AccountId: 011433970860
ContactId: 07fba5a5-0e6d-4673-b02c-01742c1abbac
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 475760 ms
Total Talk Time (AGENT): 119625 ms
Total Talk Time (CUSTOMER): 107051 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/23/07fba5a5-0e6d-4673-b02c-01742c1abbac_20250523T14:39_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. It's [PII] calling from Cleveland Clinic Foundation to check on a claim status.
[AGENT][NEUTRAL] All right, [PII]. Happy to check on a claim. Can I get the patient's policy number?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Just a second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Patient's policy number, I mean, the member's ID number is 01306681 M as in Mary, L as in Leo 8.
[AGENT][NEUTRAL] And the name and date of birth?
[CUSTOMER][NEUTRAL] Patient's first name is [PII]. Last name is [PII]
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][POSITIVE] Thank you and then data service.
[CUSTOMER][NEUTRAL] Date of service is August, I'm sorry, it's [PII] for the bill amount $431.
[AGENT][NEUTRAL] And you said [PII]?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Absolutely correct.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][POSITIVE] Thank you for your patience. So we did receive a claim for the state of service. Claim was received [PII].
[AGENT][NEUTRAL] The claim was denied same date, [PII]. The outpatient benefit max for the calendar year has already had already been met.
[CUSTOMER][NEUTRAL] The outpatient.
[AGENT][NEUTRAL] Benefit Max has already been met.
[CUSTOMER][NEUTRAL] OK, the outpatient benefit max is being exhausted.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. What we need to do for this?
[CUSTOMER][NEUTRAL] What is the resolution for this claim?
[AGENT][NEUTRAL] I'm sorry, what is the what for this claim?
[CUSTOMER][NEUTRAL] Resolution
[AGENT][NEUTRAL] The claim has been denied, so at this point it's up to the uh facility or provider to decide what patient responsibility is.
[CUSTOMER][NEUTRAL] So the amount, uh, it is available to the patient, not for the facility.
[AGENT][NEUTRAL] We're not able to advise on patient responsibility. I'm just advising that at this point it would be up to them to decide that. There's nothing additional payable from the member plan.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Are you stating that it's a provider issue?
[AGENT][NEUTRAL] Yeah, and there's nothing more that we can do on our side, [PII].
[CUSTOMER][NEUTRAL] So for this, we need to check with, uh, like for this we need to check with the provider that team, right?
[AGENT][NEUTRAL] As far as how to proceed, yes.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Can I get a claim number?
[AGENT][NEUTRAL] 355-0515.
[CUSTOMER][NEUTRAL] 35505
[CUSTOMER][NEUTRAL] 155.
[AGENT][NEUTRAL] Just 15 at the end. So I'll repeat once more.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] That is 355.
[AGENT][NEUTRAL] 0515.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure. And can we go with the, like,
[CUSTOMER][NEUTRAL] The next member's ID?
[CUSTOMER][NEUTRAL] Next question
[AGENT][NEUTRAL] I need to notate this one before we can check another 11 moment.
[CUSTOMER][NEUTRAL] him
[AGENT][NEUTRAL] Policy number?
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] Yeah, 01.
[CUSTOMER][NEUTRAL] 877
[CUSTOMER][NEUTRAL] 135 M.
[CUSTOMER][NEUTRAL] L as in Leo
[CUSTOMER][NEUTRAL] 8
[AGENT][NEUTRAL] Name and date of birth?
[CUSTOMER][NEUTRAL] Sure. Name is [PII] Last name is [PII]
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] One second. Date of birth is [PII].
[AGENT][NEUTRAL] Data service.
[CUSTOMER][NEUTRAL] Sure. The date of service is [PII].
[AGENT][NEUTRAL] Fill them out.
[CUSTOMER][NEUTRAL] Sure. But the amount is $394.
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Not showing any claims on file for uh [PII].
[AGENT][NEUTRAL] You said it was for 394?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. There is no claim on you stating.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Can I get a call reference number for these both claims?
[AGENT][NEUTRAL] It would be my name with today's date. My name is [PII], that's [PII] My last initial is [PII] like [PII], and then today's date.
[CUSTOMER][POSITIVE] Sure. Thank you so much. Have a great day. Bye.
[AGENT][NEUTRAL] You too. Bye-bye.