AccountId: 011433970860
ContactId: 10ea9e54-98fb-411f-8ed0-5ba7aea22b18
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 476980 ms
Total Talk Time (AGENT): 177107 ms
Total Talk Time (CUSTOMER): 91471 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/03/10ea9e54-98fb-411f-8ed0-5ba7aea22b18_20250203T13:33_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Yeah, hi [PII]. My name is [PII]. I'm calling from provider office and I'm looking for medical claim status. So would you mind to help me with that?
[AGENT][NEUTRAL] OK, [PII], do you have just one claim to check status on?
[CUSTOMER][NEUTRAL] Yeah, only one. Uh-huh.
[AGENT][NEUTRAL] Uh, yes, sir. I can help you with that. And what is your callback number, please?
[CUSTOMER][NEUTRAL] Callback number [PII].
[AGENT][NEUTRAL] Thank you. And what is the member's policy number, please?
[CUSTOMER][NEUTRAL] Yeah, member ID number is going to that is.
[CUSTOMER][NEUTRAL] Uh, it's 244-857-2.
[AGENT][POSITIVE] OK, thank you. Give me a couple of moments, [PII] to get all of the members' information pulled up please.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And saving any information that I do provide for you today will be a verification of benefits and not a guarantee of payment. What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, it's [PII] and the date of birth is going to, that is uh [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the date of service and total bill amount?
[CUSTOMER][NEUTRAL] Uh, sure, just a second, wait.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, the date of service is going to that is.
[CUSTOMER][NEUTRAL] Uh, [PII], sorry, [PII] for $2800.
[AGENT][NEUTRAL] And you did say [PII]?
[CUSTOMER][NEUTRAL] Uh, [PII], yes. [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, so give me a couple of moments to look through some claims on this policy.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What's the provider facility name?
[CUSTOMER][NEUTRAL] North Shore Hematology oncology Associates.
[AGENT][NEUTRAL] It's still loading some information for me to review.
[CUSTOMER][NEUTRAL] Sure, go ahead.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, so this, we've received this claim multiple times. The last two times that it's been received was denied as a duplicate of previously submitted expenses. [PII], uh, do you need the original claims information?
[CUSTOMER][NEUTRAL] Uh, it's a 353-373 claim number, is that right?
[AGENT][NEUTRAL] Oh, you didn't tell me you have the claim number, but that's correct.
[CUSTOMER][NEUTRAL] Uh, what is the status of that one?
[AGENT][NEUTRAL] Denied the calendar year maximum for outpatient office visits.
[AGENT][NEUTRAL] Due to sickness and or accident has been met for this calendar year.
[AGENT][NEUTRAL] The maximum number of visits per calendar year on this policy, [PII] is 4, and that had already been reached prior to this date of service.
[AGENT][NEUTRAL] For this claim being received.
[CUSTOMER][NEUTRAL] Mm, I didn't catch your name. Could you explain that thing?
[AGENT][NEUTRAL] I will read it to you again. The calendar year.
[CUSTOMER][NEUTRAL] No, no, you, you don't need to, you don't need to read. You, you have to explain and uh make me understand, like you have to give me in simple words like, you know, in order to understand.
[CUSTOMER][NEUTRAL] Could you, could you explain me in simple words?
[AGENT][NEUTRAL] Uh, all of, she had already used her maximum number of visits for the calendar year prior to this claim being received.
[AGENT][NEUTRAL] This is not major medical insurance, [PII]. It is a limited benefit plan.
[CUSTOMER][NEUTRAL] Just a second, wait.
[CUSTOMER][NEUTRAL] The claim is denied stating uh what was the reason? I'm, I'm noting down.
[AGENT][NEUTRAL] The calendar year maximum?
[CUSTOMER][NEUTRAL] The calendar
[AGENT][NEUTRAL] Year maximum.
[CUSTOMER][NEUTRAL] He
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For outpatient.
[AGENT][NEUTRAL] Office visits.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Due to sickness.
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] And or accident.
[AGENT][NEUTRAL] have been met.
[AGENT][NEUTRAL] For this,
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um
[AGENT][NEUTRAL] And if you, if you need a copy of that explanation of benefits, [PII] that has those remarks on there, you can actually print that by going to our portal.
[AGENT][NEUTRAL] At [PII].
[CUSTOMER][NEGATIVE] It means they are not going to pay anything. We can't do anything with this one, right?
[AGENT][NEUTRAL] This claim has been denied, and if you wish to file an appeal, appeals must be filed within 180 days from the date of the decision.
[AGENT][NEUTRAL] And this claim was denied 11-222024.
[AGENT][NEUTRAL] And it must be again submitted in writing and sent to our appeals department, attention appeals department.
[CUSTOMER][NEUTRAL] OK, not an issue. Give me the call reference number.
[AGENT][NEUTRAL] My name and today's my name that I gave you along with today's date.
[CUSTOMER][NEUTRAL] Right, uh, I think if we will send an appeal, it would be also denied because the, the, this is an uncovered. I'm right?
[AGENT][NEGATIVE] I read you the remark as to why it was denied.
[CUSTOMER][POSITIVE] OK, good time the rest of the day. Bye-bye.
[AGENT][NEUTRAL] OK, well