AccountId: 011433970860
ContactId: 0e1f7eae-3d7b-4bbe-bca7-4a71af458ef1
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 380549 ms
Total Talk Time (AGENT): 126732 ms
Total Talk Time (CUSTOMER): 154111 ms
Interruptions: 1
Overall Sentiment: AGENT=0.5, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/23/0e1f7eae-3d7b-4bbe-bca7-4a71af458ef1_20250623T13:09_UTC.wav
--------------------------------------------
[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] You said [PII]?
[AGENT][NEUTRAL] Um, it's [PII]
[CUSTOMER][NEUTRAL] Oh [PII]. Oh hi, Ms. [PII]. Uh, my name is [PII]. I'm calling the provider's office regarding a claim.
[AGENT][NEUTRAL] I'm sure [PII], I can assist you with claim status. First, could I get a good callback number just in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] Thank you. Now, could I get the policy number, please?
[CUSTOMER][NEUTRAL] I have the policy number as 02498570.
[AGENT][NEUTRAL] And please verify the patient's name and date of birth.
[CUSTOMER][NEUTRAL] Uh patient's name is [PII]. I think it's [PII] Birthday is [PII].
[AGENT][NEUTRAL] And the date of service and bill charges on the claim, please?
[CUSTOMER][NEUTRAL] It would be for [PII]. Total charge is $2,368.
[AGENT][NEUTRAL] OK, one moment, please.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm
[AGENT][NEUTRAL] OK. Yes, ma'am. We received that claim on [PII].
[AGENT][NEUTRAL] And it processed on [PII].
[AGENT][NEUTRAL] Um, the claim number is 3581646.
[AGENT][NEUTRAL] And this claim denied because the benefit maximum was reached um under this policy for outpatient services, we cover up to $1000 per occurrence and that um maxed out on a previous claim.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Occurrence you said.
[AGENT][NEUTRAL] Yeah, and every occurrence is every 90 days.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] So every 9 days. I was gonna ask you that.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Um, OK, so he already maxed out that, so it would be his responsibility for whatever that has been billed, correct?
[AGENT][POSITIVE] Yes, ma'am, that's correct.
[CUSTOMER][NEUTRAL] OK, so you said that uh because I, the policy has max coverage, right?
[AGENT][NEUTRAL] Right, for that occurrence. Yes, ma'am.
[CUSTOMER][POSITIVE] Courage of 1000 per every 9 days. OK, awesome. I'll send this over to the patient responsibility then, um, if they have any questions, they can call you guys. Um, is there a reference number at EV?
[AGENT][NEUTRAL] Yes, ma'am. So the reference number, you can use my name and today's date. Um my name is spelled [PII] and last initial is [PII] and today's date. Um, is there anything else I can assist you with?
[CUSTOMER][NEUTRAL] I do have a question regarding that because when I was looking at the EUB how come the EB didn't state that it just says.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] 0 pay everything, but it doesn't tell me.
[CUSTOMER][NEUTRAL] Um, that it's maxed or anything, where can I find that? because I'm looking at the EOB now it just says description it just gave me the date so the patient come, our provider's information service description, which is outpatient expense, and then it just gave me a remark one. When I looked at the remark one it just says that max uh amount payable to the this occurrence but it doesn't tell me.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] What's been, you know, when did it get max, uh, how many occurrence that you've been told me or blah blah blah.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Let's see, one moment, let me pull.
[AGENT][NEUTRAL] The explanation of benefits, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Does it show you remark 1D2M0180, the maximum um amount payable for this occurrence has been met and it explains the 90 days and
[AGENT][NEUTRAL] For unrelated conditions that it's been considered a pre occurrence.
[CUSTOMER][NEUTRAL] Yeah, I did say that, but it didn't say every month is 10 I mean 1000 per occurrence. It just says 90 days.
[AGENT][NEUTRAL] OK, yeah, yeah.
[CUSTOMER][NEUTRAL] That's I'm like, OK.
[AGENT][NEUTRAL] Yeah, here it, it's giving a general um reason because um different policies have different maximums like some policies, it's $250 per occurrence and others it's $500 and like for this one, it's $1000 per occurrence, so.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Oh, OK, that makes sense. I was like, well, how do we know? I mean, it's 90 days, but how do we know he's max within that 90 days of how much, you know?
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, we just have to call and get that information I'm assuming, right?
[AGENT][POSITIVE] Yes, ma'am, that's correct. Yeah.
[CUSTOMER][POSITIVE] OK. It's like, OK, I know 90 days, but OK, what's that match within that 90 days? OK. Um, thank you so much for your help though.
[AGENT][NEUTRAL] Right, yeah.
[AGENT][POSITIVE] OK, no problem. Is there anything else I can assist you with?
[CUSTOMER][POSITIVE] No, no, thank you so much. Have a good day.
[AGENT][NEUTRAL] You do the same, Kia. Thank you for calling APL. bye.
[CUSTOMER][NEUTRAL] Bye bye.