AccountId: 011433970860
ContactId: cddc2fed-dbd1-4bd2-9511-480ca361304c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1559300 ms
Total Talk Time (AGENT): 260158 ms
Total Talk Time (CUSTOMER): 305530 ms
Interruptions: 1
Overall Sentiment: AGENT=0.3, CUSTOMER=-1.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/18/cddc2fed-dbd1-4bd2-9511-480ca361304c_20250618T19:24_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] This is [PII] with APL. Can I help you?
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] This is [PII] with APL. How can I help you today?
[CUSTOMER][NEUTRAL] Hello, my name is [PII] calling from provider's office to check on a claim status. Could you please spell out your name for me for the purpose of documentation?
[AGENT][NEUTRAL] My name is [PII]
[AGENT][NEUTRAL] And you said your name was [PII]?
[CUSTOMER][NEUTRAL] Yes, [PII]
[AGENT][NEUTRAL] Can I get a good callback number in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, the callback number is [PII] with the extension of [PII].
[AGENT][NEUTRAL] And do you have the policy number?
[CUSTOMER][NEUTRAL] Yes, I do have.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Do you have the policy number?
[CUSTOMER][NEUTRAL] Are you there?
[AGENT][NEUTRAL] Can you hear me? What's the policy number?
[CUSTOMER][NEUTRAL] Yes, I do have.
[CUSTOMER][NEUTRAL] Yes, I
[CUSTOMER][NEUTRAL] Yeah, D as in Delta, 43301781.
[AGENT][NEUTRAL] Do you have anything that has the uh the policy benefit number or the policy certificate number on it?
[AGENT][NEUTRAL] That's not one of our policy numbers.
[CUSTOMER][NEUTRAL] So this is the member ID, uh, insurance ID number.
[AGENT][NEUTRAL] So is there a policy certificate number on the card?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Do you have their social security number and I can look it up that way?
[CUSTOMER][NEUTRAL] Just give me a moment.
[CUSTOMER][NEUTRAL] Uh, could you please, uh, check, uh, with the social security number of the patient?
[AGENT][NEUTRAL] What is the social security number?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Give me just a moment.
[AGENT][NEUTRAL] Can you verify the patient's name and date of birth for me, please?
[CUSTOMER][NEUTRAL] Yeah, the patients, so first name is [PII], and the last name of the patient.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the date of birth?
[CUSTOMER][NEUTRAL] Uh, date of birth of the patient is [PII].
[AGENT][POSITIVE] OK, thank you so much.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, and do you have the claim number or the date of service?
[CUSTOMER][NEUTRAL] Yeah, uh, the date of service of the claim is [PII].
[AGENT][NEUTRAL] What's the total bill amount?
[CUSTOMER][NEUTRAL] Yeah, the total bill amount of the claim is $1700 even 1700.
[AGENT][NEUTRAL] Give me just a moment.
[AGENT][NEUTRAL] It looks like we received this claim on [PII]. It was processed on [PII].
[AGENT][NEUTRAL] The claim number?
[CUSTOMER][NEUTRAL] May I know the claim number?
[AGENT][NEUTRAL] The claim number is 3458679.
[CUSTOMER][NEUTRAL] May I know the claim status?
[AGENT][NEUTRAL] It looks like the claim was denied due to the maximum benefit for that data service being met.
[CUSTOMER][NEUTRAL] Benefits is exhausted or is met, right?
[AGENT][NEUTRAL] Yes, they had already met their maximum.
[CUSTOMER][NEUTRAL] Already met us. The CPT code is 99285. Is that correct?
[AGENT][NEUTRAL] 99285, yes ma'am.
[CUSTOMER][NEUTRAL] Uh, just give me a moment. I'm just checking, uh, for the previous, uh,
[CUSTOMER][NEUTRAL] The service.
[AGENT][NEUTRAL] I'm sorry, what was that?
[CUSTOMER][NEUTRAL] Yeah, just give me a moment. I'm just checking for the details here, uh, what you have said, uh because uh the code is already, uh, I mean, uh, before the code was paid, right? So that's why this is not payable, right, you're saying.
[AGENT][NEUTRAL] Right, they had make their their benefit maximum for that, for the calendar year.
[CUSTOMER][NEUTRAL] Could you please help me with that on uh which date of service the code was paid?
[AGENT][NEUTRAL] If it's not a claim that your provider submitted, I can't give you that information.
[AGENT][NEUTRAL] But they had already met their benefit maximum for the year.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh just give me a moment. I'm just checking. Uh, 57 20244.
[AGENT][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Just bear with me. I'm just checking.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] You have said that uh the maximum we need benefits maximum is exhausted, right? If you don't mind, could you please help me with that? How many visits are there?
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Are you asking what their benefit maximum is?
[CUSTOMER][NEUTRAL] Uh-huh, you're saying visits are exhausted, right?
[AGENT][NEGATIVE] Yes, they're exhausted.
[CUSTOMER][NEUTRAL] Uh, how many visits are there?
[AGENT][NEUTRAL] Let me see.
[AGENT][NEUTRAL] Give me just one moment.
[CUSTOMER][NEUTRAL] Hello, are you there?
[AGENT][NEUTRAL] I, I'm, I'm still looking. Give me one moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] As I said, the maximum benefits are exhausted. Is this uh related to units or visits?
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] It's limited per amount.
[AGENT][POSITIVE] Just what I'm looking for.
[CUSTOMER][NEUTRAL] Sorry, sorry.
[AGENT][NEUTRAL] It goes based off of a dollar amount. It goes off of a dollar amount.
[CUSTOMER][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] OK
[AGENT][NEUTRAL] It looks like they're allotted 5 visits per calendar year.
[CUSTOMER][NEUTRAL] So, this is related to visits, right?
[AGENT][NEUTRAL] Yes, for outpatient sickness.
[CUSTOMER][NEUTRAL] And they.
[CUSTOMER][NEUTRAL] 5 visits. Could you please help me with that? Uh, when was the last visit?
[AGENT][NEUTRAL] I can't disclose that with you if it wasn't with uh your is it if it wasn't with your provider I can't disclose that.
[CUSTOMER][NEUTRAL] No, no, no. You, you only said, right, there are 5 visits. May I know the last visit?
[CUSTOMER][NEUTRAL] Date
[CUSTOMER][NEUTRAL] And the claim was denied due to maximum is exhausted, so.
[AGENT][NEUTRAL] Yes, their maximum benefit had been met already.
[CUSTOMER][NEUTRAL] Benefits. Is this related to units or is it? Could you please confirm?
[AGENT][NEUTRAL] Visits.
[AGENT][NEUTRAL] They're allowed a maximum number of visits per calendar year, 5 for an adult.
[AGENT][NEUTRAL] And children.
[CUSTOMER][NEUTRAL] So per, per year, there are 5 visits only, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] So the 5 visits already exhausted. This is the 6th visit, right, you're saying?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. Could you please help me with the, when was the 5th visit, uh, for the purpose of documentation, I'm just asking.
[CUSTOMER][NEUTRAL] Uh, when was the last visit, uh, date of service?
[AGENT][NEUTRAL] I cannot give that to you if it wasn't with your provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, so, could you please help me with that, uh, what action can we take this, uh, take to process this one?
[AGENT][NEUTRAL] You can file an appeal.
[CUSTOMER][NEUTRAL] Mm.
[AGENT][NEUTRAL] Because it's already been denied so you can file an appeal if you believe that it's an error.
[CUSTOMER][NEUTRAL] Could you please help me with the character claim timely filing limit?
[AGENT][NEUTRAL] So we don't have timely filing limits um.
[AGENT][NEUTRAL] I do have the number.
[AGENT][NEUTRAL] If you would like to send an appeal.
[CUSTOMER][NEUTRAL] So, is there any uh appeal timely filing limit?
[AGENT][NEUTRAL] No, you can file an appeal and we're allotted up to 180 days to make a decision.
[CUSTOMER][NEUTRAL] 20, 280 days is the appeal timely filing limit, right?
[AGENT][NEUTRAL] 180 days. Give me just a moment.
[CUSTOMER][NEUTRAL] 180 days from the date of denial or date of service?
[AGENT][NEUTRAL] So give me one moment for an appeal for this since it was.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The review for an appeal must be within 90 days of.
[AGENT][NEUTRAL] Must be filed within 90 days after the receipt of written notice of denial of a claim.
[AGENT][POSITIVE] So I, I apologize in advance. It's.
[CUSTOMER][NEUTRAL] So 90 days from the date of [PII], right?
[AGENT][NEUTRAL] Right, which was, let me look.
[AGENT][NEGATIVE] It looks like this was denied over 1 year ago, so it's past the 90 days to appeal.
[CUSTOMER][NEUTRAL] Uh, is there any, uh, character claim timely filing?
[AGENT][NEUTRAL] You're, you're past the right of appeals because it's been over 90 days.
[CUSTOMER][NEUTRAL] But
[AGENT][NEUTRAL] You have the right to appeal within 90 days of it being denied. It was denied um on [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Yes, but you didn't give me the proper.
[AGENT][NEUTRAL] So it would have needed to be an appeal.
[CUSTOMER][NEUTRAL] I mean, uh, you didn't give me the last visit date, so.
[AGENT][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] Uh, this is incomplete information for the documentation.
[CUSTOMER][NEUTRAL] Could you please check, is there any chance to provide the visit dates? If you don't mind, could you please check?
[CUSTOMER][NEUTRAL] Uh, if we need to appeal, we need the document, uh, proper information, right? So when was the last visit? Because the claim denied uh regarding visits, right? So I need to mention here.
[AGENT][NEUTRAL] OK
[CUSTOMER][NEUTRAL] That's why I'm asking. Please check and uh provide me the last visit dates.
[AGENT][NEUTRAL] Alright, give me just one moment, OK?
[AGENT][NEUTRAL] I'm gonna put you on hold for just a second, OK?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Alright, I'm not able to give you uh the date that they maxed out their benefits because it wasn't with your provider, but I can give you the address to file an appeal.
[CUSTOMER][NEUTRAL] they
[AGENT][NEUTRAL] Would you like the address?
[CUSTOMER][NEUTRAL] OK. Uh, could you please provide, yeah, could you please provide me the bill, uh, mailing address?
[AGENT][NEUTRAL] OK, it will be attention [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] In [PII].
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][NEUTRAL] Is there anything else I can help you with?
[CUSTOMER][NEUTRAL] Yes, please provide me the call reference number.
[AGENT][NEUTRAL] OK, so we don't have call reference numbers, but you can use my name and last initial in today's date. So [PII] and then today's date.
[CUSTOMER][NEUTRAL] May I know your last initial?
[CUSTOMER][NEUTRAL] May I know your last initial?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Thank you so much.
[CUSTOMER][POSITIVE] I got the required information from you. Have a nice day. Stay safe. Bye for now.
[AGENT][POSITIVE] Have a great day thank you for calling ATL.
[CUSTOMER][NEUTRAL] Mhm.