AccountId: 011433970860
ContactId: 17da5cc6-ef80-4c92-bafa-28ca38273600
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 443329 ms
Total Talk Time (AGENT): 119600 ms
Total Talk Time (CUSTOMER): 192507 ms
Interruptions: 2
Overall Sentiment: AGENT=0.3, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/04/17da5cc6-ef80-4c92-bafa-28ca38273600_20250304T18:22_UTC.wav
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[AGENT][NEUTRAL] APL, my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] Hi, my name is [PII]. I'm calling from provider's office to check the claim status. Could you please help me?
[AGENT][POSITIVE] I'd be happy to assist with claim status today [PII] if I can get a good call back number for you.
[CUSTOMER][NEUTRAL] OK. My callback number is [PII].
[AGENT][NEUTRAL] And what is the policy number?
[CUSTOMER][NEUTRAL] And the member's ID is [PII].
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name [PII] and date of birth, [PII].
[AGENT][NEUTRAL] And what is the date of service for the claim?
[CUSTOMER][NEUTRAL] And the date of service is [PII] and total charge of almost $660 even.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes, Z as in Zulu. A as in Alpha.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][POSITIVE] Thank you for that one moment.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, I'm showing that the claim denied because their wellness benefit had already maxed out for the year.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] You mean benefits exceeded for this service, right?
[AGENT][NEUTRAL] Yes, their benefit had already maxed out before we received the claim.
[CUSTOMER][NEUTRAL] OK. How many units are allowed for the CPT?
[AGENT][NEUTRAL] They have a $1 benefit amount of $250 per year and we had already paid that out before we received your claim.
[CUSTOMER][NEUTRAL] Can
[CUSTOMER][NEUTRAL] OK, on which date of service it was already paid?
[AGENT][NEUTRAL] It was paid to another provider.
[CUSTOMER][NEUTRAL] Oh, OK. Just a moment. On which date of service?
[AGENT][NEUTRAL] Um, I can't give that information because it's a claim for a different provider.
[CUSTOMER][NEUTRAL] OK. For the CPT only $250 allowed, right?
[AGENT][NEUTRAL] For any wellness, any wellness CPT codes.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Per year, right?
[AGENT][NEUTRAL] Yeah, they have a $250 calendar year maximum for wellness benefits, and they maxed out before we received your claim.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK. Can you provide the claim number?
[AGENT][NEUTRAL] Your claim number is 3557089.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] No, I'm not asking my claim number. I'm asking different claim number.
[AGENT][NEUTRAL] The what?
[CUSTOMER][NEUTRAL] So
[CUSTOMER][NEUTRAL] You mean, previously, uh, for this service, uh, uh,
[CUSTOMER][NEUTRAL] Paid amount, right?
[AGENT][NEUTRAL] I can't give you another provider's claim number.
[CUSTOMER][NEUTRAL] 4
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That's what I'm asking.
[AGENT][NEUTRAL] OK, we can't give you another provider's claim number that's their claim number just like we wouldn't give another provider your claim number.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So what is the claim number?
[AGENT][NEUTRAL] Do you want your claim number for the claim that you that you guys file?
[CUSTOMER][NEUTRAL] How many people.
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] OK, well, I don't understand what you're asking me. I'm sorry.
[CUSTOMER][NEUTRAL] Just a moment.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Like uh we also we also.
[CUSTOMER][NEUTRAL] OK, for this patient, uh, for this service, only $250 allowed per year, right?
[AGENT][NEUTRAL] Yes, it's 250 per year.
[CUSTOMER][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] But upon checking, we didn't receive any payment on the year [PII] related to the service.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Can you verify one more time?
[AGENT][NEUTRAL] Right, you're calling in regards to data service [PII], correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and the claim denied because we had already paid out their wellness benefit for the year before we received your claim.
[CUSTOMER][NEUTRAL] OK. When it was paid?
[AGENT][NEUTRAL] That was paid to a different provider.
[CUSTOMER][NEUTRAL] On which date of service?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It was before you filed your claim.
[CUSTOMER][NEUTRAL] You mean different facility, right?
[AGENT][NEUTRAL] It was before you filed your claim.
[CUSTOMER][NEUTRAL] You mean
[CUSTOMER][NEUTRAL] And what is the claim number? Paid claim number.
[AGENT][NEUTRAL] OK, I, that is for a different provider. I cannot give you another provider's claim information. I can only give you claim information pertaining to the claim that your company filed.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Facility also different, right?
[AGENT][NEUTRAL] I'm sorry, repeat that.
[CUSTOMER][NEUTRAL] Facility also different, right?
[AGENT][NEUTRAL] I don't understand what you're saying. I'm sorry.
[CUSTOMER][NEUTRAL] Provider and facility also different, right?
[AGENT][NEUTRAL] You said provider and what is different?
[CUSTOMER][NEUTRAL] They
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] One moment, please.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] But I don't see any payment for this CPT on the year [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I do have only 2 claims on the year [PII].
[AGENT][NEUTRAL] Is there, is there a supervisor that I can speak is there, is there a supervisor I can speak with?
[CUSTOMER][NEUTRAL] Sorry?
[AGENT][NEUTRAL] Do you have a supervisor that I can speak with?
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] Yeah.