AccountId: 011433970860
ContactId: e4ca108e-dfc3-4664-9670-5bf75102bc5d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 663500 ms
Total Talk Time (AGENT): 197600 ms
Total Talk Time (CUSTOMER): 209675 ms
Interruptions: 0
Overall Sentiment: AGENT=0.1, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/10/e4ca108e-dfc3-4664-9670-5bf75102bc5d_20250410T15:05_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII], and I'm speaking from Piedmont Rockdale Hospital. How are you doing?
[AGENT][POSITIVE] I'm good. How are you, [PII]?
[CUSTOMER][POSITIVE] I'm also good. Thank you so much for asking. Uh, can you please help me with the claim the land reason?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Yes, ma'am. I can assist you with claim status. Um, first I'll need a good callback number just in case we're disconnected.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you. Now I need the policy number, please.
[CUSTOMER][NEUTRAL] The policy number is 02443965.
[AGENT][NEUTRAL] Thank you. Now, please verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Patient's name is [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK, thank you. Now I need the date of service and bill charges on the claim.
[CUSTOMER][NEUTRAL] The date of service is on [PII] and the bill charges are $3,866.20.
[AGENT][NEUTRAL] OK, one moment, please.
[AGENT][NEUTRAL] OK. Yes, ma'am. I'm showing that we received that claim on [PII].
[AGENT][NEUTRAL] The claim was processed on Feb [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And I'm showing that this claim denied because under the policy for outpatient benefits, we cover up to $50 per day and that benefit was maxed out on a previous claim, so that's why this claim denied.
[CUSTOMER][NEUTRAL] OK, uh, can you please repeat that line again?
[CUSTOMER][NEGATIVE] It's denied us, you have, uh, you will cover only 50%.
[AGENT][NEUTRAL] We will only cover, we will only, we will only cover $50 per day for outpatient services.
[CUSTOMER][NEUTRAL] Of inpatient?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, can you please help me with that in which claim uh or uh in which?
[CUSTOMER][NEUTRAL] So with uh this.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] It has been covered?
[AGENT][NEUTRAL] The policy was, uh, the claim, the benefit was maxed out on a previous claim on a claim for the same date of service that was submitted before this claim, and that's why this claim denied. So what information do you need?
[CUSTOMER][NEUTRAL] Uh, I just needed the claim number, but let me check if I do have this.
[CUSTOMER][NEUTRAL] Uh, so.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So for the same date of service.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] But we don't have any claims for the same date of service. So can you please help me with the same number?
[AGENT][NEUTRAL] Yes, the claim number is 34163772.
[CUSTOMER][NEUTRAL] Just
[CUSTOMER][NEUTRAL] And uh it belongs to the same date of birth [PII]. That's the claim number on which I am speaking to you.
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] This is uh the claim on which we have built the services. There is no other claim.
[CUSTOMER][NEUTRAL] For the same date of August.
[AGENT][NEUTRAL] All right, because, yeah, because the other claim was for a different provider. I can give you that claim number it was for a different provider, but it was the same date of service and we received their claim first, so that's why their claim um paid out but your claim denied because by the time we received your claim.
[CUSTOMER][NEUTRAL] But as
[CUSTOMER][NEUTRAL] OK, so, but as the facilities are different, so that this claim can cannot be inclusive with the other claims that belongs to different facility.
[AGENT][POSITIVE] That's correct.
[CUSTOMER][NEUTRAL] So can you please send back the screen for review again?
[AGENT][NEGATIVE] It'll be denied again because the benefit maximum for this date of service have been reached.
[AGENT][NEUTRAL] It's been already paid out on a previous claim, but yes, you can submit it again. What information do you need to resubmit the claim?
[CUSTOMER][NEUTRAL] Like
[CUSTOMER][NEUTRAL] Uh, I want you to, uh, send back this claim for review as we have submitted the emergency room CPT on this claim. It is 99284 and the whole claim is denied as you are saying that it was already uh like paid under the different claim.
[AGENT][NEUTRAL] Yes, for the same date of service. Yes, ma'am.
[CUSTOMER][NEUTRAL] But uh as it belongs to the different facility, so it can't be inclusive with this claim. So please uh send back this claim for review and please mention that uh it can be inclusive with the different facility claim.
[AGENT][NEUTRAL] What information do you need?
[CUSTOMER][NEUTRAL] Uh, we need, uh, like we need a payment on this claim.
[CUSTOMER][NEGATIVE] As it was, it is denied incorrectly.
[AGENT][NEUTRAL] No, it wasn't. We cover up to
[AGENT][NEUTRAL] Uh, $75 per day for outpatient services, and that benefit was maxed out on a previous claim for the same date of service, ma'am.
[AGENT][NEUTRAL] The benefits for this date of service have been maxed out.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Can you please be here uh for a minute?
[CUSTOMER][NEUTRAL] Just a second.
[AGENT][NEUTRAL] Sure, sure.
[CUSTOMER][NEUTRAL] OK, uh, yes, please send back the screen for review.
[AGENT][NEUTRAL] Well, I can't send the claim back for review, but you can resubmit it. Would you like to resubmit the claim for review? I can't send it back, but you can resubmit it if you like.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] But why you uh will not be able to send back the same for review?
[AGENT][NEUTRAL] We don't send claims back for review, ma'am, but you can resubmit a claim. That's not how it works. We don't send claims back for review.
[CUSTOMER][NEUTRAL] OK. Uh, can you please be here for a minute?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Just a second please.
[CUSTOMER][NEUTRAL] Please be here.
[CUSTOMER][NEUTRAL] OK. Uh, please provide me the information, uh, with which claim and the facility, uh, this claim is inclusive with.
[AGENT][NEUTRAL] What information do you need?
[CUSTOMER][NEUTRAL] Uh, with, like, I need the information of the claim with which this claim or the services are inclusive that uh on which you have paid uh amount.
[CUSTOMER][NEUTRAL] For a different facility.
[AGENT][NEUTRAL] For SummitRadilogy Services, we received their claim for date of service [PII] before we received your claim, and the benefit maximum of $75 for that day was paid out on this claim. That claim number is, do you need the claim number?
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] The claim number is 3408621.
[CUSTOMER][NEUTRAL] OK. And please uh uh provide me the facility name again.
[AGENT][NEUTRAL] SummitRadilogy Services.
[CUSTOMER][NEUTRAL] And uh you have paid the amount of $75 on that claim?
[AGENT][NEUTRAL] Yes, ma'am.
[CUSTOMER][NEUTRAL] Just a second, please.
[CUSTOMER][NEUTRAL] Uh, please provide me your name again. I wasn't unable to write it down and uh please provide me the reference number.
[AGENT][NEUTRAL] Yes, the reference number is my name and today's date. My name is [PII] and it's spelled [PII] My last initial is [PII], and again, my name and today's date is the reference number. Is there anything else I can assist you with?
[CUSTOMER][NEUTRAL] Uh, no, that's all.
[CUSTOMER][POSITIVE] Thank you so much for your time. Have a great day. Bye bye.
[AGENT][NEUTRAL] Mm.