and actually I didn't, I mean then ask to I mean I for the class that claim number for the previous claim so could you please provide the claim number for the previous claim it will be very useful for us. Mhm.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] The claim number shows 354-0474.
[CUSTOMER][POSITIVE] OK perfect thank you.
[AGENT][NEUTRAL] You're welcome. OK. So again, that total bill amount for [PII] is 2626.00, is that correct?
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you. One moment.
[AGENT][NEUTRAL] And verify that procedure code billed, please.
[CUSTOMER][NEUTRAL] Yeah, mhm, sure, so the code will be billing the same as 36415.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, it shows that the claim was received on [PII].
[AGENT][NEUTRAL] Give me 1 2nd.
[AGENT][NEUTRAL] Actually, the claim was received on [PII] and processed on [PII] and the charges were denied. One moment, please.
[CUSTOMER][NEUTRAL] It's
[AGENT][NEGATIVE] It did not is a non-covered benefit or non-covered service.
[AGENT][NEUTRAL] By the policy?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so the claim must be made as as non-covered service or non-covered benefit.
[CUSTOMER][NEUTRAL] Right? And we need to know either is that um our service or benefit as by the patient plan as or the provider contract.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] For the patient's plan.
[CUSTOMER][NEUTRAL] Mhm. And could you please confirm what, what is, I mean, why the, I mean, what, uh, the patient doesn't have the benefits or why the claim was not covered as per the member's benefit plan.
[AGENT][NEGATIVE] It shows that it was denied.
[AGENT][NEGATIVE] It shows that it was denied as via puncture is not covered by this policy.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEGATIVE] Vena puncture is not covered by the policy. The service was not covered by the policy.
[CUSTOMER][NEUTRAL] OK, so it means under vacation policy, so the any budget is not covered under the patient policy, is that right?
[AGENT][POSITIVE] That is right.
[CUSTOMER][NEUTRAL] OK, thank you. And so we need to, upon checking now again, so we didn't see any UB for this claim, so we need to know that we need to receive the UB and we need to know whether this be responsible for the patient or may know that information because as per the patient plan this is not out right so the patient will be responsible for the amount.
[AGENT][NEUTRAL] APL does not determine patients responsibility.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] APL does not determine patient's responsibility, so I cannot tell you this is patient's responsibility. I'm not sure if the member has any other insurance but APL does not determine patient's responsibility.
[CUSTOMER][NEUTRAL] Mhm. I need to know it because you mentioned that you denied the claim as as for the patient policy. The service is not covered after the patient benefits plan. So either if the patient are secondary or any other insurance, we have to build the other insurance, no problem. But we need to know whether it's comes, I mean this is the patient responsibility or the provider responsibility to know right? Could you please check that UOB whether under the UOB mentioned that patient responsibility or the provider responsibility.
[AGENT][NEUTRAL] OK, um, [PII], APL does not determine patients responsibility. We're not contractually involved with the handling of any remaining claim amount, so therefore again, APL does not determine patients responsibility.
[CUSTOMER][NEUTRAL] So it means and
[CUSTOMER][NEUTRAL] Yeah I didn't mention any patient responsibility, right?
[AGENT][NEUTRAL] APL does not determine patients responsibility.
[CUSTOMER][NEUTRAL] You said it like IPL right India Papa Lima.
[AGENT][NEUTRAL] American Public Life or APL does not determine patients responsibility.
[CUSTOMER][NEUTRAL] OK, thank you. And so actually upon checking our end so we didn't see any UB for this claim, so we need to get the UOB so if you send the copy of the UB through our fax number.
[AGENT][NEUTRAL] OK, and again, [PII], you are able to obtain ELBs from that website that is [PII]. So let me provide you with the claim number.
[AGENT][NEUTRAL] The claim number is 3529589.
[CUSTOMER][NEUTRAL] Mm, OK, just give me one second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I want checking again, so I am able to log in the provider portal you mentioned that [PII].
[AGENT][NEUTRAL] Secured. [PII].
[CUSTOMER][NEUTRAL] Mhm and so far it on so we need to.
[CUSTOMER][NEUTRAL] Need to log in the.
[CUSTOMER][NEUTRAL] Portal, right, we need to log in for the portal, right?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so thank you for um for and so you will not send the copy of the UB through fax number, right? We need to get the UB through the provider portal.
[AGENT][POSITIVE] Correct, that is correct, yeah, through the provider's portal.
[CUSTOMER][NEUTRAL] Bye.
[CUSTOMER][NEUTRAL] Mhm. And upon checking in for the portal, be unable to access the portal that I'm asking to send the copy of the UB through fax. So could you please send the copy of the UB.
[AGENT][NEUTRAL] As a courtesy I can send it through fax. What is your fax number?
[CUSTOMER][NEUTRAL] OK, sure, and the tax number is.
[CUSTOMER][NEUTRAL] Just give me 1 2nd.
[CUSTOMER][NEUTRAL] OK, so the fax number is [PII].
[CUSTOMER][NEUTRAL] 289.
[CUSTOMER][NEUTRAL] [PII] you can mention attention my name [PII].
[CUSTOMER][NEUTRAL] And if you don't mind, so, and we need to get that the previous claim EOB also, so if we send the both of the claims EOB, it is very useful for us once we receive the EOB. So kindly send the both claims EOB.
[AGENT][NEUTRAL] OK, [PII], I will fax over both claim numbers as 354-047-4 and 352958-9 to fax number provided [PII] attention [PII].
[CUSTOMER][POSITIVE] Perfect. And I said I didn't catch your name. So, so would you please spell out your name for me?
[AGENT][NEUTRAL] My name is [PII], that is [PII] My last initials [PII] We do not provide reference numbers. You can use my name and today's date, [PII]. Is there anything else I can assist you with? Yes.
[CUSTOMER][NEUTRAL] And and
[CUSTOMER][NEUTRAL] Yeah, sure, [PII], I have to verify with you one more patient. So if you help me with that patient also, so can I provide the
[AGENT][NEUTRAL] One moment please. One moment, [PII], one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, OK, sure.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] What is the policy number, [PII]?
[CUSTOMER][NEUTRAL] Mhm, sure, so the policy number is.
[CUSTOMER][NEUTRAL] 025.
[CUSTOMER][NEUTRAL] 12377
[AGENT][NEUTRAL] Verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Sure, so the member's name is [PII] and date of birth is [PII].
[AGENT][NEUTRAL] What is the date of service and build out please?
[CUSTOMER][NEUTRAL] Sure, so the deduct falls on [PII], and the total charge amount is $336 even.
[AGENT][NEUTRAL] OK, it shows that the claim was received and no payment was made. One moment please, like get the information for you when it was received and processed and denied.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] OK, that claim shows received on [PII].
[AGENT][NEUTRAL] 2 excuse me, [PII] processed and denied on [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] As office visits are not covered by the policy.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm. So you mentioned that, so the under the patient plan, right, under the patient plan only the office is not called, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] Correct
[CUSTOMER][NEUTRAL] Mhm and so previously you mentioned right?
[CUSTOMER][NEUTRAL] You don't know any.
[CUSTOMER][NEUTRAL] APL not determine the patient responsibility, right?
[AGENT][NEUTRAL] Um, as I say it before previously, APL does not determine patients responsibility.
[CUSTOMER][NEUTRAL] Mhm. And so and why I'm asking again and again again for this question is we need to know that
[CUSTOMER][NEUTRAL] Because you didn't the claim like so the and the after the patient plan so this is not covered I mean not been able to apply for the aeration plan, right? That's why you need to know whether we we need to go to patient or we need to write off the claims or we need to adjust the contract to adjustment as to the provider. That's I'm asking to you whether under the U and also we need to get that EOB. So once we need to get the UOB, then only we decide we either we have to build the claim to patient or we need to.
[CUSTOMER][NEUTRAL] Adjust the contractual adjustment as per the pro the write off. So that is why I am asking to you that.
[CUSTOMER][NEUTRAL] What is the, I mean, whether it is goes to patients responsibility or the internet provider right uh you mentioned that clearly I mean IPL, I mean APL not determine the patient's responsibility. I completely understand that.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Again,
[AGENT][NEUTRAL] I'm sorry.
[AGENT][NEUTRAL] OK, now with this particular claim, uh, claim number 352-8920, actually the claim denied because the office visit max have been met for the year, so my apologies for that. So it did cover office visits. It's just that the maximum number allowed for the year had been used, so that's why we did not this particular claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so, uh, OK, so now you mentioned like, so the maximum a lot of office.
[CUSTOMER][NEUTRAL] That rate already existed, right?
[AGENT][NEUTRAL] Correct, has been already met prior to this receiving this claim, but again, APL does not determine the patient's responsibility.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, I understand that. And so you mentioned, right, so the, uh, maximum offices will be exited, so we need to know how many offices allowed for the patient, uh, as per the policy like we need to know, right?
[AGENT][NEUTRAL] The numbered allow is 4 office visits per year and 4 had already been used.
[CUSTOMER][NEUTRAL] OK, so 4 office businesss per year, right? And also previously the 4 offices is covered, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, sure, and thank you for the information providing to me, and could you please send the copy of the UB because I'm unable to log in the provider portal right uh right time and so kind.
[AGENT][NEUTRAL] Would be sent to the same fax number [PII]. OK, attention [PII].
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Yeah, exactly, and so, so, uh, kindly send that EOB. So once, once we get the UOB, then only we need to decide, right, what we do next action for this claims either we have to build the patient or we need to build the second or any other insurance. So we need to get the, I mean we need to.
[CUSTOMER][NEUTRAL] Determine that once the UOB, then only we need to move the next action for those clients so that's why I'm asking for the UOB.
[AGENT][NEUTRAL] Um, [PII], um, I will fax over the EOB's to fax number.
[AGENT][NEUTRAL] [PII]. OK, is there anything else I can help you with?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh yes, I need to check it out one more data service.
[AGENT][NEUTRAL] Is it for the same patient?
[CUSTOMER][NEUTRAL] Yes, same patient.
[AGENT][NEUTRAL] What is that date of service and the bill amount?
[CUSTOMER][NEUTRAL] Just give me one
[CUSTOMER][NEUTRAL] Yeah, sure, just give me one second.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, so the date was on [PII], and the total charge amount was $1,466 even.
[AGENT][NEUTRAL] OK, [PII] $1,466 even.
[AGENT][NEUTRAL] And what procedure codes were billed for the service date for the member?
[CUSTOMER][NEUTRAL] Mhm. And so we build the multiple position cos like 99214961279939690656 I mean 90656913209047190480.
[AGENT][NEUTRAL] OK 9936.
[CUSTOMER][NEUTRAL] 7 CPT codes will be under the claim.
[AGENT][NEUTRAL] 2967.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, shows that the claim was received and all claims were all lines were denied shows it denied as for the same reason. The maximum number of office visits had been met for the year.
[AGENT][NEUTRAL] Which again was 4.
[CUSTOMER][NEUTRAL] On
[CUSTOMER][NEUTRAL] And, and, and so per year as per the business plan, so the offices is allowed is only 4 weeks as per the as per year, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm. And if you don't mind, could you please provide, uh, because, so the allowable office visit is 48. May I know when was the 4 visits met.
[AGENT][NEUTRAL] 4 visits have already been paid. Would you like the claim number for this particular claim date of service? I can provide it to you.
[AGENT][NEUTRAL] OK, that claim number shows.
[CUSTOMER][NEUTRAL] OK, and can you forward the details.
[CUSTOMER][POSITIVE] My number as well as under the claim it's a plus.
[AGENT][NEUTRAL] The claim number for date of service of [PII] is 3,536,650.
[CUSTOMER][NEUTRAL] Sorry, could you please provide the [PII] after [PII] claim number?
[AGENT][NEUTRAL] It is 353-665-0.
[CUSTOMER][NEUTRAL] The bill amount is $1,466.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm. And could you please send the copy to you for the detail claim UOB?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] And the same number.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And may I know how long it will be within the apps?
[AGENT][NEUTRAL] Um, it'll be sometime today if not tomorrow, but you'll be quicker to get it on the online service center, but they'll be faxed over to you, [PII]. Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] OK, sure, so we need.
[CUSTOMER][NEUTRAL] Mhm. And you, we need to know, right, so the allowable I mean allowable 4 per year we need to know when will be all, I mean when will be met the allowable units or allowable.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] It as one of the all of the if it's met.
[AGENT][NEUTRAL] I do not have the information, [PII]. I do not have information, [PII]. I do not, um, is there anything else I can assist you with?
[CUSTOMER][NEUTRAL] And I, yes, I need to verify one more service for the patient.
[AGENT][NEUTRAL] Wait, is that data service, you please, yes please do.
[CUSTOMER][NEUTRAL] Can I go ahead and make that.
[CUSTOMER][POSITIVE] OK, yeah, yeah, thank you one moment.
[AGENT][NEUTRAL] Do you have that date of service yet, [PII]? OK, thank you.
[CUSTOMER][NEUTRAL] OK, so the next, yes, yes, I have it. Mhm. The data was on [PII], and the total charge amount was $348 even.
[AGENT][NEUTRAL] And what procedure codes were billed for this service date for the member?
[CUSTOMER][NEUTRAL] Uh, sure, so the code is 83036800508230682607.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, shows that the claim was received on [PII].
[AGENT][NEGATIVE] Processed and denied [PII] and denied as, give me one second please, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It kind of shows that the max number of office visits had been met for the year.
[AGENT][NEUTRAL] And that claim number is 352-438-9.
[CUSTOMER][NEUTRAL] Mhm and this claim also didn't have the same reason as the maximum.
[CUSTOMER][NEUTRAL] OK this is already met.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] And once you receive the EOBs, it will state that on the explanation of benefits.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And how about this I just.
[CUSTOMER][NEUTRAL] And I like
[CUSTOMER][NEUTRAL] Laboratory services.
[CUSTOMER][NEUTRAL] But still you guys didn't have the maximum offices is already made for the same claim also right.
[AGENT][NEUTRAL] It states that the calendar year maximum for outpatient office visits has been met for this calendar year for this particular claim.
[CUSTOMER][NEUTRAL] Mhm. And as per outpatient offices per year is 4 as per the patient plan, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK, sure, thank you. And for this claim also we need to get UB. So if you don't mind, so could you be sending copy of the UB through the sameS number.
[AGENT][NEUTRAL] I can. Mhm.
[CUSTOMER][NEUTRAL] Mhm. And so [PII] we need to know um is that uh I mean under the UB is there any information?
[CUSTOMER][NEUTRAL] I mentioned and you be right like how many, I mean, how much it is allowed or what is the reason for the claim denied. So all the information.
[AGENT][POSITIVE] It will have on the EOB the explanation of benefits what I just read to you it will be on the EOB, yes.
[CUSTOMER][NEUTRAL] Having the
[CUSTOMER][NEUTRAL] So all information mentioned in the expression of the right.
[AGENT][NEUTRAL] The reason why I did not would be mentioned on the explanation of benefits.
[CUSTOMER][NEUTRAL] OK, sure.
[CUSTOMER][POSITIVE] Thank you for the information and just give me one moment.
[CUSTOMER][POSITIVE] OK thank you and so.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Mhm, I have to wait for with you one more claim, so can I provide an extra the service?
[AGENT][NEUTRAL] I'm sorry, [PII].
[AGENT][NEUTRAL] Do you have another date of service for the same member?
[CUSTOMER][NEUTRAL] I have
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, give me one moment, OK?
[CUSTOMER][NEUTRAL] Oh yeah, sure.
[AGENT][NEUTRAL] And again you are able to check claim status by visiting that secure website.
[AGENT][NEUTRAL] Providers can do that. What is the date of service and the bill amount, please?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, sure, so the data was on [PII], and the total charge amount is $336 even.
[AGENT][NEUTRAL] $336 even. OK, is that for procedure code 99214?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, it shows that we made a maximum payment of $50 on this date of service, which is the max allowed for an office visit per visit.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That was paid with a paper check.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Is it single check or bulk check?
[AGENT][NEUTRAL] A single paper check.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, are you ready for the check number?
[CUSTOMER][NEUTRAL] I know, I know.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] 2006927
[CUSTOMER][NEUTRAL] Sorry, the number is 2006927.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] May I know when the check was issued?
[AGENT][NEUTRAL] Certainly.
[AGENT][NEUTRAL] The check was issued on [PII] and cleared [PII].
[CUSTOMER][NEUTRAL] Mhm, could you just confirm the pay to address?
[AGENT][NEUTRAL] Community Medical Associates [PII] [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, thank you, [PII] and [PII], could you please send the copy of the with the same fax number so then only we need to know that.
[CUSTOMER][NEUTRAL] Information about the claim. So kindly send the copy of the UB the same fax number.
[AGENT][NEUTRAL] OK, are we done with this number, [PII]? Anything else I can help you with?
[CUSTOMER][NEUTRAL] Um, just give me one second.
[CUSTOMER][NEUTRAL] Alright
[CUSTOMER][NEUTRAL] OK, and so I have one more to about the same patient, and can I provide the service.
[AGENT][NEUTRAL] I'm sorry, give me one moment, [PII]. I'm gonna transfer you to this department that can help you better, but in regards to the claims that we went over, I will get those faxed over to the fax number of [PII]. Now that's a total of 123456. OK, so give me one moment, I'm gonna transfer your call to that department, OK? One moment please.
[CUSTOMER][NEUTRAL] Yeah, and before, yeah, before that, and so we will be the you will be within 22 22 hours to 48 hours, right?
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] The it'll be be faxed over to you, [PII], OK? It'll be they will be faxed over to you, OK? Give me one moment to put you on hold to transfer you, OK? One moment.
[CUSTOMER][NEUTRAL] One
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] [PII], how many more days of service do you have for this member?
[CUSTOMER][NEUTRAL] And I have to verify it.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] 4 claims are 2 for the same number so kindly as will be.
[CUSTOMER][NEUTRAL] Other for claims.
[AGENT][NEUTRAL] OK, how many more claims again? I'm sorry for this number.
[CUSTOMER][NEUTRAL] Yeah, full names [PII].
[AGENT][NEUTRAL] So 4 more claims for this member.
[CUSTOMER][POSITIVE] Yes, exactly.
[AGENT][NEUTRAL] And do you have another member after this particular member [PII]?
[CUSTOMER][NEUTRAL] No, no, this is the last number, so I have only 4 clients, so kindly ask the our clients.
[AGENT][NEUTRAL] What is the date of service?
[CUSTOMER][NEUTRAL] Uh, sure, so the data was on [PII] and the total bill amount is $337 even.
[AGENT][NEUTRAL] OK, [PII] and what was that billed amount?
[CUSTOMER][NEUTRAL] And the total charge amount is $337 even.
[AGENT][NEUTRAL] $37 even, OK.
[AGENT][NEUTRAL] And was the procedure code 99203?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, it shows a maximum of $50 paid for that date of service for that office visit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And many of the mode of payment?
[AGENT][NEUTRAL] Single paper check.
[CUSTOMER][NEUTRAL] Mhm. May I know the number?
[AGENT][NEUTRAL] Mhm one moment.
[AGENT][NEUTRAL] Check number shows 2006648. Again, that's 2006648.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that was mailed to the same address as mentioned previously?
[CUSTOMER][NEUTRAL] May I know the date?
[AGENT][NEUTRAL] The receipt date?
[CUSTOMER][NEUTRAL] No, I know when the check was issued.
[AGENT][NEUTRAL] The check was issued on [PII] and it cleared as of [PII].
[CUSTOMER][NEUTRAL] OK, thank you. And so the maximum allowed amount of our office is $50 and you guys, you guys probably pay for $50. May I know the remaining balance?
[AGENT][NEUTRAL] $50.
[AGENT][NEUTRAL] APL does not determine patient responsibility. [PII], we're not contractually involved.
[CUSTOMER][NEUTRAL] OK, and so kindly send the copy of you will be the only we need to know, right? So could you please send the copy you be with the same fax number.
[AGENT][NEUTRAL] Of course, [PII], of course, [PII]. Yes. What's the next date of service?
[CUSTOMER][NEUTRAL] OK, thank you, [PII], and just give me one second. So the next data service falls on.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] OK, so the next for on [PII] and the total charge amount is.
[CUSTOMER][NEUTRAL] $453 even.
[AGENT][NEUTRAL] OK, it shows that we made a payment in the amount of $50 max for an office visit. Give me one moment to get that information for you.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] OK, that was paid with a single paper check and that check number shows 2006649 again that's 2006649.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That check was issued on [PII] and cleared as of [PII] and that claim number shows 3514791.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, thank you [PII], can you send the copy of your withdrawal with the same fax number.
[AGENT][POSITIVE] Yes, thank you. What's the next date of service?
[CUSTOMER][NEUTRAL] Um, just one moment.
[CUSTOMER][NEUTRAL] So the next so it falls on.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the total charge amount is $336 even.
[AGENT][NEUTRAL] OK, [PII], OK.
[AGENT][NEUTRAL] OK, so the check was made or payment was made, sorry, in the amount of $50 max for this date of service. One moment please get the claim details for you.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] That was check number again that was a single paper checks check number 2006651.
[AGENT][NEUTRAL] 2006651.
[AGENT][NEUTRAL] Mailed to the same address as previously mentioned. Check has cleared as of [PII] issued on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that claim number shows 351-479-5.
[AGENT][NEUTRAL] And I'm ready for that last date of service for this member.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] The claim number shows.
[CUSTOMER][NEUTRAL] May I know the claim number one month?
[AGENT][NEUTRAL] Yes, of course, 351-479-5.
[CUSTOMER][NEUTRAL] OK. And so, and, and we need to know, right? So you mentioned that the maximum of uh for office visit is $50. And is that as per the patient plan or you as per the policy you'll be having like each of the patients or or
[AGENT][NEUTRAL] This is part of the patient's plan. This is for the patient's plan, yes, the payments have been per the patient's plan with APL.
[AGENT][NEUTRAL] OK, I'm ready for that last date of service please.
[CUSTOMER][NEUTRAL] OK, so, and just confirm that, so as per the patient plan only you paid the amount of $50 as per the office visit, right?
[AGENT][NEUTRAL] Correct. Per the patient's policy with APL, the max payable is $50 for an office visit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So it's very from each patient, right?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEUTRAL] OK, no, it, it's very, it varies from each patient's right. So if any other patient having any plan, so, uh, the plan will pay more than $50 for office visit each office visit, right? So it's based upon the patient plan, right.
[AGENT][NEUTRAL] These benefits are based on the patient's plan.
[CUSTOMER][POSITIVE] OK, got it, thank you and OK, I can move the.
[CUSTOMER][NEUTRAL] Next to the servicers one moment mhm.
[AGENT][NEUTRAL] The last date of service, thank you.
[CUSTOMER][NEUTRAL] OK, just give me one moment. I my is slow.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, you can check claim status on the secure website for the last date of service for the member. Is there anything else I can help you with, [PII]?
[CUSTOMER][NEUTRAL] Oh yeah
[CUSTOMER][NEUTRAL] Yeah, I have the the deductible was on [PII], and the total charge amount was $228 even.
[AGENT][NEUTRAL] OK, and we received the claim and no benefit was paid on this particular date of service. It shows that the maximum allowed office visits.
[AGENT][NEUTRAL] Had been met so no payment was made on this and that information will be on the explanation of benefits and the claim number shows 3514797. Let me get the information when it was received and denied if you need that as well.
[CUSTOMER][NEUTRAL] Mhm. Could be a year before this claim and you mentioned that so.
[CUSTOMER][NEUTRAL] The maximum number of office visit is already exceeded, right, so that's why the claim was no payment right.
[AGENT][NEUTRAL] That is correct and that will be on the explanation of benefits.
[CUSTOMER][NEUTRAL] Mhm. And so, um, [PII], you mentioned that so for the [PII], so the office visit is maxim office is mid rate, but our we receive the payment from after July, right? So, uh, August September or October we received the payment for the office visit site. May I know how it is possible.
[CUSTOMER][NEUTRAL] Because um you mentioned that too.
[AGENT][NEUTRAL] The claims are processed in the order of the claims are processed in the order they are received. Now if you want to know any in depth information, I can transfer you to that department. Um, I can do that for you, but I can send those EOBs and it will be if not today tomorrow. Is there anything else I can help you with, please, [PII]?
[CUSTOMER][NEUTRAL] And so may I know when was the claim was received for the last claim?
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] We
[CUSTOMER][NEUTRAL] That
[AGENT][NEUTRAL] The last claim was received on [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah, OK, so you mentioned that, so how they receive the claims, right? They only take claims process, right, upon checking our end. So you mentioned that the claim was received on [PII]. So after Jo service we received payment for office visits, but this claim only you didn't that the maximum allowed unit is reached, right? And you also mentioned that as per year, so the four offices is only met, right? I mean allowed for 4 offices which is at the efficient plan.
[AGENT][NEUTRAL] OK, I'm sorry, let me transfer you to the department to get a better understanding. OK? Give me one moment. I'm gonna place you on hold and transfer your call again. This is in regards to the office visits for Mr. [PII]. OK, give me one moment, OK.
[AGENT][NEUTRAL] And they'll be able to to uh go in depth with you as to why, OK?
[CUSTOMER][NEUTRAL] You know
[CUSTOMER][NEUTRAL] And may, may I know why you transfer the claim to other department? They are the placing the claims.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I did not process the claims now I was helping out with this department. You are asking more in depth questions which I cannot answer, so I'm transferring you to the department, but I was able to assist you with claim status.
[AGENT][NEUTRAL] So I'm going to transfer you to your call, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] One moment please thank thank you.
[CUSTOMER][NEUTRAL] Mhm sure.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] On APL, this is [PII]. How may I help you?
[AGENT][NEUTRAL] Good afternoon [PII]. Hi, this is [PII]. I have a provider on the line, [PII]. I have gone over claim status with several claims for a particular member under policy number 2512377.
[AGENT][NEUTRAL] He wants to know um.
[AGENT][NEUTRAL] Like I said, I have several claims I've already gone over with him now he wants to know why some were paid after the.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I told him that they are processed in the in order they are received now he does have questions as to why some were paid after a certain date, um, so I.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] So for instance, the last two claims I have 351-47997, that's [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That one I think the 9 797 yeah and then we had one for.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 351-4795.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then we had, let's see.
[AGENT][NEUTRAL] 351-479-1.
[AGENT][NEUTRAL] OK, and 4789.
[AGENT][NEUTRAL] That's just a list of few, uh, yeah, but um, he wants to know. I told him that per the policy only 4 office visits are allowed per year.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And we are not responsible for any type of um responsibility we don't determine that, but he wants to know why some were paid I guess after we.
[AGENT][NEUTRAL] It was
[AGENT][NEUTRAL] He wants to know why.
[CUSTOMER][NEUTRAL] Some office visits were paid, is, is, is they all the same provider?
[AGENT][NEUTRAL] Um, I didn't go in depth as far as the provider, as far as specific provider, but they're with community, um.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][POSITIVE] Community medical associates, so it's very well made by different.
[AGENT][NEUTRAL] Doctor.
[AGENT][NEUTRAL] But he wants to know why some were paid after.
[AGENT][NEUTRAL] We say the max was allowed.
[CUSTOMER][NEUTRAL] OK, I'll have to look at some of the claims that he's referring to that he's questioning.
[AGENT][NEUTRAL] OK, so, OK, so, um, 351-479-97, that's the last 13.
[CUSTOMER][NEUTRAL] Mhm. OK.
[AGENT][NEUTRAL] 351-479-5
[AGENT][NEUTRAL] 351479-1
[AGENT][NEUTRAL] Another is 351-4789 and he if he asks you tell him I will get all of them faxed over [PII] [PII] sometime today.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So all those claims that were processed on.
[CUSTOMER][NEUTRAL] Looks like 108 of 24.
[CUSTOMER][NEUTRAL] So the 791-795.
[CUSTOMER][NEUTRAL] I'll just talk to him, just send them to me.
[AGENT][POSITIVE] OK, good luck with that. OK, um, his name is [PII], and again, I'm sure, I'm sure he'll ask you again, tell him if you would please. I'll get all of those you'll be.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Fax over to him sometime today.
[CUSTOMER][NEUTRAL] OK, will do.
[AGENT][POSITIVE] Alright thank you one moment please, [PII], thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Yeah, yeah.
[AGENT][POSITIVE] OK, thank you so much, [PII]. I have [PII] on the line. She's going to assist you further, and I will get those you'll be faxed over to you, OK? Thank you so much. And her name is [PII]. Take care.