AccountId: 011433970860
ContactId: e7225b76-966e-48f0-b897-2aeb56ceb72c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 856669 ms
Total Talk Time (AGENT): 243711 ms
Total Talk Time (CUSTOMER): 254120 ms
Interruptions: 2
Overall Sentiment: AGENT=0.3, CUSTOMER=-0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/03/e7225b76-966e-48f0-b897-2aeb56ceb72c_20250603T13:34_UTC.wav
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[AGENT][NEUTRAL] Calling APL, this is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] calling for the provider to check on the claim status. Please be informed that this call is being recorded and monitored for quality and training purposes. So, may I know how can I help you with the patient's information or the provider's information?
[AGENT][POSITIVE] [PII], can I have a callback number for you just in case the call is disconnected and I'll be able to assist you.
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] It's [PII]. No extension, it will be a direct line.
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And what is the policy number of the member that you're calling to check the status of a claim for and I'll be able to assist you.
[CUSTOMER][NEUTRAL] It's 02434990. M as in Mike, L as in Lima, 8.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Thank you, [PII]. Could you verify that patient's name and date of birth?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] It's [PII]. The date of birth will be [PII].
[AGENT][NEUTRAL] And what is the date of service that you're calling about?
[CUSTOMER][NEUTRAL] [PII] and the charges will be
[CUSTOMER][NEUTRAL] Just a second.
[CUSTOMER][NEUTRAL] $1,146 even.
[AGENT][NEUTRAL] What is the procedure code for your claim?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Just a second.
[CUSTOMER][NEUTRAL] The procedure code will be.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 24071 RT.
[AGENT][NEUTRAL] Thank you. So there was no payment made on this claim, and the reason why there was no payment, [PII], is because the policy, the benefits were maxed out by the time your claim made here, the yearly benefits were maxed out.
[CUSTOMER][POSITIVE] OK. The benefits are maxed out.
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] So the services were not cover under the member's plan.
[AGENT][NEGATIVE] The services were covered, however, there were no benefits available for the for the max, the calendar year because they were maxed out.
[CUSTOMER][POSITIVE] Exactly.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] In terms of dollar or visit, is it maxed out in terms of dollars of visit?
[AGENT][NEUTRAL] Yes, dollar amount in terms of dollar amount.
[CUSTOMER][NEUTRAL] OK, just a second.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] Is there anything else that I can assist you with today?
[CUSTOMER][NEUTRAL] Uh, yeah, I do have a few questions to ask. Just a second.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So, and there will be no further payments, am I right?
[AGENT][NEUTRAL] That is correct because there are no benefits available because the benefits were maxed out. The member has $1250 per calendar year and once that that benefit has been reached and paid out, then there's no more benefits available until the following year, which is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Could
[CUSTOMER][NEUTRAL] OK. And what will be the claim received date and the process date or denial date?
[AGENT][NEUTRAL] The claim was received [PII]. It was processed and denied [PII].
[CUSTOMER][NEUTRAL] OK, could you please help me with the claim number?
[AGENT][NEUTRAL] The claim number is 358-8819. That's 3588819.
[CUSTOMER][NEUTRAL] OK. And what will be the allowed dollar amount for the services?
[AGENT][NEUTRAL] There is no allowed amount. This is a gap insurance.
[AGENT][NEUTRAL] You have to contact the primary about the allowed amount.
[CUSTOMER][NEUTRAL] Uh, no, I'm talking about a lot.
[CUSTOMER][NEUTRAL] No, I'm talking about the allowed dollar amount for the services, means how many dollars are allowed for the services.
[AGENT][NEUTRAL] There were no dollars available available [PII] is what I'm what I'm trying to express to you. So this is a gap insurance. This is not a primary. So whatever dollar amount allowed, that will be up to the primary insurance company, not this one, because we're not in network. This is not a policy that is in network with any provider.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And could you please tell me when was the last this type of services were billed?
[AGENT][NEUTRAL] I can't verify that information for you due to it not being your claim, however, the benefits were maxed out prior to your claim being received.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Could you please help me with the timely filing limit to submit the corrected claim?
[AGENT][NEGATIVE] There's no timely filing.
[CUSTOMER][NEUTRAL] What will be the mailing address to submit the corrected claim?
[AGENT][NEUTRAL] The mailing address will be the same address to submit the where you submitted the claim, which is [PII].
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes, [PII].
[CUSTOMER][NEUTRAL] OK, and what will be the timely filing limit to submit an appeal?
[AGENT][NEGATIVE] There is no timely filing.
[CUSTOMER][NEUTRAL] And appeals will go to the same address which you gave me right now.
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][NEUTRAL] OK, and is there any specific form for an appeal?
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] And the ID is required while submitting an appeal or a claim.
[AGENT][NEUTRAL] Um, I can't tell you yes or no. I just can only verify that the benefits were maxed out.
[CUSTOMER][NEUTRAL] OK, and could you please tell me your name?
[AGENT][NEUTRAL] Could you repeat yourself?
[CUSTOMER][NEUTRAL] Could you please tell me your name?
[AGENT][NEUTRAL] My name is [PII], and today's date is a reference.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] So we move to the last claim. I do have the last claim on the file.
[AGENT][NEUTRAL] For this, the same patient?
[CUSTOMER][NEUTRAL] Different patient.
[AGENT][NEUTRAL] What is that policy number, [PII]?
[CUSTOMER][NEUTRAL] The policy number for another one is 01617874 M as in Mike L as in Lima.
[AGENT][NEUTRAL] Could you verify that patient's name and date of birth?
[CUSTOMER][NEUTRAL] The patient's first name is [PII] and the last name is [PII]. The date of birth will be [PII].
[AGENT][NEUTRAL] And what is the date of service that you're calling to check the status of the claim for?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] It's
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the amount will be $810 even.
[AGENT][NEUTRAL] What is your procedure code?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] The procedure code, just a second.
[AGENT][NEUTRAL] And you said [PII], correct?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Feb.
[CUSTOMER][NEUTRAL] Yeah, [PII].
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. The procedure code is 99214.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] 152.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Claim was received [PII]. It was processed [PII].
[AGENT][NEUTRAL] But I'm not that you said it was for how much? Because I'm not showing a claim for that much.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] What was the total bill amount?
[CUSTOMER][NEUTRAL] 8
[CUSTOMER][NEUTRAL] $810.
[AGENT][NEUTRAL] Bear with me because I'm not showing a claim on file for that bill amount that you're inquiring about.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] Can I place you on a brief hold while I research this.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] Thank you, I'll be right back.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] Thank you for holding and I apologize, so I'm not showing a claim on file for $810. Could you verify the name of the provider or the facility?
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yeah, sure, just a second.
[CUSTOMER][NEUTRAL] OK. Do you have a claim on file for $640?
[AGENT][NEUTRAL] Yes, I do have a claim on file for $640 but not $810.
[AGENT][NEUTRAL] So is this the claim that you're inquiring about?
[CUSTOMER][NEUTRAL] OK, you can.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] So there was no payment made on this claim because office visits are not covered under the policy. The member's policy does not offer benefits for services received in the office because it's not covered.
[CUSTOMER][NEUTRAL] OK, just a second, give me a second.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] 17
[CUSTOMER][NEUTRAL] Just a second. OK. Could you please help me with the claim, receive date, denial date, and the claim number?
[AGENT][NEUTRAL] The claim number is 357-815-2. It's 3578152.
[AGENT][NEUTRAL] This claim was received [PII]. It was processed [PII] [PII] and denied [PII].
[CUSTOMER][NEUTRAL] And what will be the
[CUSTOMER][NEUTRAL] S
[CUSTOMER][NEUTRAL] My date of birth is [PII].
[AGENT][NEUTRAL] Is there anything else that I can assist you with today?
[CUSTOMER][NEUTRAL] And the CPD code will be 99214 which is not covered under the member's plan, am I right?
[AGENT][NEUTRAL] Yes, that is correct. The member's plan does not offer offer benefits for services received in the office or office visits.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK. And before the details will remain the same, the time, the filing limit and everything else.
[AGENT][POSITIVE] Yes, that is correct.
[CUSTOMER][POSITIVE] OK, thanks for your assistance. I hope you have a wonderful day. It was a pleasure talking to you.
[AGENT][POSITIVE] Thanks for calling APL. You have a great day. Goodbye, [PII].