AccountId: 011433970860
ContactId: 059ebba2-c673-40d9-8c18-1d18706477fc
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 580559 ms
Total Talk Time (AGENT): 203601 ms
Total Talk Time (CUSTOMER): 207437 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/05/059ebba2-c673-40d9-8c18-1d18706477fc_20250505T22:50_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Good afternoon, [PII]. My name is [PII], and I'm calling from faculty physicians and surgeons, and I was wondering if you could help me regarding a claim that was denied.
[AGENT][NEUTRAL] Yeah, I can check on that claim for you. Oh, we're just needing clarification on that, Dane, is that right?
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Yes, clarification actually, yes.
[AGENT][NEUTRAL] Got you. OK, yes, I can check that. Uh, [PII], can I get a good call back number from you first in case we're disconnected?
[CUSTOMER][POSITIVE] Perfect
[CUSTOMER][NEUTRAL] Certainly, of course [PII].
[AGENT][NEUTRAL] Thank you. And then do you have that policy number?
[CUSTOMER][POSITIVE] Yes, let me get that for you. It is going to be.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Uh, I have policy number 02504362.
[AGENT][NEUTRAL] OK and then what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] Members's name is going to be.
[CUSTOMER][NEUTRAL] [PII]'s birthday [PII].
[AGENT][POSITIVE] Perfect, thank you for verifying that. Do you happen to have that claim number?
[CUSTOMER][NEUTRAL] Yes, I have claim number 3507714.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. So we were unable to pay a benefit as their calendar year maximum for this benefit had been exhausted. So this is a uh limited indemnity medical plan. Uh, so it does pay a set dollar amount per office visit or uh covered procedure. Um, let me see what that total benefit was. Give me just a moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] I apologize, bear with me. This policy is no longer active, so I have to kinda bring it back to life for a second.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][POSITIVE] No, no, that's perfectly fine, thank you for looking into that.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so this was for an emergency room visit. Their total allowance for this benefit was $500 per calendar year and that had been previously exhausted prior to this claim.
[CUSTOMER][NEUTRAL] And it was met prior.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] To the date of service, let me see if I get this right, so this patient has a calendar it was denied because the patient's calendar year max.
[AGENT][POSITIVE] Correct.
[AGENT][POSITIVE] Had been met for this benefit, correct.
[CUSTOMER][NEUTRAL] Allowed was already met.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] So then the patient is then responsible for the full amount of the visit?
[AGENT][NEUTRAL] Uh, we don't say what is patient responsibility. That would be up to the provider.
[CUSTOMER][NEUTRAL] OK, that's what I need to confirm.
[CUSTOMER][POSITIVE] Thank you. You know what I have? How many can I give you to confirm because I have.
[CUSTOMER][NEUTRAL] I'm wondering if most of these claims were denied.
[CUSTOMER][NEUTRAL] On this patient
[CUSTOMER][NEUTRAL] And I'm wondering if it it's all because of the same reason.
[AGENT][NEUTRAL] Um, possibly, uh, you have multiple claims for this number you needed to look at?
[CUSTOMER][NEUTRAL] Yes, yes, that I needed to verify because I have another one that also um was denied, but um the service was rendered in [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, um, yes, if you, do you have that policy number I could take a look?
[CUSTOMER][NEUTRAL] Um, it's the same policy, same patient, but let me give you exactly what's on the claim denial.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And uh.
[CUSTOMER][NEUTRAL] Let's see, I just had it right now.
[CUSTOMER][NEUTRAL] Policy number is going to be.
[CUSTOMER][NEUTRAL] 02504362
[AGENT][NEUTRAL] I'm so sorry I meant to ask for the claim number.
[CUSTOMER][NEUTRAL] Oh, OK, uh, claim number 3, no, no, you're perfectly fine, 349-4545.
[AGENT][POSITIVE] I'm so sorry.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] This one is saying that the claim previously denied as the policy had lapsed, but then it was reinstated with continuous coverage, so give me just a moment let me try to find that corrected one.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so I did find the corrected one however it's the same, um, as the benefit amount had been exhausted, so there was nothing payable.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, so for the same reason, the max allowed has been met the calendar year calendar year max allowed has been met for this kind of benefit.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] Right.
[CUSTOMER][POSITIVE] Perfect.
[CUSTOMER][POSITIVE] OK, thank you so much for confirming that.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] How many can I give you to cross check the denial?
[AGENT][NEUTRAL] You had how many for this member? were they all for this member?
[CUSTOMER][NEUTRAL] Just one more, yes, they're all for the same number.
[AGENT][NEUTRAL] Yeah, no, that's perfectly fine. uh, what was the next one?
[CUSTOMER][NEUTRAL] The next one claim number is going to be.
[CUSTOMER][NEUTRAL] Mm let's see where you at.
[CUSTOMER][NEUTRAL] Claim number 3507312.
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEGATIVE] OK, this then all reason is the exact same, uh, calendar year maximum for this benefit have been exhausted.
[CUSTOMER][NEUTRAL] Same, OK.
[CUSTOMER][POSITIVE] Perfect. Let me write that down for that that's for [PII], the [PII], same reason.
[CUSTOMER][NEUTRAL] [PII], the same reason, and [PII] has to be the same reason. Do you see any claim outstanding for service date [PII] or 2? I don't have a denial, but I just have it outstanding for [PII].
[AGENT][NEUTRAL] Let me see, give me just a moment.
[CUSTOMER][NEUTRAL] Do you show any claims?
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Yes, OK, so I do see that one, for, uh, $2,349.
[CUSTOMER][NEUTRAL] Oh you do.
[CUSTOMER][POSITIVE] Exactly, yes.
[AGENT][NEUTRAL] OK, yes, so now this one, it looks like we are missing some information for this claim. Uh, it does state that anesthesia benefits are based on benefits allowable under the surgical benefit, so we would need the surgical charges for this date, uh, so that both benefits can be considered. So it simply looks like we didn't receive enough information for this claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh, OK, um, because, uh, was there an EB that was sent, do you know or requesting this information?
[AGENT][NEUTRAL] Um, as long ago as this was, I'm not sure, but I can definitely send it to you if you need it. Do you have a fax number?
[CUSTOMER][NEUTRAL] I know.
[CUSTOMER][NEUTRAL] Yes please, I do. It is going to be area code [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, I'm going to read that back to make sure I heard that correctly. That was [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, I will go ahead and get that sent now. I should get it within about 10 minutes or so.
[CUSTOMER][POSITIVE] That's perfectly fine thank you so much for looking into all that. Your name again was?
[AGENT][NEUTRAL] Yeah, of course. Did you have, was there anything else? Oh, [PII]
[CUSTOMER][POSITIVE] Alright perfect if there's a reference number for the call.
[AGENT][NEUTRAL] Sure, reference number would just be my first name, last initial, and today's date, uh, so my last initial is A.
[CUSTOMER][POSITIVE] Hey thank you [PII]. You have a wonderful day stay safe.
[AGENT][POSITIVE] You are very welcome. Thank you. You too. Bye bye.
[CUSTOMER][NEUTRAL] Mhm bye bye.