AccountId: 011433970860
ContactId: 15d42b81-b3c3-45c8-93a6-4f9961c024db
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 378209 ms
Total Talk Time (AGENT): 141818 ms
Total Talk Time (CUSTOMER): 131796 ms
Interruptions: 2
Overall Sentiment: AGENT=1.1, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/30/15d42b81-b3c3-45c8-93a6-4f9961c024db_20250530T16:41_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], this is [PII] from provider's office to check on a denied claim. How are you doing today?
[AGENT][NEUTRAL] I'm doing fine. And you said that your name is [PII], is that correct?
[CUSTOMER][POSITIVE] Yes, that's correct.
[AGENT][NEUTRAL] OK, [PII], and I can help you with that. What is your callback number?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Callback number is [PII]. That's a direct line.
[AGENT][POSITIVE] Thank you. And how do you spell your first name?
[CUSTOMER][NEUTRAL] It's spelled as [PII], initial is [PII].
[AGENT][NEUTRAL] Thank you. And [PII], what is the member's policy number?
[CUSTOMER][NEUTRAL] Member policy number is going to be, give me a moment, please.
[CUSTOMER][NEUTRAL] I will
[CUSTOMER][NEUTRAL] Number ID number 02425331.
[AGENT][NEUTRAL] OK, thank you. One moment, please.
[CUSTOMER][NEUTRAL] Yeah, sure.
[AGENT][NEUTRAL] And any information [PII] that I do provide for you today would be a verification of benefits and not a guarantee of payment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] What is your patient's name and their date of birth?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII] with the date of birth [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] And what is the date of service and total bill amount, please?
[CUSTOMER][NEUTRAL] Date of service is [PII]. I do have the total charge amount of
[CUSTOMER][NEUTRAL] Uh, $2460 even.
[AGENT][NEUTRAL] OK, thank you, one moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so, so I do show that this claim was received on [PII].
[AGENT][NEGATIVE] It was processed and denied on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 357-468-2.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And one moment and I'll provide you the reason for the denials.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, the denial, it's kind of long. The maximum outpatient, excuse me, the maximum amount payable for this occurrence has been met. Per occurrence means treatment for the same or related condition unless separated by a period of 90 days. Treatment for the same or related conditions separated by 90 days or an unrelated condition will be considered a new per occurrence.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, as you said that that the maximum benefits has been exhausted for the member. Uh, may I know whether it has been?
[AGENT][NEUTRAL] For this occurrence, correct.
[CUSTOMER][NEUTRAL] Yeah. May I know whether it was exhausted under dollar value or doctor visit?
[AGENT][NEUTRAL] This was under a dollar amount and it was related to a claim that was received prior to yours.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] I was not.
[AGENT][NEUTRAL] And if you need a copy of that explanation of benefits with the remark that I read to you, [PII], you can actually go to our portal and print that yourself now that you have the claim number and the website for our portal is located at [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK. And may I know when it was met during the same date of service?
[AGENT][NEUTRAL] For the same date of service, yes, ma'am.
[CUSTOMER][NEUTRAL] OK. Give me a moment.
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEGATIVE] She stated that it was made during the same date of service, but there is no payment made for the OK.
[AGENT][NEUTRAL] Under a different claim for a different provider in which I cannot provide you that information.
[CUSTOMER][NEUTRAL] Met on the same uh date for different provider and differently, OK.
[AGENT][POSITIVE] Correct, yes ma'am.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] And uh may I know how much is the total dollar value for this member?
[AGENT][NEUTRAL] The max the maximum outpatient benefit max per occurrence is $500.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. OK.
[CUSTOMER][POSITIVE] Mm, OK, thank you so much. So this will be the member responsibility, right then?
[AGENT][NEUTRAL] We do not determine patient responsibility, [PII], that would be up to the provider.
[CUSTOMER][POSITIVE] OK, thank you so much, [PII], may I have the reference number for the call?
[AGENT][POSITIVE] Yes ma'am, you would use my name that I gave you along with today's date.
[CUSTOMER][POSITIVE] Thank you. Take care. Bye-bye.
[AGENT][POSITIVE] You're welcome. Yes, ma'am. And if that's all I can help you with, [PII], thank you again for calling APL and I hope you have a nice weekend.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye. Yeah.