AccountId: 011433970860
ContactId: da0d6c53-b17f-4e1c-a886-32c96b597e06
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 704770 ms
Total Talk Time (AGENT): 357948 ms
Total Talk Time (CUSTOMER): 126504 ms
Interruptions: 4
Overall Sentiment: AGENT=0.3, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/29/da0d6c53-b17f-4e1c-a886-32c96b597e06_20250429T12:51_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] And thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is A, uh, calling from provider's office regarding a
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Hello? Can you hear me?
[AGENT][NEUTRAL] Hello.
[AGENT][NEUTRAL] Uh, barely.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Can you hear me?
[AGENT][POSITIVE] That is better. There's just some background noise that's making it difficult.
[CUSTOMER][NEUTRAL] OK. I said my name is [PII]. I'm calling from provider's office regarding claim.
[AGENT][NEUTRAL] OK, could you please spell your name for me?
[CUSTOMER][NEUTRAL] Yeah, sure. Uh it is [PII]
[AGENT][NEUTRAL] I'm so sorry, but I can't hear you.
[CUSTOMER][NEUTRAL] I said it is [PII].
[AGENT][NEUTRAL] Thank you. And [PII], what is your callback number?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And you said that you have one claim to check status on, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so yes, sir, I can help you with that and what is the member's policy number?
[CUSTOMER][NEUTRAL] It is 01845704 M as in Mary, L as in Lima, number 8.
[AGENT][NEUTRAL] OK, thank you. Give me a moment please to get the member's information pulled up.
[AGENT][NEUTRAL] And any information that I provide for you today will be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] [PII] and date of birth is [PII].
[AGENT][POSITIVE] Thank you. One moment.
[AGENT][NEUTRAL] What is the date of service and total bill amount for him please?
[CUSTOMER][NEUTRAL] Date, date of service is [PII] with the bill amount of $4,0006 even.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] Uh, and for this claim, we have also submitted an appeal, uh, I'm checking the status for the appeal.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] It's still loading some information for me. Bear with me just a moment, please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so I do see that that was received back on [PII].
[AGENT][NEUTRAL] It was processed on.
[CUSTOMER][NEUTRAL] Uh, the claim.
[AGENT][NEUTRAL] No, the appeal.
[AGENT][NEUTRAL] You said you were needing the appeal status, was that correct?
[CUSTOMER][POSITIVE] Yes, yes. Yes.
[AGENT][NEUTRAL] And the appeal was processed on [PII]?
[AGENT][NEUTRAL] Under claim 348.
[AGENT][NEUTRAL] 8270.
[AGENT][NEUTRAL] And that claim.
[CUSTOMER][NEUTRAL] And what is the document control number?
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] Pardon me?
[CUSTOMER][NEUTRAL] The document control number?
[CUSTOMER][NEUTRAL] For the bill?
[AGENT][NEUTRAL] It's
[AGENT][NEUTRAL] It's issued under another claim number which I just provided for you.
[AGENT][NEUTRAL] 348-827-0.
[CUSTOMER][NEUTRAL] Can you please repeat?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And this appeal was upheld.
[CUSTOMER][NEUTRAL] Of her reason.
[AGENT][NEUTRAL] I can read you the letter.
[AGENT][NEUTRAL] That was issued and mailed.
[AGENT][NEUTRAL] This correspondence is in response to your letter received in our office on [PII] regarding your claimant under Jorge cardiosaosis supplemental Limited Benefit medical expense insurance plan. Your state.
[AGENT][NEUTRAL] Excuse me, you said your correspondence is a level one appeal. You said you believe the service should be considered for payment due to medically necessary services were rendered by a credential physician.
[AGENT][NEUTRAL] You state procedure code 73,060 is denied as non-covered services under the provider's contract, and the services rendered with reference to 4903 CPT code 73,060 should be included in the total reimbursement of the $2,364.46. You said according to your coding the claim and services are correctly billed. You state for the term of your contract the service type 295.
[AGENT][NEUTRAL] HUMER 3 is to be reimbursed in the amount of $1,585.71 $313,151 flat.
[AGENT][NEUTRAL] Give me just a second. I need to adjust this. One moment, OK?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] I need the viewing, I accidentally made it too large on my screen.
[AGENT][NEUTRAL] We have considered your claim and determined it was processed correctly and in accordance with the policy contract.
[AGENT][NEUTRAL] The supplemental limited benefit medical expense insurance plan under which Mr. [PII] is covered, is not a major medical plan but instead a supplemental limited medical expense insurance plan. The policy is a HIPAA expected benefit and therefore not subject to many public Health Service Act requirements, including the mandates imposed by healthcare reform.
[AGENT][NEUTRAL] Benefits payable under this policy are not based on reasonable and customary in or out of network RAP provision.
[AGENT][NEUTRAL] Or unit value. Benefits are based on
[AGENT][NEUTRAL] Excuse me, Benefits are payable based upon the applicable policy provisions. The claim form submitted to our office for Data Service 913-2023 indicates charges or for services rendered at a hospital outpatient facility. The schedule a benefits section of Mr. [PII]'s policy states the following.
[AGENT][NEUTRAL] And it states, it shows that that is not a covered place of service.
[CUSTOMER][NEUTRAL] OK, [PII], uh, I saw that the claim was denied for the outpatient benefit for this calendar year has been met. So what was the out
[AGENT][NEUTRAL] And that is correct. The conclusion states, please review the description of coverage for the above outpatient benefit amounts. The plan only allows for coverage for services shown on the schedule. The maximum payable outpatient benefit is $1500 per cover person per calendar year.
[AGENT][NEUTRAL] Covered outpatient services, the maximum payable outpatient benefit for this service was exhausted with the processing and payment of claims received prior to your claim from other providers. No benefits are payable.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what was the last date of service when the benefits were met met?
[AGENT][NEUTRAL] It was for a claim received prior to yours.
[AGENT][NEUTRAL] On
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] Just one second.
[AGENT][NEUTRAL] For a claim received in [PII].
[CUSTOMER][NEUTRAL] What's the exact date of all this?
[AGENT][NEGATIVE] It, the claim was just received prior to yours being received at all. I can't provide you another provider's information.
[AGENT][NEUTRAL] Data service was for [PII]. [PII] was the date of service the claim was received and processed for.
[CUSTOMER][NEUTRAL] Uh, no, I'm not needing all that.
[CUSTOMER][NEUTRAL] [PII] was the last date of service. Am I correct?
[AGENT][NEUTRAL] When the benefit was maxed.
[CUSTOMER][NEUTRAL] So this is patient's responsibility.
[AGENT][NEUTRAL] We do not determine patient responsibility, that would be up to the provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And [PII], uh, just for the documentation purpose, uh, I just saw that we have also sent another appeal in the month of April this year.
[CUSTOMER][NEUTRAL] [PII]. So can you check uh if you have received that appeal I need just it for the documentation process.
[AGENT][NEUTRAL] No, sir. It does not. Yes, sir. It does not show that.
[AGENT][NEGATIVE] I don't show anything received in [PII] for this number.
[CUSTOMER][NEUTRAL] Just a second.
[CUSTOMER][NEUTRAL] Can I get the call reference number?
[AGENT][NEUTRAL] Sure, you would use my name along with today's date.
[AGENT][NEUTRAL] And then in the future for claim, yes, sir, it is. Well, actually, I spell it [PII]
[CUSTOMER][NEUTRAL] It's [PII]? [PII]
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then in the future we also have a portal if you are not familiar with that age that you should be able to check claim status for our members as well.
[AGENT][NEUTRAL] And that website is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. Well, is there anything else that I can help you with today?
[CUSTOMER][NEUTRAL] No, that's all I needed.
[AGENT][POSITIVE] OK, well then, thank you so much for calling APL and I hope you have a great day.
[CUSTOMER][NEUTRAL] You too.
[AGENT][POSITIVE] Thank you. Bye-bye.