AccountId: 011433970860
ContactId: 1eb05fe8-a9b9-4c68-b624-6009657666a3
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 727869 ms
Total Talk Time (AGENT): 160390 ms
Total Talk Time (CUSTOMER): 221111 ms
Interruptions: 0
Overall Sentiment: AGENT=0, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/03/1eb05fe8-a9b9-4c68-b624-6009657666a3_20250603T18:34_UTC.wav
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[AGENT][NEUTRAL] Calling APL, my name is [PII]. How can I assist you today?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII]. I'm calling from Nicholas Children Hospital. May I know the status of claim, please?
[AGENT][NEUTRAL] Yeah
[AGENT][POSITIVE] I'd be happy to assist with same uh claim status today, [PII], if I can get a good call back number for you.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] The
[AGENT][NEUTRAL] And what is the policy number?
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] The policy number is uh
[CUSTOMER][NEUTRAL] 02497629
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] OK. The patient's first name is [PII] and last name is uh [PII].
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] The date of birth is [PII].
[AGENT][NEUTRAL] And the date of service for the claim?
[CUSTOMER][NEUTRAL] Mm [PII].
[AGENT][NEUTRAL] And your tax ID.
[CUSTOMER][NEUTRAL] Your name, please?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK. [PII].
[AGENT][NEUTRAL] Thank you for that information. I'm showing the claim was denied because we need the EOB from the primary insurance.
[CUSTOMER][NEUTRAL] OK, and what's the claim number?
[AGENT][NEUTRAL] 356-2201
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEGATIVE] And this, uh, the denied it.
[AGENT][NEUTRAL] Claim was denied on [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, can you give me the call reference number for please?
[AGENT][NEUTRAL] Was very
[AGENT][NEUTRAL] Reference is just my name [PII] last initial [PII], and the date and time of the call.
[CUSTOMER][NEUTRAL] OK, and give me the next claim status, please.
[AGENT][NEUTRAL] Is it a different member or the same member?
[CUSTOMER][NEUTRAL] Different member same facility.
[AGENT][NEUTRAL] What's the policy number?
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] And the policy number is 14414693.
[AGENT][NEUTRAL] Um, repeat that for me because that doesn't.
[AGENT][NEUTRAL] Sounds like one of our policy numbers.
[CUSTOMER][NEUTRAL] 144
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 14693 1 yeah I'm uh now being debated 14414693.
[AGENT][NEUTRAL] That's not one of our policy numbers. Do you have a social?
[CUSTOMER][NEGATIVE] Uh, no.
[AGENT][NEUTRAL] What's the name?
[CUSTOMER][NEUTRAL] I have a uh um the name is.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, one moment.
[CUSTOMER][NEUTRAL] The name is [PII]. Sorry, I'm asking the same.
[CUSTOMER][NEUTRAL] And the different, uh, can you, uh,
[CUSTOMER][NEUTRAL] And uh again uh the correct member ID?
[AGENT][NEUTRAL] I'm sorry, I don't understand.
[CUSTOMER][NEGATIVE] OK, please not correct member ID that was my mistake.
[AGENT][NEUTRAL] What's the ID number?
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] What is the policy number?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] 14414693
[AGENT][NEUTRAL] OK, that's not one of our policy numbers.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can you give me the correct?
[CUSTOMER][NEUTRAL] OK. Well, let me check again, the policy number 80062.
[AGENT][NEUTRAL] OK, that's not a valid policy number.
[AGENT][NEUTRAL] What's the patient's name?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] The patient's first name is uh [PII]. Last name is uh [PII].
[AGENT][NEUTRAL] Spell the last name for me?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] We don't have anyone in our system by that name.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Hello. Can you check, uh, again the, uh, is [PII] by this ID?
[AGENT][NEUTRAL] That's not one of our IDs.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][POSITIVE] OK, no issue. And give me the next test status, please.
[AGENT][NEUTRAL] What next status?
[CUSTOMER][NEUTRAL] Mm.
[CUSTOMER][NEUTRAL] Next different uh member in the same facility.
[AGENT][NEUTRAL] OK, can I have a policy number?
[CUSTOMER][NEUTRAL] Yeah, sure.
[CUSTOMER][NEUTRAL] The policy number is 02440231.
[CUSTOMER][NEUTRAL] ML 8.
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] First name is uh [PII] Last name is uh [PII]
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] And the date of service for the claim?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And the tax ID?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEGATIVE] I'm showing that claim denied because the outpatient benefit has maxed out for the year.
[CUSTOMER][NEUTRAL] Uh, denied due to?
[AGENT][NEUTRAL] Outpatient benefit maxed out.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][POSITIVE] Benefit, the max.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Uh, how many units are allowed for this year?
[AGENT][NEUTRAL] They have a dollar amount benefit and it is $3000 per year.
[CUSTOMER][NEUTRAL] And they have an $8 amount for this year.
[AGENT][NEUTRAL] 3000 per calendar year for outpatient and it was already maxed out when we received your claim.
[CUSTOMER][NEUTRAL] Am I right?
[CUSTOMER][NEUTRAL] Uh, one moment, and denied as a benefit max out this year and they have a, uh, 3000. Am I right?
[AGENT][NEUTRAL] Their outpatient maximum per year per calendar year is $3000. When we received the claim from your facility, they had already used all their benefits. There was nothing left for us to pay.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what's the claim number?
[AGENT][NEUTRAL] Claim number is 3572002.
[CUSTOMER][NEUTRAL] 79.
[AGENT][NEUTRAL] 3572002
[CUSTOMER][NEUTRAL] 72,035,720.
[AGENT][NEUTRAL] 02.
[CUSTOMER][NEUTRAL] 357202.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK. And denied it?
[AGENT][NEUTRAL] Claim was denied on [PII].
[CUSTOMER][NEUTRAL] Call reference number?
[AGENT][NEUTRAL] Reference is just my name [PII] last initial [PII], and the date and time of the call. Was there anything else I could assist with today?
[CUSTOMER][NEUTRAL] Same as previous.
[CUSTOMER][NEUTRAL] Yeah, give me then one more claim status.
[AGENT][NEUTRAL] What is the policy number?
[CUSTOMER][NEUTRAL] One second.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Policy number 021175.
[CUSTOMER][NEUTRAL] 79 ML 7.
[AGENT][NEUTRAL] Patient's name and date of birth.
[CUSTOMER][NEUTRAL] First name, [PII]. Last name is [PII].
[CUSTOMER][NEUTRAL] Date of birth is [PII].
[AGENT][NEUTRAL] Data service for the claim?
[CUSTOMER][NEUTRAL] 727 2024.
[AGENT][NEGATIVE] Claim denied because we need the EOB from the primary insurance.
[CUSTOMER][NEUTRAL] OK, and the claim number?
[AGENT][NEUTRAL] Claim number is 3512536.
[CUSTOMER][NEUTRAL] Can you repeat?
[AGENT][NEUTRAL] 351-253-6
[CUSTOMER][NEGATIVE] Denied it.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] OK, thank you so much. Have a great day.
[AGENT][POSITIVE] Thank you for calling APL. Have a good day.