AccountId: 011433970860
ContactId: 1612a45f-7476-48d7-ab0f-f601632e6afc
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 678080 ms
Total Talk Time (AGENT): 233603 ms
Total Talk Time (CUSTOMER): 244079 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/21/1612a45f-7476-48d7-ab0f-f601632e6afc_20250321T20:16_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII] calling from provider's office to check on complaints.
[AGENT][POSITIVE] OK, well, I'll be more than happy to help you with the claims and [PII], may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah, it is [PII].
[AGENT][NEUTRAL] Thank you for that. And how many claims do you have in total today?
[CUSTOMER][NEUTRAL] Uh, I have around 3 claims.
[AGENT][NEUTRAL] OK, may I have the member's policy number?
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Yeah, it's uh 02388973 ML 8.
[AGENT][NEUTRAL] Thank you. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, it's uh [PII].
[CUSTOMER][NEUTRAL] And date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim you'd like me to check on?
[CUSTOMER][NEUTRAL] Yeah, it is 12-15-2024 and with the bill amount $710.
[AGENT][NEUTRAL] Alright, and that was [PII] for $710?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, um, just a moment. It's a Holy Cross Hospital.
[CUSTOMER][NEUTRAL] For Holy Cross emergency physicians.
[AGENT][NEUTRAL] Thank you, and I'm showing that the the claim was received on [PII].
[AGENT][NEUTRAL] The claim number is 356.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 3838.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because the maximum benefit payable for the data service has been met.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mm, because
[CUSTOMER][NEUTRAL] The maximum benefits for this payable has met.
[AGENT][NEUTRAL] Right, the maximum benefits payable has been met.
[AGENT][NEUTRAL] So the max was um up to $200 per calendar day.
[CUSTOMER][NEUTRAL] $200 per calendar day. OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And uh uh so, can I know uh this is the last, uh, for this date of service only. They have met this, uh, total of $200 isn't it?
[AGENT][NEUTRAL] Right, so that's saying by the time your claim came in, the $200 had already been paid to other claims for that data service.
[CUSTOMER][NEUTRAL] OK. OK.
[CUSTOMER][NEGATIVE] And so for this number, there is no benefits.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. And, uh, yeah, and the call reference for this one?
[AGENT][NEUTRAL] So the call reference for the entire call is going to be my name and today's date.
[CUSTOMER][NEUTRAL] Your name and today's date, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it.
[CUSTOMER][NEUTRAL] And yeah. Uh, so, can I go with the next member ID?
[AGENT][NEUTRAL] Um, hold on one moment, I'm almost done with this. No. Yes, you can go with the next member.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah, mm, just a moment.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So the member ID is 02.
[CUSTOMER][NEUTRAL] 013763.
[CUSTOMER][NEUTRAL] 99224.
[AGENT][NEUTRAL] Thank you. And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, it's [PII], and date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that. And all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service for the claim?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] It's uh [PII].
[CUSTOMER][NEUTRAL] And with the bill amount, $1,324 1,324 dollars.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] And would it be the same provider or a different provider for this claim?
[CUSTOMER][NEUTRAL] It's a different provider and the provider's name is Small Hospital Innovations.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Alright, so I'm showing the claim was received on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 3559048.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied.
[AGENT][NEUTRAL] Because the benefit maximum for this data service has been met.
[CUSTOMER][NEUTRAL] And has been met.
[CUSTOMER][NEUTRAL] And could you please provide uh information regarding that?
[AGENT][NEUTRAL] Mhm. So for this policy,
[CUSTOMER][NEUTRAL] Uh, it's a
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, yeah, you're saying.
[AGENT][NEUTRAL] So for this policy, the emergency room benefit is up to $100 per visit with a max of 2 visits per calendar year.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] So for this data service, uh, [PII], by the time your claim came in, there was already a charge that uh
[CUSTOMER][NEUTRAL] Maybe
[AGENT][NEUTRAL] That claim was paid on.
[CUSTOMER][NEUTRAL] Uh, so for, uh, emergency, uh, for emergency, it's $100.02 visits per year.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. Uh, but I can see only one visit, uh, it's happened in this year. So, so can I know when was the other visit which just happened on which date?
[AGENT][NEUTRAL] So basically this, this uh denial reason is saying on [PII], there were, there were multiple claims that came in. The first claim that came in was paid, so we can't pay out on the other claims because that max that used the emergency room max for that day.
[CUSTOMER][NEUTRAL] Actually
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, it's under hospital, uh, claims or uh physician claims?
[AGENT][NEUTRAL] This is a um facility, a hospital charge.
[CUSTOMER][NEUTRAL] Hospital charge.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Is it possible to provide me the paid uh information on which claim it got?
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Unfortunately, I can't give that information because it's a different provider. It's not your claim.
[CUSTOMER][NEUTRAL] OK. OK, I got it. And
[CUSTOMER][NEUTRAL] Uh, the call reference will be your name and today's date, isn't it, for this one too?
[AGENT][POSITIVE] Yes, mhm, that's right.
[CUSTOMER][NEUTRAL] OK. And just a moment, let me go with the next one, the last one.
[CUSTOMER][NEUTRAL] Yeah, um, so.
[CUSTOMER][NEUTRAL] So the member ID is 1979903.
[AGENT][NEUTRAL] 1979903.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, it's uh [PII]. Uh date of birth is [PII].
[AGENT][NEUTRAL] Thank you for that. And all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bills?
[CUSTOMER][NEUTRAL] Yeah, it's a [PII] and with the bill amount $997.
[AGENT][NEUTRAL] OK, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] 19
[AGENT][NEUTRAL] Alright, I'm showing we received the claim on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 357.
[CUSTOMER][NEUTRAL] Right.
[AGENT][NEUTRAL] 0367.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And on [PII], the claim was denied requesting the explanation of benefits from primary insurance.
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] First in the
[CUSTOMER][NEUTRAL] Explanation
[CUSTOMER][NEUTRAL] From primary insurance. And may I know who is primary for this number?
[AGENT][NEUTRAL] Sure, hold on one moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Hold on one moment.
[CUSTOMER][NEUTRAL] Mhm yeah.
[AGENT][NEGATIVE] For some reason, my screen is glitching. I apologize.
[CUSTOMER][NEUTRAL] It's OK.
[AGENT][NEUTRAL] Primary insurance is Aetna. It's Gray, G R A V I E and then in parenthesis it says Aetna.
[CUSTOMER][NEUTRAL] A Aetna is the primary. OK. And is it possible to provide me the ID ID?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Well, we don't have access to the policy information. It, it just shows the name of the carrier.
[CUSTOMER][NEUTRAL] OK. Uh, then we need to contact the patient regarding this.
[AGENT][POSITIVE] Yes, correct.
[CUSTOMER][NEUTRAL] OK. OK, [PII]. And even for this also the call reference will be your name and today's date.
[AGENT][POSITIVE] Yes, mhm, that's correct, yes.
[CUSTOMER][NEUTRAL] Wasn't there?
[CUSTOMER][POSITIVE] Yeah. And yeah, that's it for today. And yes, thanks, thanks for your strength and have a great day.
[AGENT][POSITIVE] You're very welcome, [PII]. Well, thanks for calling APL. I hope you have a great weekend.
[CUSTOMER][NEUTRAL] You too. Bye-bye.
[AGENT][NEUTRAL] Bye bye.