AccountId: 011433970860
ContactId: dbacac30-6734-40a4-ba97-49400d71ac13
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 390690 ms
Total Talk Time (AGENT): 171761 ms
Total Talk Time (CUSTOMER): 102149 ms
Interruptions: 0
Overall Sentiment: AGENT=0.7, CUSTOMER=0.8
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/19/dbacac30-6734-40a4-ba97-49400d71ac13_20250319T18:31_UTC.wav
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[AGENT][POSITIVE] Thanks for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi [PII], you're calling from provider's office to check on a status.
[AGENT][NEUTRAL] Sure, are you just calling to check the status of a claim?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Sure, I can assist you with that. Can I have your name and a callback number?
[CUSTOMER][NEUTRAL] Before you proceed, I'll let you know this call will be recorded for quality and training purpose. And uh my name is [PII] and callback number is [PII].
[AGENT][NEUTRAL] I could barely hear you, ma'am. Could you repeat your name?
[CUSTOMER][NEUTRAL] Yeah, [PII]
[CUSTOMER][NEUTRAL] And phone number is [PII].
[AGENT][NEUTRAL] Did you say [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Did you say [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Thank you and what's your call back number?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] And you're calling to check the status of a claim for what policy number?
[CUSTOMER][NEUTRAL] 02221656 M as in Mike. L as in Lima, number 8.
[AGENT][NEUTRAL] Thank you. And could you verify the patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] and date of birth is [PII].
[AGENT][NEUTRAL] And what is the date of service that you're calling to check the status of a claim for and I'll be able to assist you?
[CUSTOMER][NEUTRAL] [PII] and the amount is $619 even.
[AGENT][NEUTRAL] And what are your procedure codes?
[CUSTOMER][NEUTRAL] 7681776819.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] So it looks like we received the claim [PII]. It was processed [PII]. There was a payment of $419.12 paid on that claim.
[CUSTOMER][NEUTRAL] Yes, after that, claim deni for the primary. So you already sent the primary on [PII].
[AGENT][NEUTRAL] Yes, correct, but you did send in the EOB, but then we made a payment of $419.12. Would you like that check number? Because the check was sent out on the [PII]. It was cash [PII].
[CUSTOMER][NEGATIVE] After payment is received, we call the denial of deny of primary reason.
[AGENT][NEUTRAL] So for the claim that I'm verifying for procedure code of 76817 and 76819, there was a payment of $419.12 sent out [PII] and then you guys cashed the check [PII].
[CUSTOMER][NEUTRAL] OK. So there is a remaining balance or in the code 76819, which is 138.17 cents. So it is contractual and uh it is discounted rate or what?
[AGENT][NEUTRAL] No, the member's benefit were maxed out.
[CUSTOMER][NEUTRAL] OK. So,
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So we pay what was remaining for the yearly max and after that we paid the remaining that was left over for the yearly max it was maxed out so that's why you only got that amount instead of the full amount that the patient responsibility was.
[CUSTOMER][NEUTRAL] OK. So the remaining amount is patient responsibility, correct?
[AGENT][NEUTRAL] So we're not a primary insurance company so I can't get tell you that. I can only verify what we pay and the reason why we only pay that amount.
[CUSTOMER][NEUTRAL] OK, so, uh,
[CUSTOMER][NEUTRAL] Is the patient is outpatient or what?
[AGENT][NEUTRAL] Could you repeat yourself?
[CUSTOMER][NEUTRAL] Yeah. Could you please confirm the patient is outpatient or what?
[AGENT][NEUTRAL] Is this member's benefits or outpatient is $3500 per calendar year, and this is not a guaranteed benefits, just a disclaimer of the policy's coverage.
[CUSTOMER][NEUTRAL] How can you, could you please confirm when it was last maxed out?
[AGENT][NEUTRAL] So, the benefit were maxed out on your claim.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] That's why we didn't make the full payment on that procedure code that you're inquiring about.
[CUSTOMER][NEUTRAL] Could you please provide me that data service when was it maxed out?
[AGENT][NEUTRAL] The date of service that the benefits were maxed out is for your date of service as expressed before.
[AGENT][NEUTRAL] If the benefits were maxed out before prior to your data service, then there would have been no payment made on your claim. However, there was a payment made on your claim for both of those procedure codes. It's just when we got to one of those procedure codes, it was maxed out and we only pay what was remaining.
[AGENT][NEUTRAL] When we got to procedure code of 76819, the only remaining balance that she had left was $127.09 which we paid towards the 265 26, which was the patient responsibility.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Is there anything else that I can assist you with today?
[CUSTOMER][POSITIVE] Mm thank you so much. Could you please explain me the call reference number?
[AGENT][NEUTRAL] We don't provide those, unfortunately. However, [PII], you can use my name in today's date as a reference. It's [PII], and today's date.
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] Thanks for calling APL. Have a good day. Goodbye.
[CUSTOMER][POSITIVE] Have a great day. Bye-bye.