AccountId: 011433970860
ContactId: 0626caef-db75-4685-8d87-380b08c59c70
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 637979 ms
Total Talk Time (AGENT): 157642 ms
Total Talk Time (CUSTOMER): 256737 ms
Interruptions: 0
Overall Sentiment: AGENT=1, CUSTOMER=1.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/09/0626caef-db75-4685-8d87-380b08c59c70_20250409T17:57_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] Hello. Good afternoon. My name is [PII] and I'm calling from the provider's office and I'm looking for the claim status.
[AGENT][POSITIVE] All right, [PII], I'm happy to check on a claim for you today. Can I get the patient's policy number, please?
[CUSTOMER][NEUTRAL] Yes, of course. Before that, I just want to inform you that this call is recorded for quality and training purposes. So may I proceed the call? 8.
[AGENT][NEUTRAL] Yes, that is fine.
[CUSTOMER][POSITIVE] Thank you so much. So the policy number, I have the D as in Delta 43510705.
[AGENT][NEGATIVE] Unfortunately I can't pull the member with that number. [PII], do you have their name or social?
[CUSTOMER][NEUTRAL] Uh, I have the member's name and the date of birth and the address, but I don't have the social security number of the member.
[AGENT][NEUTRAL] OK, what's the name?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] Spell the last name, please.
[CUSTOMER][NEUTRAL] Yeah, sure. It is [PII].
[AGENT][NEUTRAL] All right. And first name is [PII].
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK. One moment.
[CUSTOMER][POSITIVE] Sure, take your time.
[CUSTOMER][NEUTRAL] $62.
[CUSTOMER][NEUTRAL] And your, can you please spell me your name right.
[AGENT][NEUTRAL] What state does the insured live in?
[CUSTOMER][NEUTRAL] Oh, I'm so sorry. Are you asking for the date of birth?
[AGENT][NEUTRAL] No, no, no. What state do they live in?
[AGENT][NEUTRAL] Do they live in [PII]?
[CUSTOMER][NEGATIVE] Oh, I'm sorry. I'm not getting it.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] Data service.
[CUSTOMER][NEUTRAL] OK. So the date of service is [PII].
[AGENT][NEUTRAL] And the build the amount?
[CUSTOMER][NEUTRAL] It is $363 even.
[AGENT][NEUTRAL] All right. One moment.
[CUSTOMER][POSITIVE] Sure, take your time.
[AGENT][NEUTRAL] And [PII], do you have a good callback number in case we're disconnected?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Yes, I have. It is [PII] and it's a direct line.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK. And do you have any care ID as well?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What's your family finally find them things.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Thank you for your patience on that [PII]. So it looks like we did receive a claim for this on [PII].
[AGENT][NEUTRAL] There was a benefit payment made in the amount of $50.
[CUSTOMER][NEUTRAL] Can you see that on your end?
[CUSTOMER][NEUTRAL] Like the profit right? Could you verify which line item is paid and which one is denied.
[CUSTOMER][POSITIVE] Thank you
[AGENT][NEUTRAL] Uh, procedure code 99214.
[AGENT][NEGATIVE] Was the only procedure code that was paid. The other two were denied.
[CUSTOMER][NEUTRAL] OK. And what's the reason of denial?
[AGENT][NEUTRAL] Maximum benefit payable for the state of service had been met.
[CUSTOMER][NEUTRAL] OK. And could you also verify what's the maximum table units for these procedure codes?
[AGENT][NEUTRAL] Yes, so with that payment of $50 that was the max benefit payable for that date.
[CUSTOMER][NEUTRAL] Oh, I'm sorry. As the, as you, uh, you said that only $50 you can pay for a date of service.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEGATIVE] OK. So as we billed for $362 but uh uh I'm sorry, I'm not getting this scenario. Why did you pay only $50 for a claim?
[AGENT][NEUTRAL] The patient has a limited benefit hospital indemnity plan where it's going to pay a set amount depending upon what the patient's being seen for. The office visit benefit amount on this patient's plan is $50. That's why that's the max benefit payable for the date of service.
[CUSTOMER][NEUTRAL] OK, I got it. So as the insurance pay the, the uh the part that is $50 per day of service. So the remaining balance is the member's responsibility?
[AGENT][NEUTRAL] We're not able to advise on that. That's up to the facility or provider.
[CUSTOMER][NEUTRAL] OK, just give me a moment.
[CUSTOMER][POSITIVE] OK. Thank you so much for that information. And I don't have any other question for this number, so could you please provide me the reference number?
[AGENT][NEUTRAL] Call reference is my name with my last initial than today's date. My name again is [PII], which is [PII] Last initial is [PII].
[CUSTOMER][POSITIVE] OK, I got it. Thank you so much. And I have one more more member, so could you please help me with that?
[AGENT][NEUTRAL] Yeah, what's the other member's ID?
[CUSTOMER][NEUTRAL] Yeah, just give me a moment.
[CUSTOMER][NEUTRAL] It is.
[CUSTOMER][NEUTRAL] It is D as in Delta, 43731964.
[AGENT][NEUTRAL] OK, unfortunately that's not a valid policy number that we can pull, so I'll need the member's name to search them as well.
[CUSTOMER][NEUTRAL] Yeah, sure. It is [PII].
[CUSTOMER][NEUTRAL] My
[CUSTOMER][NEUTRAL] And the last name is spelled as [PII].
[AGENT][NEUTRAL] And did you say the first name is [PII]?
[CUSTOMER][NEUTRAL] No, it's [PII]. It's [PII]
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] It is [PII].
[AGENT][NEUTRAL] And data service.
[CUSTOMER][NEUTRAL] It is [PII].
[CUSTOMER][NEUTRAL] And the amount is $339 even.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] We received this claim on [PII]. Claim was processed on [PII]. A benefit payment was made in the amount of $75. This was the max benefit payable for the state of service.
[CUSTOMER][NEUTRAL] OK. So, as I can see, I have the two line items. So which one is paid?
[AGENT][NEUTRAL] Procedure code 99213 was paid.
[CUSTOMER][NEUTRAL] OK. So as you said that the procedure code 99213 is paid for the $75 and that is the maximum payable amount for this data service. Am I correct?
[AGENT][POSITIVE] Correct. Uh-huh.
[CUSTOMER][NEUTRAL] Uh, OK. So the $75 that is paid for the [PII] is according to the member's limited benefit plan.
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK, I got it. Thank you so much.
[CUSTOMER][POSITIVE] OK, thank you so much. And the reference number is your name and the today's date. Am I correct?
[AGENT][POSITIVE] Correct.
[CUSTOMER][POSITIVE] OK, I got it. Thank you so much, sir, for all the information. That's very helpful. Have a great day. Bye-bye, stay safe.
[AGENT][NEUTRAL] You too bye bye.