AccountId: 011433970860
ContactId: d05fe16b-25a0-447a-82b1-d13ded1ceed4
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 918640 ms
Total Talk Time (AGENT): 291570 ms
Total Talk Time (CUSTOMER): 363755 ms
Interruptions: 1
Overall Sentiment: AGENT=1.8, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/09/d05fe16b-25a0-447a-82b1-d13ded1ceed4_20250109T15:29_UTC.wav
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[AGENT][POSITIVE] Good. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hello [PII]. My name is [PII]. I'm calling from provider's office. I have a member that I need to claim status for.
[AGENT][POSITIVE] [PII] it would be my pleasure to assist you with claim status today. What is a good callback number?
[CUSTOMER][NEUTRAL] Sure, that is going to be [PII].
[AGENT][NEUTRAL] Thank you, [PII]. What is the policy number for the patient?
[CUSTOMER][NEUTRAL] I'm just taking that one out, just allow me one moment.
[AGENT][POSITIVE] Take your time.
[CUSTOMER][NEUTRAL] I didn't expect it to connect this fast so yeah I was just on that.
[AGENT][POSITIVE] Well, that's a good thing, huh?
[CUSTOMER][NEUTRAL] Yeah, it, it is indeed.
[CUSTOMER][NEUTRAL] So, and I have 4 claims for the same number. So the claim number, yeah, I mean the member ID. Yeah, the member ID is 019641777.
[AGENT][POSITIVE] Not a problem.
[AGENT][POSITIVE] Thank you, [PII]. It would be my pleasure to assist you with all 4 claim statuses for the patient. What is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII], and date of birth is [PII].
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] And what is the date of service for the first claim?
[CUSTOMER][NEUTRAL] So that is going to be [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So the total bill for this one is $1,052 even.
[AGENT][NEUTRAL] Thank you. And what is the facility name?
[CUSTOMER][POSITIVE] Optima.
[AGENT][NEUTRAL] Is it, will it be the same facility for all claims?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] All right. I'm getting that claim information for you.
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] And that claim Ganish we did receive on [PII].
[AGENT][NEUTRAL] And it was processed on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim was denied because the outpatient benefit for the Mac uh for this calendar year has been met.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] To Max Benefits met.
[CUSTOMER][NEUTRAL] OK, what is going to be the claim number for this one?
[AGENT][NEUTRAL] This claim number is 352.
[AGENT][NEUTRAL] 3988.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] OK. So I do have the access to the portal. So I just need the claim number to check what happened on it correctly. So you're saying that the outpatient benefit for this calendar has been met. Could you tell me how much was the limit?
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Sure, that is under the outpatient benefit. Let me get that amount for you.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it is a calendar year maximum of $4000. Now that is a verification of coverage and not a guarantee of payment.
[CUSTOMER][NEUTRAL] And that was um could you tell me, uh, till which date it was completed?
[AGENT][NEUTRAL] Now I can't give you the date of service but it was maxed out on [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] The balance that would be that would come under member responsibility I believe.
[AGENT][NEUTRAL] Well, we're secondary, not major medical, so we do not determine patient responsibility that would be determined by the provider.
[CUSTOMER][NEUTRAL] Understood.
[CUSTOMER][NEUTRAL] OK, so I was able to see the claim here, but I'm trying to look if I'm able to open the EOB. Allow me one moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And even if I'm not able to do so, is it possible for you to maybe email me or fax me the CV?
[AGENT][POSITIVE] Well, if you can get it from the portal, that's gonna be a lot quicker for you.
[CUSTOMER][NEUTRAL] Yeah, I was just checking that I'm, it's just uh taking a little longer.
[CUSTOMER][NEUTRAL] I think it's, yeah.
[CUSTOMER][NEUTRAL] I got it.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so, yeah, treatment now.
[CUSTOMER][NEUTRAL] The claim number, yeah, the claim number is matching 3988. Yeah, that's the one.
[CUSTOMER][NEUTRAL] OK. I do have the access for the UOBs.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][POSITIVE] And we can always fax it, but if you can get it from the portal, it's a lot quicker. You have it instantly you don't have to wait for a fax.
[CUSTOMER][NEUTRAL] Yeah, could we move on to the
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, but OK, what I'm trying to understand is I, I, I did understand what you said that it being, uh, it was maxed out but the data service was for June, uh, wouldn't that, I mean, could you help me out with that?
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] Sure, so we process claims in order that we receive them.
[AGENT][NEUTRAL] And the claim, the benefit was maxed out prior to receiving your claim.
[CUSTOMER][NEUTRAL] Understood.
[CUSTOMER][NEUTRAL] Uh huh OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] OK, could we move on to the next claim, uh, if I'm able to get the claim number I should be able to get the UB as well.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Absolutely. What's that next data of service?
[CUSTOMER][NEUTRAL] So that would be for [PII].
[AGENT][NEUTRAL] And what is that bill amount?
[CUSTOMER][NEUTRAL] That would be $57 even.
[AGENT][NEUTRAL] Checking that one.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] $57 even?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm checking, there's a lot of claims. Do you have the um.
[AGENT][POSITIVE] The first CPT code and I can pull it up that way quicker.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so, yeah, I believe it might have gotten split. So, OK, yeah, for this one, the CBD that I'm showing here is there are two codes. One is [PII].
[AGENT][NEUTRAL] 85369.
[CUSTOMER][NEUTRAL] 8
[CUSTOMER][NEUTRAL] 79 85379.
[AGENT][NEUTRAL] 79.
[CUSTOMER][NEUTRAL] And the the code that is billed with this one is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Got it. Thank you so much for that. I appreciate that.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And that claim we received on [PII] processed on [PII] and denied for the same reason, maximum benefit met for the calendar year.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] Got it. Can I please get the claim number for this one?
[AGENT][NEUTRAL] 352-398-2
[CUSTOMER][NEUTRAL] Got it.
[AGENT][POSITIVE] And I'm ready for the next data service just whenever you are. Take your time.
[CUSTOMER][POSITIVE] Thank you so much for that.
[CUSTOMER][NEUTRAL] Next service that's going to be the same as well. [PII] for the total charge $17.17.
[AGENT][NEUTRAL] Do you have that CPT? There's looks to be a lot of claims.
[CUSTOMER][NEUTRAL] OK, so the CBD for this one, that's going to be uh $17.
[CUSTOMER][NEUTRAL] 9:30.
[CUSTOMER][NEUTRAL] It is 86431.
[AGENT][NEUTRAL] Right.
[AGENT][POSITIVE] Thank you. I appreciate that as well.
[AGENT][NEUTRAL] That claim we received on.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Gotta put on that received date. Do you need the receipt date or just the claim number?
[CUSTOMER][NEUTRAL] Uh, it would be nice, uh, the received date and the process date. I get it.
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Not a problem.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Getting that pulled up, bear with me.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] That was received on [PII] and processed on.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] Denied for the same reason and that claim number is 352.
[AGENT][NEUTRAL] 3999.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, it is 352-3 and the last three digits are three consecutive lines.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][POSITIVE] 352-399-99. Got it. Thank you so much, [PII]. And this one last claim that I needed. Uh.
[AGENT][NEUTRAL] Yes sir.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So for the date of service that would be [PII].
[AGENT][NEUTRAL] That bill amount?
[CUSTOMER][NEUTRAL] Total charge is $1050 even.
[AGENT][NEUTRAL] 1050.
[CUSTOMER][NEUTRAL] 52, yes. 1052.
[AGENT][NEUTRAL] And again that's for data service 7-Eleven.
[CUSTOMER][NEUTRAL] Yes, ma'am.
[AGENT][NEUTRAL] Now I have a claim on file for that data service but not for that amount.
[CUSTOMER][NEUTRAL] OK, I think I might have given you the wrong one. Let me give, let me check again.
[CUSTOMER][NEUTRAL] Because along with those claims have a bunch of claims here on my end so I was just sorting them out.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][POSITIVE] Thank you so much for holding. Uh, yeah, I've got it. So, it is, the the charge amount for this one is $343 even, $343.
[AGENT][POSITIVE] Perfect. Alright, thank you. Now that claim we received on [PII] and processed on [PII].
[AGENT][NEGATIVE] Now this claim was denied as office visits are not covered under the patient's plans, it's not covered.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK, so one moment.
[CUSTOMER][NEUTRAL] Office visits are not covered in the member plan.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can I get the claim number for this one, please?
[AGENT][NEUTRAL] 352.
[AGENT][NEUTRAL] 3996.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 352-399-96
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Got it. So, OK, let me just see.
[CUSTOMER][NEUTRAL] I was able to check for the two of the EOBs. I'm checking for this one as well.
[CUSTOMER][NEUTRAL] I'm sure it comes, it's just that I have to be sure.
[AGENT][POSITIVE] Absolutely, I understand.
[CUSTOMER][POSITIVE] Thank you so much for that, [PII]. And how's your day going so far? I'm sorry, I didn't ask.
[AGENT][POSITIVE] It's going good. How about you?
[AGENT][NEUTRAL] I didn't either. I was all about this is good.
[CUSTOMER][POSITIVE] It's going good as well.
[AGENT][NEUTRAL] Is it cold where you are?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][MIXED] It is, it is a little the time that we're, it, it is fall over here so it's kind of lovely uh this might not like the little cool but it's it's fine for me.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] I really enjoy it. Yeah, so 123. OK.
[CUSTOMER][NEUTRAL] And also [PII], before that, uh, I wanted to know if, uh, do you happen to have any fax number that we could send any medical records to if they are asked.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Or any additional information for the claims mhm.
[AGENT][NEUTRAL] Absolutely. We do have a claims fax number and that is 877.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 365.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 942 3.
[AGENT][NEUTRAL] And that comes straight to our claims department.
[CUSTOMER][POSITIVE] Got it, thanks so much.
[CUSTOMER][NEUTRAL] Yeah, attention at claims department you said right?
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] Got it. And what would be the initial claim timely filing?
[AGENT][NEGATIVE] For it claims there's no timely filing.
[AGENT][NEUTRAL] Oh, there's only a, a limitation for an appeal.
[CUSTOMER][NEUTRAL] OK, what's that going to be?
[AGENT][NEUTRAL] 180 days from the date of denial.
[CUSTOMER][NEUTRAL] DOD and no TFO.
[CUSTOMER][NEUTRAL] Understood.
[CUSTOMER][POSITIVE] And yeah, I was able to look for all the UBs and and I got them. Thank you so much, [PII]. I would just need the call reference number for this [PII].
[AGENT][NEUTRAL] Call reference number is my name and today's date, and I spell my name [PII].
[AGENT][POSITIVE] And [PII], it was such a pleasure to assist you with that claim status. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][POSITIVE] That would be it. You have been to me, [PII]. You have a wonderful day.
[AGENT][POSITIVE] I hope you have a wonderful day as well, [PII]. Thank you for calling APL. Take care.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Bye bye.