AccountId: 011433970860
ContactId: 200f2791-4c3d-4563-adda-ebf5487a60ca
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 342109 ms
Total Talk Time (AGENT): 125353 ms
Total Talk Time (CUSTOMER): 61516 ms
Interruptions: 0
Overall Sentiment: AGENT=0.6, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/20/200f2791-4c3d-4563-adda-ebf5487a60ca_20250220T16:31_UTC.wav
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[AGENT][NEUTRAL] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] for the provider to check on additional option on a claim that has been denied. Please note, this call will be monitored and recorded for quality and training purposes.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, sure, I can assist you with claims Mr. [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Callback number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] It's a direct line.
[AGENT][NEUTRAL] I think
[AGENT][NEUTRAL] Mhm. Thank you. All right, and may I have the patient's policy number, Mr. [PII]?
[CUSTOMER][NEUTRAL] Policy number is
[CUSTOMER][NEUTRAL] 014
[CUSTOMER][NEUTRAL] 572
[CUSTOMER][NEUTRAL] 33
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Patient's name is [PII], with the date of birth, [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Thank you. And uh do you have the claim number or you have the date of service?
[CUSTOMER][NEUTRAL] I have the claim number. It's 355.
[CUSTOMER][NEUTRAL] 7060.
[AGENT][NEUTRAL] OK, thank you. One moment, let me pull out the image of that EOB, OK? One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so this one was denied, let's see, I care socialist.
[AGENT][NEUTRAL] Um,
[AGENT][NEUTRAL] No so this is a duplicate. Let me check and see if I can find the original 11 moment.
[AGENT][NEUTRAL] That's for [PII].
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it looks like the original one was processed and denied because the outpatient maximum for the calendar year has been met, um, so this, this number doesn't have any other benefits available for that year. So it's gonna be up to the provider's discretion. Um, they can either go back to the primary EOB and just apply it towards the member's responsibility, or they can just make their own decision. We don't have any contractual involvement on the remaining.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] They already assess to their benefit with us.
[CUSTOMER][NEUTRAL] And how much is the allowed amount for, for outpatient visit?
[AGENT][NEUTRAL] OK.
[AGENT][POSITIVE] Um, yes, let me get that for you.
[AGENT][NEUTRAL] So it looks like she has, or he has or she has calendar year maximum of 2500.
[CUSTOMER][NEUTRAL] And when was it last bill, the outpatient visit?
[CUSTOMER][NEUTRAL] Or last paid?
[AGENT][NEUTRAL] We cannot release that information because it doesn't pertain to your claim or to your provider that you're calling from, so we cannot release that information. The only thing I can give you is the denial or reason of the claim.
[CUSTOMER][NEUTRAL] Thank you. And the outstanding amount is it the patient's responsibility?
[AGENT][NEUTRAL] Again, we don't have any contractual involvement on the remaining of the claim, so it's up to the provider's discretion. Again, they can go back to the primary EOB and just apply towards the member responsibility, or they can make their own decision. We cannot really tell you what to do with the remaining.
[CUSTOMER][NEUTRAL] Thank you. And the card reference number, please?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] We don't have reference numbers you can use my name in today's date if you will.
[CUSTOMER][NEUTRAL] And can I have your name spelled and your last name initial?
[AGENT][NEUTRAL] Yes, [PII].
[CUSTOMER][POSITIVE] Thank you for your assistance. Have a great day.
[AGENT][POSITIVE] You're welcome. You as well, Mr. [PII] and thank you for calling APL. Bye-bye.
[CUSTOMER][NEUTRAL] Bye.