AccountId: 011433970860
ContactId: e8ba19c5-fd67-46b1-a953-dc098d1923f0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1188640 ms
Total Talk Time (AGENT): 399566 ms
Total Talk Time (CUSTOMER): 367775 ms
Interruptions: 6
Overall Sentiment: AGENT=0.7, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2024/12/31/e8ba19c5-fd67-46b1-a953-dc098d1923f0_20241231T19:16_UTC.wav
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[AGENT][NEUTRAL] Good afternoon thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII] calling for the provider's office. And this callers need to get additional information on a claim that has been denied. Please be informed that this call will be recorded and monitored for quality and training purposes.
[AGENT][NEUTRAL] OK, [PII], you're needing additional information on the denied claim, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, I can help you with that. And what is your callback number?
[CUSTOMER][NEUTRAL] [PII]. This a direct line?
[AGENT][NEUTRAL] Thank you and the member's policy number?
[CUSTOMER][NEUTRAL] Member ID is 02117402.
[AGENT][POSITIVE] Thank you. One moment, please.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And any information that I do provide for you today, [PII] will be a verification of benefits and not a guarantee of payment. What is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient, first name is, one moment. [PII], last name is [PII]
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Date of birth, [PII].
[AGENT][NEUTRAL] Thank you. date of service and total bill amount, please.
[CUSTOMER][NEUTRAL] Data services on [PII]. And the total cha
[AGENT][NEUTRAL] I'm sorry, November. Say that. I, I need you to repeat the date again, please.
[CUSTOMER][NEUTRAL] Yeah, yeah, um.
[CUSTOMER][NEUTRAL] Yeah, OK. Yeah, it is number [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] For $494 even.
[AGENT][NEUTRAL] And the claim number?
[CUSTOMER][NEUTRAL] Claim number, one moment.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] 35,400
[CUSTOMER][NEUTRAL] 07.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and how can I help you with that?
[CUSTOMER][NEUTRAL] Yeah, it is denied needing services were under after coverage is terminated. Can I have the patient policy?
[AGENT][NEUTRAL] Yes, sir, this policy.
[CUSTOMER][NEUTRAL] Yeah, one moment.
[AGENT][NEUTRAL] One.
[CUSTOMER][NEUTRAL] Can I have the policy of
[AGENT][NEUTRAL] The effective date was.
[CUSTOMER][NEUTRAL] Yeah, go ahead, sorry.
[AGENT][NEUTRAL] That's OK. [PII].
[AGENT][NEUTRAL] And the term date is [PII].
[CUSTOMER][NEUTRAL] OK, thank you. Can I know the any other active coverage for my data service?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] No, sir, there is not.
[CUSTOMER][POSITIVE] OK. Thank you. And I do have
[AGENT][NEGATIVE] Not with our company.
[CUSTOMER][NEUTRAL] Yeah, I do have a few more patients. Could you please help me on that?
[AGENT][NEUTRAL] Oh, you didn't say that you had more than one patient. So you'll need to give me some time to make my note on each one.
[CUSTOMER][POSITIVE] Yeah, sure. Take your time. And uh
[AGENT][NEUTRAL] How many patients do you have?
[CUSTOMER][NEUTRAL] 4.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Including this
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And the next member's policy number?
[CUSTOMER][NEUTRAL] Member ID, uh, yeah, and before that, can I know that uh single call reference number for each patient or?
[AGENT][NEUTRAL] Will be my name in today's date.
[CUSTOMER][NEUTRAL] Uh, single.
[AGENT][NEUTRAL] For each one it would be my name and today's date and also for each one any information that is provided will be a verification of benefits and not a guarantee of payment and lastly, [PII], if there's any of them that you need a copy of the explanation of benefits.
[CUSTOMER][POSITIVE] OK. Thank you.
[AGENT][NEUTRAL] You can obtain that by going to our portal at [PII].
[CUSTOMER][NEUTRAL] Thank you. Member ID is 02117402.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] That's the same one you just gave me.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Yeah, I'm sorry, just for the same patient.
[CUSTOMER][NEUTRAL] OK. Yeah, one.
[AGENT][NEUTRAL] So you have another data service for the same patient?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Day of service and total bill amount.
[CUSTOMER][NEUTRAL] Number 18, 20244
[CUSTOMER][NEUTRAL] $455.12.
[AGENT][NEUTRAL] Claim number?
[CUSTOMER][NEUTRAL] Claim number.
[CUSTOMER][NEUTRAL] It does
[CUSTOMER][NEUTRAL] 3539395.
[AGENT][NEUTRAL] OK. So that claim was also denied for the same reason as the other one, and I gave you the effective and termination date on this policy.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Thank you. And there is no other active queries for the data service, right?
[AGENT][NEUTRAL] Yes, sir. For this number, there is no other active coverage. The policy terminated 71, and there is no other coverage beyond that time.
[AGENT][NEUTRAL] With APL
[CUSTOMER][POSITIVE] Thank you. And so I'm on to the next question.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Is it a different patient or is it a different data service for the same policy number?
[CUSTOMER][NEUTRAL] Different patient.
[AGENT][NEUTRAL] OK, so let me make a note regarding this claim on this member's policy.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and the next number is policy number?
[CUSTOMER][NEUTRAL] Uh that's D delta 41203471.
[AGENT][NEUTRAL] OK, now that is not a number, that is a 90 degree benefit number. I can't look up the member's information with that number. Do you have the APL policy number?
[CUSTOMER][NEUTRAL] 02563342.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient, first name is [PII]. Last name is [PII]. Date of birth, [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] Data service and total bill amount.
[CUSTOMER][NEUTRAL] [PII] for $918 even.
[AGENT][NEUTRAL] And you just said data service is [PII], is that correct?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the claim number.
[CUSTOMER][NEUTRAL] Claim number one moment.
[CUSTOMER][NEUTRAL] 353-9501
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and how can I help you with this claim?
[CUSTOMER][NEUTRAL] And denied stating, we are awaiting information to confirm eligibility from benefits in the card.
[AGENT][NEUTRAL] OK. So this claim has
[CUSTOMER][NEUTRAL] Could you please provide me additional information?
[AGENT][NEUTRAL] OK, so this claim has now been processed.
[AGENT][NEUTRAL] And there was, um, let's see, just one moment.
[AGENT][NEUTRAL] This claim was processed on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] There was a benefit paid in the amount of $75.
[AGENT][NEUTRAL] That was paid on, do you want this check number?
[CUSTOMER][NEUTRAL] Right
[CUSTOMER][NEUTRAL] Yeah, one moment. Before the, that means the claim was initially denied on and reprocessed on [PII].
[CUSTOMER][NEUTRAL] [PII], right?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK. [PII].
[CUSTOMER][NEUTRAL] And can I have the pay?
[AGENT][NEUTRAL] The pay date is the same.
[CUSTOMER][NEUTRAL] OK, thank you. And can I have the allowed amount?
[AGENT][NEUTRAL] The paid amount on this claim and lot was $75.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Actually, we do have the
[CUSTOMER][NEUTRAL] 3 CBD on the same claim.
[AGENT][NEUTRAL] Yes, sir. On this, with this check with the $75 check, it states with this check, the maximum benefit payable for this state of service has been met.
[AGENT][NEUTRAL] Two of the codes were then denied stating the maximum benefit payable for this service has been met.
[AGENT][NEUTRAL] And the other two states that the policy does not provide benefits for services in which no charges were incurred.
[CUSTOMER][NEUTRAL] Yeah, can I know
[CUSTOMER][NEUTRAL] OK. Can I know which CBD is paid and uh which CBD is denied?
[AGENT][NEUTRAL] That's
[AGENT][NEUTRAL] 9999204 was the $75 benefit.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] On the 913-221-9040894 maximum benefits, right?
[AGENT][NEUTRAL] The maximum benefit payable, yes, sir. Mhm for this state of service has been met.
[CUSTOMER][POSITIVE] Thank you. And can I know
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh, how many units allowed for the CBT?
[CUSTOMER][NEUTRAL] 9
[AGENT][NEUTRAL] I'm sorry, [PII], your voice cut completely out. What was your question? I didn't hear you.
[CUSTOMER][NEUTRAL] Yeah, can I know how many visits is allowed for the CBD 91322?
[AGENT][NEUTRAL] Again,
[AGENT][NEGATIVE] We paid on the 99204 and that maxed the benefit payable. This is not a major medical plan.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] This is a hospital indemnity limited benefit plan.
[CUSTOMER][NEUTRAL] OK, that means for per service, you can pay only $75 right?
[AGENT][POSITIVE] That is correct. We have met you correct.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] And we do not determine patient responsibility, that would be up to the provider to determine that.
[CUSTOMER][NEUTRAL] And it is already
[CUSTOMER][NEUTRAL] OK. Thank you. Can I have the appeal mailing address?
[AGENT][NEUTRAL] So it would be [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] It must be submitted in writing to that address attention appeals department.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And that must be filed within 180 days from the date of the decision.
[CUSTOMER][NEUTRAL] 180 from the.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It
[AGENT][NEUTRAL] D of decision.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] And then,
[CUSTOMER][NEUTRAL] Well, can I
[CUSTOMER][NEUTRAL] Yeah. And can I have the
[CUSTOMER][NEUTRAL] Check number for the
[CUSTOMER][NEUTRAL] P CBD.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That is single check. It is a single check.
[AGENT][NEUTRAL] The number is [PII].
[AGENT][NEUTRAL] 179.
[CUSTOMER][NEUTRAL] Thank you. I issued on [PII], right? And is that a clear date?
[AGENT][NEGATIVE] No, sir, that is, it has not cleared. That was 3 days ago.
[AGENT][NEUTRAL] 4 days ago.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, yeah.
[CUSTOMER][NEUTRAL] And could you please verify the pay to address and patient account number?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Go ahead with the patient account number?
[CUSTOMER][NEUTRAL] [PII], sorry, [PII] [PII] [PII], [PII].
[AGENT][NEUTRAL] OK, what you gave me is not exactly what is on this claim. You gave me some numbers twice.
[CUSTOMER][NEUTRAL] Yeah, it is [PII], 12833.
[AGENT][NEUTRAL] That is correct. That is the, that is what is on this claim.
[CUSTOMER][NEUTRAL] And the pay to address is [PII].
[AGENT][POSITIVE] That is correct.
[CUSTOMER][POSITIVE] Thank you. So I'm on the last question.
[AGENT][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Uh, no, so not yet. I'll have to make my note on all of these things we discussed, so just a moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And your last patient?
[CUSTOMER][NEUTRAL] Member ID is 02349369.
[AGENT][POSITIVE] Thank you. One moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the patient's name and date of birth.
[CUSTOMER][NEUTRAL] First name is [PII], last name is [PII]. Date of birth, [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Data service and total bill amount.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the bill amount.
[AGENT][NEUTRAL] 1 [PII].
[CUSTOMER][NEUTRAL] 30.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] 30.
[AGENT][NEUTRAL] OK, thank you. And the total bill amount?
[CUSTOMER][NEUTRAL] $254 even.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the claim number?
[CUSTOMER][NEUTRAL] Claim number, one moment. 354-057-0.
[AGENT][NEUTRAL] OK. Yes, sir. And this claim was denied. That's the same reason as the first claim that we went over that services were rented after coverage was terminated.
[AGENT][NEUTRAL] This policy was in effect from [PII].
[AGENT][NEUTRAL] To its term date of [PII] and there is no other policy that is active for that data service.
[CUSTOMER][NEUTRAL] Thank you. And you said the reference number is your name and date of date of uh today's date, right?
[AGENT][NEUTRAL] Uh-huh. And today's date, yes sir. Uh-huh.
[CUSTOMER][POSITIVE] Thank you and have a great day. Stay safe. Bye-bye.
[AGENT][POSITIVE] You're welcome. OK. Well, if that's all I can help you with, thank you again for calling APL. I hope you have a nice uh rest of your day and a happy holiday and a happy new year.
[CUSTOMER][NEUTRAL] You to have in your
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.