AccountId: 011433970860
ContactId: 154b785c-99f7-453b-a23b-06599fbb0f8c
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 457779 ms
Total Talk Time (AGENT): 71951 ms
Total Talk Time (CUSTOMER): 184501 ms
Interruptions: 0
Overall Sentiment: AGENT=0.3, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/18/154b785c-99f7-453b-a23b-06599fbb0f8c_20250618T20:31_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] calling from provider's office to check on a denial clarification.
[AGENT][NEUTRAL] All right, what is the policy number, Reva?
[CUSTOMER][NEUTRAL] One moment, please. Sorry. Policy number, it is 02110727 M as in Mary, L as in Lima number 8.
[AGENT][NEUTRAL] Thank you. And patient name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name, it's uh [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] What is the data service?
[CUSTOMER][NEUTRAL] [PII], it's [PII] total bill amount $940 even.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] A
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, so it looks like we did receive this claim. It was denied the outpatient benefit max for the data service had already been met.
[CUSTOMER][NEUTRAL] OK, so the maximum benefit was already met, is it uh uh by the dollar value?
[AGENT][NEUTRAL] Correct, the outpatient benefit max is 500 per day.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, and how much is the dollar value for for per day?
[AGENT][NEUTRAL] I'm sorry, what was that again?
[CUSTOMER][NEUTRAL] So you said the benefit maximum uh for the time period has been met by the dollar value, right?
[AGENT][NEUTRAL] Correct, the outpatient benefit max on the member plan is $500 per calendar day.
[CUSTOMER][NEUTRAL] OK, and uh one moment please. So you guys paid $500 earlier for the same date of service?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK [PII].
[CUSTOMER][NEUTRAL] OK, but, but I don't see any claims which got paid for uh from our end. So did you guys pay to any other provider?
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah,
[CUSTOMER][NEUTRAL] Uh, I just need to get the number.
[AGENT][NEUTRAL] It looks like it was a facility charge for Cleveland Clinic, Florida.
[CUSTOMER][NEUTRAL] to my total amount is 72.
[CUSTOMER][NEUTRAL] OK. For the same group actually. So is it possible to let me know the facility information like uh the patient account number?
[AGENT][NEUTRAL] No, ma'am. I cannot provide that information.
[CUSTOMER][NEUTRAL] One moment, let me just uh.
[CUSTOMER][NEUTRAL] Try to look up into my system for that facility claim.
[CUSTOMER][NEUTRAL] You said it was for the same date of service, OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. Is it possible, can you confirm that if I tell you the patient account number?
[AGENT][NEUTRAL] I don't have access to the patient account number. I'm not able to provide any details on any other providers. I can only provide you information on your provider and date of service.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, one moment because I see a facility claim which was um
[CUSTOMER][NEUTRAL] Paid in the amount of $500.
[CUSTOMER][NEUTRAL] And it was also
[CUSTOMER][NEUTRAL] Um, I'm, I'm not sure where the places service here.
[CUSTOMER][NEUTRAL] OK, I assume that uh this would be the claim, so uh which is being paid for $500. So one moment.
[CUSTOMER][NEUTRAL] So is there any other uh way that could, that we could make this claim to get processed or uh no?
[AGENT][NEUTRAL] No, there would not be.
[CUSTOMER][NEUTRAL] OK, one moment, please.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. Thank you so much uh for holding on the line, sir. Sorry, sorry for the long hold. So since uh this has been denied stating uh the dollar value has met for the outpatient visit, uh, can we bill the member on this?
[AGENT][NEUTRAL] We're not able to advise on patient responsibility that would be up to the facility or the providers to build the patient.
[CUSTOMER][POSITIVE] OK, [PII], thank you so much for patiently assisting me. I guess that's all for today. What's the reference number for our call today then?
[AGENT][NEUTRAL] It is my name with today's date. My name is [PII] spelled [PII] and then today's date.
[CUSTOMER][POSITIVE] OK, [PII], thank you so much for patiently assisting me. You have a wonderful day and take care.
[AGENT][NEUTRAL] You bye.