AccountId: 011433970860
ContactId: fd0b9778-8389-4563-8d14-c298081eed06
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1027130 ms
Total Talk Time (AGENT): 271941 ms
Total Talk Time (CUSTOMER): 265164 ms
Interruptions: 1
Overall Sentiment: AGENT=-0.3, CUSTOMER=-0.7
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/25/fd0b9778-8389-4563-8d14-c298081eed06_20250325T19:20_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Oh sorry, I was speaking on mute. Um, this is [PII], initial [PII], calling from office to check on the claim status.
[AGENT][NEUTRAL] OK, sure. I can assist you with claim status, Mr. [PII]. And may I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Sure, it's [PII]. And is this medical department, right?
[AGENT][NEUTRAL] This is a uh insurance company for medical and yeah, there's many insurance. um, Mr. [PII], um, you're calling from which facility for my medication?
[CUSTOMER][NEUTRAL] Yes, OK.
[CUSTOMER][NEUTRAL] Mhm yes
[AGENT][NEUTRAL] What's the name of the facility for my notation?
[CUSTOMER][NEUTRAL] It's cardiovascular Institute of Mount Sinai.
[AGENT][NEUTRAL] When.
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure, it's um
[CUSTOMER][NEUTRAL] 02520427.
[AGENT][NEUTRAL] OK, thank you. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] And the date of birth, number [PII].
[AGENT][NEUTRAL] OK, thank you. And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] [PII] and the charge amount $570 even.
[AGENT][NEUTRAL] And that was [PII]?
[CUSTOMER][NEUTRAL] Mhm. Yes.
[AGENT][NEUTRAL] OK. Thank you. Let me see if I can find this claim for you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And for future, you can check claim status online through our website at [PII] and that's just optional.
[AGENT][NEUTRAL] And let's see, can you provide me with the procedure codes?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, it's 99
[CUSTOMER][NEUTRAL] 99214. The email procedure code is 99214. And before that, could you please uh spell out your name one more time?
[AGENT][NEUTRAL] That's all. That's [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. And it looks like um this claim has been processed twice. The most recent one is processed a duplicate, so I'm gonna pull the original claim and give you information about that one, OK?
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK. May I know when the claim was received and denied also?
[AGENT][NEUTRAL] Uh, you're talking about the original one or the duplicate one?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] For the duplicate one initially, first, after that, I just want to know the original also.
[AGENT][NEUTRAL] OK, bear with me just a second, let me pull that one.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK. So the most recent one was received on [PII], processed [PII].
[AGENT][NEGATIVE] And that one was denied as a duplicate.
[AGENT][NEUTRAL] Um, the one prior to that one.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Was I'm sorry, was received [PII] [PII].
[CUSTOMER][NEUTRAL] You
[AGENT][NEUTRAL] And this one was paid um we paid $75 towards the $99214 which is the maximum allowed by the policy.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Just a moment. Um,
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Could you please repeat the received date one more time? Or what is breaking in between?
[AGENT][NEUTRAL] Yes
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK, so.
[CUSTOMER][NEUTRAL] [PII]. And you said the claim got paid for the CIPD code 9300 or only for the SIPD code 99214 not to receive any payment for that. May I know the exact reason of the denial.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] I'm sorry, can you repeat what you said because I didn't get that.
[CUSTOMER][NEUTRAL] Yes, um, you said the claim got paid, um, the paid amount of $75 even. But upon checking here, yeah, we received the payment. But for the only safety code 9300, we received payment. For the CD code 99214, there is no payment received for that.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It means the claim got delayed for some reason. Mhm.
[AGENT][NEUTRAL] OK, you have that.
[AGENT][NEUTRAL] Mr. [PII], you have that information incorrect.
[AGENT][NEGATIVE] We only paid for the 99214. We did not pay for the 9300.
[CUSTOMER][NEUTRAL] Oh, OK. Um, may I know the claim number one more time? The claim number.
[AGENT][NEUTRAL] The claim number is 3537061.
[CUSTOMER][NEUTRAL] OK. Is this the original claim status, right?
[AGENT][NEUTRAL] Yeah, this is the original claim status, the one we paid.
[CUSTOMER][NEUTRAL] And, uh, let me give you the, mhm, let me give you the one more claim number. Could you please verify with the claim number? Because we have the claim number with the denial of 99214D code. The claim number is 3,547,090.
[AGENT][NEUTRAL] That's the duplicate claim.
[AGENT][NEGATIVE] That was denied as a duplicate. Yeah, that was denied as a duplicate. That's all duplicate denial.
[CUSTOMER][NEUTRAL] That's a duplicate name.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Under the duplicate claim, we receive the payment uh for the CPT code 9300.
[AGENT][NEGATIVE] We, we did not, no, we did not pay on that claim. On that claim, it was all denied. Everything was denied. It was just a duplicate.
[CUSTOMER][NEUTRAL] I'm just confused what is happening.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK. Just a moment. Let me confirm what's happening here. Just a moment, sir. Can you please hold on a moment? Sure, thank you.
[AGENT][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] Mhm, yes.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh OK, um, can I have the.
[CUSTOMER][NEUTRAL] Uh, paid information, uh, sorry, the, the claim paid through EFT or check.
[AGENT][NEUTRAL] It was a check
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] With a single check.
[CUSTOMER][NEUTRAL] Can I have that number?
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The check number was 2016666.
[CUSTOMER][NEUTRAL] It's 46, right? For continuous 6.
[AGENT][NEUTRAL] Yes, mhm.
[CUSTOMER][NEUTRAL] OK. It's a single check.
[CUSTOMER][NEGATIVE] And really that's issued.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It got issued the same day that it was processed, which is the uh [PII].
[CUSTOMER][POSITIVE] [PII] yes. Thank you so much and
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Can I have the, the, the copy of the paid EOB?
[AGENT][NEUTRAL] Mhm. What is the fax number?
[CUSTOMER][NEUTRAL] Just a moment, let me give you that.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, instead of that, I just want to confirm one more thing. Uh, for the SIP code 93,000, what is happening on the original claim.
[AGENT][NEUTRAL] OK.
[AGENT][NEGATIVE] Mm, OK. So that one's denied because the maximum benefit paid by the policy is $75 and it's for the office visit, so that's what we paid so that one denied because, yeah, it's been exhausted for the date of service.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Uh, got it. Thank you so much. And yeah, the fax number is [PII].
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, uh, can you repeat it one more time? [PII].
[CUSTOMER][NEUTRAL] Sure, sure. Mhm.
[CUSTOMER][NEUTRAL] [PII], sorry, it's uh let me repeat it one more time. It's [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 344. OK.
[CUSTOMER][NEUTRAL] And uh the attention, yeah, the attention should be my name, [PII], along with 31508. [PII], 31508.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 31508. OK, so let me repeat this fax number back to you. It's [PII].
[CUSTOMER][NEUTRAL] Yes
[AGENT][NEUTRAL] And then we have 354.
[AGENT][NEUTRAL] And then, no, I'm sorry, [PII].
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] Yes, is it correct?
[AGENT][NEUTRAL] OK, and then we're gonna put it attention, [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes. And yes, um, so, and I just want to confirm one more thing. Um, what's the time frame to submit an appeal or a claim?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] 180 days from the decision date.
[AGENT][NEUTRAL] Which it was [PII]. Do you mind holding for me while I send this fax out to you?
[CUSTOMER][NEUTRAL] Sure, sure.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for me. OK, I went ahead and send that over to you. It should be there in a few minutes. Is there anything else I'm gonna help you with today?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That's all. Uh, can I have the call reference number? Yeah.
[AGENT][NEUTRAL] Mr. [PII].
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will.
[CUSTOMER][NEUTRAL] OK, thank you so much. Um, and I just want to confirm one more thing. Um, can I have the mailing address to submit and, uh, appeal or contact claim? This is a general question for the future reference.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, that is [PII].
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] The zip code is [PII].
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Yeah. Have a wonderful day. Bye.
[AGENT][POSITIVE] That's right. You as well. Thank you for calling ATL. Have a good day, Mr. [PII]. You're welcome. Bye-bye.
[CUSTOMER][POSITIVE] Nothing else. Thank you, sir.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] It