AccountId: 011433970860
ContactId: 1f931fe8-9e00-4b4f-870d-de2593dedfb0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1638180 ms
Total Talk Time (AGENT): 413342 ms
Total Talk Time (CUSTOMER): 327671 ms
Interruptions: 2
Overall Sentiment: AGENT=0.3, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/08/1f931fe8-9e00-4b4f-870d-de2593dedfb0_20250408T13:54_UTC.wav
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[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] from providers office.
[CUSTOMER][NEUTRAL] I want to know the client status.
[AGENT][NEUTRAL] How many
[AGENT][NEUTRAL] OK, how do you spell your name?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and may I have a callback number just in case we get disconnected in this issue.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. And what's the name of the facility you're calling from?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, Samilton Hospital Roy.
[AGENT][NEUTRAL] Hello.
[AGENT][NEUTRAL] What's the name again?
[CUSTOMER][NEUTRAL] Famiton Hospital, right.
[AGENT][NEUTRAL] I
[AGENT][NEUTRAL] OK. Thank you. May I have the patient's policy number?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 1330836 M as in Mike L as in Lima 8.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][NEUTRAL] OK, perfect. And what is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] 124. How much is the total charge?
[CUSTOMER][NEUTRAL] $468 even.
[AGENT][NEUTRAL] Alright, so [PII] for 468, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK. And for future, you can check claim status online through our website at [PII] and that's just optional. And let me pull the EOB one moment.
[AGENT][NEUTRAL] OK, so the claim has been processed twice. The most recent one was processed as a duplicate, so I'm gonna give you the information of the original claim, OK?
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Um, the original claim was processed on [PII], and it was denied. The reason for the denial is that outpatient benefits for the calendar year has been met.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Can you please tell me that then I.
[AGENT][NEUTRAL] Outpatient benefits for the calendar year has been met.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, can you please again tell me the process date.
[AGENT][NEUTRAL] The process date was [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you need the claim number?
[CUSTOMER][NEUTRAL] Yeah, yes.
[AGENT][NEUTRAL] OK, the claim number is 353-5212.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What is the pay date?
[AGENT][NEUTRAL] The processing?
[CUSTOMER][NEUTRAL] OK, a loan amount.
[AGENT][NEUTRAL] OK, yeah, um, the, the claim was not paid. The claim was not paid. The claim was denied outpatient max, um.
[AGENT][NEUTRAL] So we don't have an allowed amount.
[AGENT][NEUTRAL] We are um just a secondary.
[AGENT][NEUTRAL] For this member.
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Yes, Miss.
[AGENT][NEUTRAL] Again, the claim was processed and denied, so it, it is the denial reason, which is the outpatient benefits for the calendar year has been met. So there's not pay amount or allowed amount.
[CUSTOMER][NEUTRAL] OK. Wait a minute.
[CUSTOMER][NEUTRAL] Can you please spell your name?
[AGENT][NEUTRAL] Sure, my name is [PII]. Yes, can you hear me?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Yeah, yes.
[AGENT][NEUTRAL] OK. My name is [PII].
[CUSTOMER][NEUTRAL] Yes, thank you. Wait a minute. I will get down and uh ask you some questions, uh.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, thank you for your waiting. Uh, may I get the denial date? Uh, the denial reason is patient benefits for the calendar year has been not met, right?
[AGENT][NEUTRAL] Outpatient benefits for the calendar year has been met.
[AGENT][NEUTRAL] And it's the same as the process date.
[CUSTOMER][NEUTRAL] What is the
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] But that is not a denying reason, right? Can you please tell me the denying reason?
[AGENT][NEUTRAL] That is the denial reason. It's the same one I've been telling you since the beginning. Outpatient benefits for the calendar year has been met.
[CUSTOMER][NEUTRAL] Uh, in this time, yes, uh, there is an EOB, um, uh, the EOB number is 353-5212.
[CUSTOMER][NEUTRAL] You said change the claim number and the denied reason is lack of information needed for registration or has sufficient billing.
[AGENT][NEUTRAL] No, no, no, no, no, no, Ms. [PII], um, the information I'm giving you is the correct one, so you need to write it down, OK? Outpatient benefits for the calendar year has been met, and that is the denial reason. Outpatient benefits for the calendar year has been met.
[AGENT][NEUTRAL] Under claim number 3535212. Outpatient benefits for the calendar year has been met. You can write it down like that, OK. Outpatient benefits for the calendar year has been met.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] If all of the primary insurances they can.
[CUSTOMER][NEUTRAL] Your, uh, primary insurance or secondary?
[AGENT][NEUTRAL] We're secondary.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Patient. Hello?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah, how much amount for the yearly patient benefit um?
[AGENT][NEUTRAL] OK, let me get that for you. One moment.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] OK, the calendar year maximum on this one is 750 per year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] How much he
[CUSTOMER][NEUTRAL] Be
[CUSTOMER][NEUTRAL] How much do we want for, for the amount?
[AGENT][NEUTRAL] I'm sorry, can you repeat?
[CUSTOMER][NEUTRAL] How much amount we meant?
[CUSTOMER][NEUTRAL] Patient
[AGENT][NEUTRAL] Patient met the whole amount in order for us to deny the claim stating that she used or she don't have any other outpatient benefits because she already exhausted the benefit or has met the benefit, it means she used all her benefits.
[AGENT][NEUTRAL] So if you need another word for what I'm saying on the denial, it means that she exhausted her benefit basically outpatient has been exhausted for the calendar year.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah. Hi, my name is [PII]. Uh
[AGENT][NEUTRAL] How do you spell
[CUSTOMER][NEUTRAL] Can you please help me with the, yeah, yeah. I, I, I do apologize to interrupt you.
[AGENT][NEUTRAL] It's OK. Mm.
[CUSTOMER][NEUTRAL] Can you please help me with the patient? Uh, actually, the claim was denied due to patient benefit for the calendar year has been met, right?
[AGENT][NEUTRAL] Outpatient, outpatient benefits for the calendar year has been met. That is the denial reason. Meaning outpatient benefit has been exhausted. It's the same thing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So, the outpatient benefit is uh terminated, right?
[AGENT][NEUTRAL] It's been exhausted, it means that she used all her benefits for the year.
[CUSTOMER][NEUTRAL] OK. Thank you so much. And can you please help me with the, when the patient uh met his exhausted uh amount under the claim number?
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] We cannot release that information. We can only release information that is pertaining to the claim you're calling about, to the provider you're calling about. When we receive the claim that you are calling about, the benefits already been exhausted, so that is the denial reason we cannot release information from another provider to you.
[CUSTOMER][NEUTRAL] Lastly,
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. But uh for the document documentation purpose, we have to uh
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, we, we want that information. Can you please, if you can, or else, can you please help me with the, uh, can you please help me with that, what, who are the responsible for the remaining balance?
[AGENT][NEGATIVE] No, we can't.
[AGENT][NEUTRAL] OK, we are just a secondary, and I'm sorry, what is your name again?
[CUSTOMER][NEUTRAL] Yeah, my name is [PII].
[AGENT][NEUTRAL] OK, Mr. She, OK, we are the secondary policy to the major medical. So once we process the claim and we deny the claim, you can go back to the primary EOB and decide what to do with the remaining balance that they left, OK? Because it was not payable by us because she already exhausted her benefit.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, you have the supplementary plan for the Cigna.
[AGENT][NEUTRAL] OK, we're just a secondary.
[AGENT][NEUTRAL] Correct. We are just a secondary policy, the supplemental plan. Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So, uh, actually, upon checking, the primary one is allowed $261.71.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And they are paying $196.71. Remaining balance is co-pay amount, uh, that one is patient under the patient responsibility is $65 even. That amount was transferred to
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, you, uh, so.
[AGENT][NEUTRAL] To us, mhm, correctly, yes. Mhm. But she don't have any more benefits because she already used all her benefits. So it goes right back to the patient's responsibility based on the primary EOB.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] So, uh,
[CUSTOMER][NEUTRAL] Can you please help me with this one? We want updated, it will be from you that could help us to bill to the patient, uh, without a proper reason or proper explanation of benefits, we do not bill to patient for the remaining balance of $65 even. Can you please help me with the updated it will be for your end?
[AGENT][NEUTRAL] Don't
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] What I can do, Mr. [PII] is send you a copy of this EOB because I already gave all the information of the explanation and benefits and that's all I can give to you. I cannot um give you something else that is not on the EOB. So I can only go ahead and send you a copy to this to your fax number if you would like, and that's all I can do. It's been denied. It's not gonna be paid um because she already used all her benefits, OK?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, thank you so much. We, we, we are also asking the same. Can you please provide me the denial it will be through our fax, uh, if you can.
[AGENT][NEUTRAL] What is your fax number?
[CUSTOMER][NEUTRAL] Yeah, it is [PII]. Shall I repeat it again?
[AGENT][NEUTRAL] No, [PII].
[AGENT][NEUTRAL] Is that correct? OK.
[CUSTOMER][NEUTRAL] Yes. And, yeah, yes. And attention is [PII], and today's date, it is [PII], [PII], and today's date is the attention. Can you please uh mention the attention and send through AOB.
[AGENT][NEUTRAL] OK, you need um the you said the name is [PII], and then you need uh the date and the date today's date is gonna be on which form. Is it gonna be [PII] or [PII]? How do you want that to be reflected.
[CUSTOMER][NEUTRAL] Through fas
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, OK.
[AGENT][NEUTRAL] All right, um, let me put you on a brief hold so I can go ahead and send a copy of this, OK, one moment.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] Thank you so much for your help.
[AGENT][NEUTRAL] One moment. Yes, please hold on the line so I can send it, OK?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][POSITIVE] Thank you for holding and being patient for me, Mr. [PII]. OK, I went ahead and send that over to you. It should be there in a few minutes. Is there anything else I'm gonna help you with today?
[AGENT][NEUTRAL] Hello?
[AGENT][NEUTRAL] Hm
[CUSTOMER][POSITIVE] Yeah, thank you so much for the help. And can you please help me with the tracking number that could help us to track the fax?
[AGENT][NEUTRAL] We don't have a tracking number.
[CUSTOMER][NEUTRAL] And how much time we get to receive the AOB?
[AGENT][NEUTRAL] Before the end of the day today?
[CUSTOMER][POSITIVE] Oh thank you, thank you so much for the help. And can you please help me with the call reference number?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We don't have reference numbers you can use my name in today's date.
[CUSTOMER][POSITIVE] Thank you so much.
[AGENT][POSITIVE] You're welcome. Is there anything else I can help you with today?
[CUSTOMER][POSITIVE] No, as of now. Uh thank you so much. It's nice talking to you. Have a great day.
[AGENT][POSITIVE] You're welcome. You're as well. Thank you for calling ATM.
[CUSTOMER][POSITIVE] Yeah. Take care. Take care. Bye-bye.
[AGENT][NEUTRAL] You too bye bye.