AccountId: 011433970860
ContactId: 207a8ca4-f221-4b78-82b2-528527f136ed
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 582109 ms
Total Talk Time (AGENT): 222536 ms
Total Talk Time (CUSTOMER): 241182 ms
Interruptions: 10
Overall Sentiment: AGENT=0.6, CUSTOMER=-0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/17/207a8ca4-f221-4b78-82b2-528527f136ed_20250417T13:16_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Good morning. Thank you for calling ATO. This is [PII].
[CUSTOMER][NEUTRAL] Hi, good morning, miss. Can you please spell your name for me?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII] first and your last name?
[AGENT][NEUTRAL] S
[CUSTOMER][POSITIVE] Thank you so much. My name is [PII]. First name is last name [PII], calling you from provider office looking for claim.
[AGENT][NEUTRAL] Spell your name?
[AGENT][NEUTRAL] OK, I need for you to spell your name.
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] mean
[CUSTOMER][NEUTRAL] Uh, [PII].
[AGENT][NEUTRAL] Can you spell your name?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And your last initial?
[CUSTOMER][NEUTRAL] [PII],
[AGENT][NEUTRAL] Thank you. And anything you said that you're needing to check claim status, is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, I can help you with that. And what is your callback number, please?
[CUSTOMER][NEUTRAL] [PII]. No direct line.
[AGENT][NEUTRAL] Thank you. And how many clients, [PII], do you have to check status on?
[CUSTOMER][NEUTRAL] Only one
[AGENT][NEUTRAL] OK, and what is that member's policy number, please?
[CUSTOMER][NEUTRAL] It's 244-857-2.
[AGENT][NEUTRAL] Thank you one moment while I get the member's information pulled up.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And anything, any information that I provide for you today will be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] for
[CUSTOMER][NEUTRAL] First name is [PII]. Last name is [PII], spelled as in [PII]
[CUSTOMER][NEUTRAL] The date of birth is [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] The data of service and total bill amount please.
[CUSTOMER][NEUTRAL] July uh sorry, [PII].
[CUSTOMER][NEUTRAL] And the bill amount I have, it's uh $1,895 even.
[AGENT][POSITIVE] Thank you one moment.
[CUSTOMER][NEUTRAL] Mm, yeah, and I do a specific question.
[AGENT][NEUTRAL] OK, what is the claim number?
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] 351-218-1
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Um
[AGENT][POSITIVE] OK. Yes, sir. How can I help you with that?
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] OK, miss, uh, actually, we do have to receive the denial right as uh
[CUSTOMER][NEUTRAL] Service is not covered under the member plan. Uh, can you please, uh, tell me when did you receive the claim?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Was received 926-2024.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEGATIVE] And denied on.
[AGENT][NEUTRAL] The night on [PII].
[CUSTOMER][NEUTRAL] on skin.
[CUSTOMER][NEUTRAL] OK. And what is the reason?
[AGENT][NEUTRAL] One moment.
[AGENT][NEUTRAL] The remarks specifically states the calendar your maximum for outpatient office visits due to accidents and excuse me, due to sickness and or accident.
[CUSTOMER][NEUTRAL] The remarks specifically states that calendar your max.
[CUSTOMER][NEUTRAL] For outpatient.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEGATIVE] So, uh, sorry to interrupt you. You are reading the denial.
[AGENT][NEGATIVE] The denial is.
[CUSTOMER][NEGATIVE] The denial, yeah.
[AGENT][NEUTRAL] The calendar year maximum.
[CUSTOMER][NEUTRAL] The maximum.
[AGENT][NEUTRAL] For outpatient office visits.
[CUSTOMER][NEUTRAL] For out.
[AGENT][NEUTRAL] Due to sickness and or accident.
[CUSTOMER][NEUTRAL] And or accident.
[AGENT][NEUTRAL] Has been meant for this calendar year.
[CUSTOMER][NEUTRAL] has been met for this calendar.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Uh, what is the member plan name?
[AGENT][NEGATIVE] This is a limited benefit.
[CUSTOMER][NEUTRAL] Let
[AGENT][NEUTRAL] Hospital indemnity plan.
[CUSTOMER][NEUTRAL] Hospital and
[AGENT][NEUTRAL] Indemnity.
[CUSTOMER][NEUTRAL] How to spell?
[AGENT][NEUTRAL] I N D E M N I T Y. This is not major medical insurance.
[CUSTOMER][NEUTRAL] I I N.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I N D E M.
[AGENT][NEUTRAL] N I T Y.
[CUSTOMER][NEUTRAL] N I T Y.
[CUSTOMER][NEUTRAL] Uh, I repeat, I N D E M N I T Y, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK. And uh can you please uh tell me one more thing like uh how is benefit maximum?
[AGENT][NEUTRAL] What's your question?
[CUSTOMER][NEUTRAL] How many like uh benefit maximum for this claim?
[AGENT][NEUTRAL] The maximum number of visits per calendar year, is that what you're asking? It's 4?
[CUSTOMER][NEUTRAL] And.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] Yes sir, I just gave you the number.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEGATIVE] Uh, for the entire call I'm talking about claim got denied.
[AGENT][NEUTRAL] I read you the remark as for the specific reason of the denial.
[CUSTOMER][NEUTRAL] OK. Do you have the copy of EOB?
[AGENT][NEUTRAL] You may print that by going to our portal at [PII].
[CUSTOMER][NEUTRAL] Is it like manual log in or we need to create a like sign up your portal?
[AGENT][NEUTRAL] You would be, you would be able to sign up for it yourself. It's a self-registering portal now that you have the claim number.
[CUSTOMER][NEUTRAL] You would be you would be able to sign up for it.
[CUSTOMER][NEUTRAL] Now that we have to find.
[CUSTOMER][NEUTRAL] Just a moment
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I need the benefit maximum like how many times we can build these services for this particular code which we have already.
[AGENT][POSITIVE] Yes sir, yes.
[AGENT][NEUTRAL] I get, OK, so one more time, [PII], the maximum number of visits per calendar year on this limited benefit plan is 4. That was already met prior to your claim being received.
[CUSTOMER][NEUTRAL] I did OK.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. Only 4, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Uh, OK. Just uh hold on.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] I'm checking just a moment.
[CUSTOMER][NEUTRAL] And what is the call reference number?
[AGENT][NEUTRAL] It would be my name in today's date, and the website for our portal, Ethan is secured.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And if you'll go ahead and give me your fax number, I will fax this one to you.
[CUSTOMER][NEUTRAL] Go ahead and give me your fax number I will fax.
[CUSTOMER][NEUTRAL] Yeah, please uh take the fax number, 631.
[CUSTOMER][NEUTRAL] And you said it like uh we can bill 4 time, right?
[AGENT][NEUTRAL] No, sir. I said that the maximum number of visits on this limited benefit plan per calendar year would be 4.
[CUSTOMER][NEUTRAL] There, I said that the map.
[CUSTOMER][NEUTRAL] For a visit on this limited benefit plan for calendar year would be 4.
[AGENT][NEUTRAL] And does this facts need to be put to your attention, [PII], or is that not necessary?
[CUSTOMER][NEUTRAL] Just a moment. Your fax number is [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. Do I, again, do I need to put your name on there or not?
[CUSTOMER][NEUTRAL] Yes, yes.
[AGENT][NEUTRAL] One moment for me to get that information pulled up.
[CUSTOMER][NEUTRAL] One moment you want me to get that.
[CUSTOMER][NEUTRAL] And how much time it will take?
[AGENT][NEUTRAL] [PII], give me a moment. I'm working on sending it to you at this moment, so it's gonna be dependent upon if your fax can receive it, but it has been sent.
[CUSTOMER][NEUTRAL] If you're
[CUSTOMER][NEUTRAL] But it
[AGENT][NEUTRAL] And it's been sent to
[AGENT][NEUTRAL] [PII] and if for any reason you do not receive it, you would just need to print that from our portal at the website that I gave you.
[CUSTOMER][NEUTRAL] 10 and if for any reason we do not.
[AGENT][NEUTRAL] And is there anything else that I can help you with this morning?
[CUSTOMER][POSITIVE] No, thank you so much. Bye-bye.
[AGENT][POSITIVE] All right. Well, you're very welcome and thank you for calling APL. Have a nice day.
[CUSTOMER][POSITIVE] You're very welcome.