AccountId: 011433970860
ContactId: 20ddfce4-efe6-4475-9b64-d6b716fec917
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 892359 ms
Total Talk Time (AGENT): 212181 ms
Total Talk Time (CUSTOMER): 177409 ms
Interruptions: 0
Overall Sentiment: AGENT=0.8, CUSTOMER=-1.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/03/20ddfce4-efe6-4475-9b64-d6b716fec917_20250103T15:58_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Yeah, hi, sir. This is [PII] calling from provider of to Chi on Clinic.
[AGENT][POSITIVE] OK, sure, I can assist you with time, [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Uh-huh. It's [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Thank you. And may I have the patient's policy number?
[CUSTOMER][NEUTRAL] Yes. It's 02212163, M as in Mike, L as in Lima.
[CUSTOMER][NEUTRAL] And number 8.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] What's the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] Yes. So the patient's first name I have is [PII], last name is [PII]. Their date of birth is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] All right. What is the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yes. So, the date of services I'm looking for is uh two date of service I have. One is for [PII] and uh with the charge amount, I have it's one moment.
[CUSTOMER][NEUTRAL] So it's $153.
[AGENT][NEUTRAL] OK, thank you. Let me see if I can find this claim for you and for future, you can check claim status online through our website at [PII] and that's just optional.
[AGENT][NEUTRAL] Um, let's see, so that was [PII].
[AGENT][NEUTRAL] OK, let me see if this is your plate. One moment.
[AGENT][NEUTRAL] OK, mm just adding.
[AGENT][NEUTRAL] Do you know what the procedure codes or?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] And the first procedure code I have is A as in Alpha, 7038 and the other code is A as in Alpha, 301.
[AGENT][NEUTRAL] Is it just those two codes or is it more than those two codes?
[CUSTOMER][NEUTRAL] Do you have a claim?
[CUSTOMER][NEUTRAL] Uh, only for the two girls.
[AGENT][NEUTRAL] OK, I don't have one just with those two codes. I got, uh, I got a claim but it has more than one, just two codes.
[CUSTOMER][NEUTRAL] Uh, one moment. Let me give you the claim number.
[AGENT][NEUTRAL] Mhm. Mhm.
[CUSTOMER][NEUTRAL] Uh, I, I, I mean, the same data service, we have two bills amount.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, the claim number I have.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Um, it's uh 353-0705.
[AGENT][NEUTRAL] OK, that is for a total of $681. Is that correct?
[CUSTOMER][NEUTRAL] Oh, OK. OK, OK. Yes. So they split up the claim and they paid. And uh, so my question is in that same code, uh, the
[CUSTOMER][NEUTRAL] A as in Alpha 7038 has been denied. Uh, can I have the reason why it has been denied?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, the reason for the denial on the 7038 is that um we do not cover disposable supply, that is a disposable supply.
[CUSTOMER][NEUTRAL] OK. For this patient, that code is not covered under this plan?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And uh yes, can I have another data service too. Can you check that too? Uh whether do you have any claim or claim.
[AGENT][NEUTRAL] OK, what is your date of birth?
[CUSTOMER][NEUTRAL] It's for [PII].
[AGENT][NEUTRAL] [PII]? OK.
[CUSTOMER][NEUTRAL] Yes, [PII].
[AGENT][NEUTRAL] OK, and how much is that one for?
[CUSTOMER][NEUTRAL] Uh, it's, uh, it's for one moment. It's 153, hold on.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so it looks like that one was denied stating that the maximum per calendar year has been met.
[AGENT][NEGATIVE] So the maximum has been exhausted.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, for the code ASN 7031.
[AGENT][NEUTRAL] I'm sorry, can you repeat?
[CUSTOMER][NEGATIVE] Uh, yes, for which code it has been denied. You mean the A7038 is not covered under this plan?
[AGENT][NEUTRAL] Both
[AGENT][NEGATIVE] Both quotes have been denied because um the first one is not covered under the plan. The second one is not payable because the maximum benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] OK. How many units is allowed for the call?
[AGENT][NEUTRAL] It's not about units. It's about the maximum benefit.
[CUSTOMER][NEUTRAL] Uh, yeah, can you see that benefit about that one?
[AGENT][NEUTRAL] OK, that's 3000 per covered person per calendar year.
[CUSTOMER][NEUTRAL] OK, so we can build that code once in a year?
[AGENT][NEUTRAL] No. Again, um, let me go ahead and explain to you how this works, Ms. [PII]. This is a secondary supplemental plan to the major medical. What we do is we help with the high deductibles, co-payment, and co-insurance from the major medical.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] The maximum benefit per year for outpatient services is 3000, and this is for any outpatient service. We cover up to 3000 after they use all the 3000, then we'll deny stating that all benefits have been exhausted for the year, which is the denial that you see on this EOB outpatient benefits for the calendar year has been met.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] So, can I have the EOB to be fax?
[AGENT][NEUTRAL] What is the fax number?
[CUSTOMER][NEUTRAL] 678
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh yes. So when did you receive the claim?
[AGENT][NEUTRAL] When we do, you need to know when we received the claim? Is that what you're asking?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, let me get that for you. And to what attention do I need to send this fax to?
[CUSTOMER][NEUTRAL] Yeah, yeah, right.
[CUSTOMER][NEUTRAL] Um, to my name, it's [PII].
[AGENT][POSITIVE] OK. Alright, thank you.
[AGENT][NEUTRAL] OK, we received the claim [PII], processed [PII]. And do you mind holding for me so I can send this fax out to you.
[CUSTOMER][NEUTRAL] Yeah, sure. I'll just wait.
[AGENT][POSITIVE] Thank you. Bye.
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEGATIVE] You are on hold.
[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 Miss [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?
[CUSTOMER][NEUTRAL] Oh yeah.
[CUSTOMER][NEUTRAL] Uh yes. Can you give me the claim number?
[AGENT][NEUTRAL] OK, that's 353-7854.
[CUSTOMER][POSITIVE] 54. OK, thank you so much. And uh can you give me the call reference number?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will.
[CUSTOMER][NEUTRAL] Yeah, can, yeah, can I have?
[AGENT][NEUTRAL] My name is [PII]. That's [PII]. Last initial is [PII].
[CUSTOMER][POSITIVE] OK. Thank you so much for assisting me and a great day and happy weekend.
[AGENT][POSITIVE] US so thank you for calling ATL. bye bye, Miss.