AccountId: 011433970860
ContactId: 08c1770f-6d34-4662-8cfa-57189bcf4013
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 895190 ms
Total Talk Time (AGENT): 308171 ms
Total Talk Time (CUSTOMER): 206295 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/03/08c1770f-6d34-4662-8cfa-57189bcf4013_20250303T15:21_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII], this is [PII] from Pros office calling for claim status.
[AGENT][NEUTRAL] OK, [PII], you're needing claim status, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, I can help you with that. And [PII], what is your callback number?
[CUSTOMER][NEUTRAL] Callback number is [PII].
[CUSTOMER][NEUTRAL] [PII] is a direct line.
[AGENT][NEUTRAL] OK, thank you and [PII], how many claims do you have to check status on?
[CUSTOMER][NEUTRAL] Only do claims.
[AGENT][NEUTRAL] Are they for the same patient or different patients?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Different patients.
[AGENT][NEUTRAL] OK [PII], so I can help you with both. You will use my name along with today's date as your call reference number for each one. Also, any information that I provide for you [PII] will be a verification of benefits and not a guarantee of payment. And lastly, if we do have the claims on file and you need a copy of the explanation of benefits, you may print that by going to our portal which is located at secured.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, and what is your first patient's policy number, please?
[CUSTOMER][NEUTRAL] Yes, sure, one second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The first policy number is 022.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 216
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 56
[CUSTOMER][NEUTRAL] M for Mike, L for Lima, number 8.
[AGENT][NEUTRAL] OK, thank you. One moment please.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK. And when your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is?
[CUSTOMER][NEUTRAL] [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Thank you. What is the date of service, the total bill amount for her, please?
[CUSTOMER][NEUTRAL] It's [PII], uh sorry, it's [PII].
[AGENT][NEUTRAL] So just one moment, [PII].
[CUSTOMER][NEUTRAL] Total bill is, yeah, [PII].
[AGENT][NEUTRAL] OK, total bills.
[CUSTOMER][NEUTRAL] It's $671 even.
[AGENT][POSITIVE] Thank you, one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so this claim was received.
[AGENT][NEUTRAL] The received date on this claim is going to be.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 217.
[AGENT][NEGATIVE] 2025 processed and denied the same day. I'm sorry, that's not true. It was processed and denied on 2-18, so it was received 2-17 processed 218. The claim number is 356-526-8.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the reason for the denial on this claim, Sean states.
[AGENT][NEUTRAL] Outpatient benefit for this calendar year has been met.
[CUSTOMER][NEUTRAL] OK, so how much the benefit was allotted to the patient?
[CUSTOMER][NEUTRAL] And in which terms?
[AGENT][NEUTRAL] The outpatient benefit maximum per calendar year for covered outpatient services is $3500.
[CUSTOMER][NEUTRAL] For the calendar, right?
[AGENT][POSITIVE] That is correct, yes ma'am. I mean, yes, sir.
[CUSTOMER][NEUTRAL] 3500, yeah, it's OK.
[CUSTOMER][NEUTRAL] And uh the current 3500, right?
[AGENT][NEUTRAL] 3500 and that was already met. Yes, sir.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][POSITIVE] And it was last me.
[CUSTOMER][NEUTRAL] And was last met on which data service?
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Yeah, yeah, sure.
[AGENT][NEUTRAL] I'm having to locate that information just a moment.
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] Oh
[AGENT][POSITIVE] Bless you.
[CUSTOMER][POSITIVE] Sorry for that.
[AGENT][NEUTRAL] That's OK.
[AGENT][NEUTRAL] That was met with the claim that was processed on [PII].
[CUSTOMER][NEUTRAL] [PII] or [PII]?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And the different provider?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] OK, not an issue.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Uh thank you for that information. Uh, and for the same member, can you check the date of service [PII]?
[AGENT][NEUTRAL] And it
[AGENT][NEUTRAL] Oh, you have more than how many dates of service, you said you had 2 claims. How many dates?
[CUSTOMER][NEUTRAL] Only 1 for this member. How many help can you help me with? Only 2 claims for the day, for the call?
[AGENT][NEUTRAL] And so that's how many you said that you had, [PII]. I asked you how many claims you had and you said 2.
[CUSTOMER][NEGATIVE] Oh no, sorry.
[CUSTOMER][NEUTRAL] Yeah, this is one more claim I found on the same member.
[AGENT][NEUTRAL] What is the next date of service?
[CUSTOMER][NEUTRAL] The date of service is [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Uh-huh, total bill amount.
[CUSTOMER][NEUTRAL] Of 24.
[CUSTOMER][NEUTRAL] $1,019 even.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so this claim was received on [PII] and it was processed.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm sorry, if this claim has been received more than once, the most recently received and was denied as a duplicate, you need the original claim status, is that correct?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So the original claim was received on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it was processed and denied on [PII].
[AGENT][NEUTRAL] Who was the provider on this claim?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Can I provide the name the ending of the.
[AGENT][NEUTRAL] Actually, I gave you, that's, yes, give me just a moment because that is not the correct information. Just one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] I'm sorry, I was looking at the at.
[AGENT][NEUTRAL] The wrong line. The correct, OK.
[CUSTOMER][NEUTRAL] Different
[AGENT][NEUTRAL] Yeah. No, so the correct claim, it, it was received.
[AGENT][NEUTRAL] And the correct claim number that you need for this one is going to be it was received on 122 0 just one moment.
[AGENT][NEUTRAL] Let me refresh my screen. Give me just one second please.
[CUSTOMER][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] OK, this one was received on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it was processed on [PII].
[AGENT][NEUTRAL] The claim number is 353-6003.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And this claim was denied for the same reason.
[CUSTOMER][NEUTRAL] Outpatient.
[AGENT][POSITIVE] Be benefit for this calendar year has been met.
[CUSTOMER][NEUTRAL] But it was before, it was the data services before [PII], right?
[AGENT][NEUTRAL] Claims are processed, yes sir, but claims are processed in the order that they are received, not the date of service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes sir I'm here.
[CUSTOMER][NEUTRAL] The last me data service was [PII], so how can you deny this claim as outpatient benefits were met on that day.
[AGENT][NEUTRAL] As I explained to you, this claim was not received until December.
[CUSTOMER][NEUTRAL] OK, so that's why the it was met under this issue?
[AGENT][NEUTRAL] We received another claim before this claim that was processed. Claims are processed according to when they are received, not the date of service.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, so the.
[CUSTOMER][NEUTRAL] Yeah, I got you. So, so benefits were went under the date of service, right? Which was received first.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] The claim, OK, got you, thank you for that. So this will be the same reason, right?
[AGENT][NEUTRAL] Yes, sir.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mm mm mm
[CUSTOMER][NEUTRAL] Yeah, OK, thank you. So can we move to the next member?
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and the next member's policy number, [PII]?
[CUSTOMER][NEUTRAL] Next member's policy number is 024.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 74261
[AGENT][NEUTRAL] 61
[CUSTOMER][NEUTRAL] Yeah, 261. It's 74261.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] And yeah.
[AGENT][NEUTRAL] And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII] and the date of birth is [PII].
[AGENT][POSITIVE] Thank you. Data service and total bill amount.
[CUSTOMER][NEUTRAL] Our service is [PII].
[CUSTOMER][NEUTRAL] And the total bill is $1,761 even 1761 even.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] OK, so this claim was received on [PII]. It was processed and denied on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 356-527-3.
[AGENT][NEUTRAL] And the reason for the denial on this claim states this service is not covered when performed in a doctor's office or clinic.
[CUSTOMER][NEUTRAL] So it is a quotation plan.
[AGENT][NEUTRAL] Yes.
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Not an issue, and the call difference will be the same, right?
[AGENT][NEUTRAL] Yes, sir. My name in today's date.
[CUSTOMER][POSITIVE] OK. Thank you so much, [PII], for assistance. Have a nice day. Bye-bye.
[AGENT][POSITIVE] Well, I hope you have a nice day too. That's all I can help you with, and thank you again for calling APL today, [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Bye-bye.