AccountId: 011433970860
ContactId: 221a1d0b-669d-4221-941e-2b1c58171747
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 820469 ms
Total Talk Time (AGENT): 333322 ms
Total Talk Time (CUSTOMER): 244463 ms
Interruptions: 2
Overall Sentiment: AGENT=1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/16/221a1d0b-669d-4221-941e-2b1c58171747_20250116T18:12_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi [PII]. My name is [PII] and I'm calling you from the provider's office to check up on the claim status.
[AGENT][NEUTRAL] OK, [PII], you're needing to check claim status, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, I can help you with that. And what is your callback number, please?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][POSITIVE] Thank you and [PII]
[CUSTOMER][NEGATIVE] It's a direct line with no extension.
[AGENT][NEUTRAL] OK, perfect. Thank you. And how many claims, [PII], do you have to check status on?
[CUSTOMER][NEUTRAL] Um, 2.
[AGENT][NEUTRAL] OK, is it for the same member or is it for different members?
[CUSTOMER][NEUTRAL] That's
[CUSTOMER][NEUTRAL] Different member.
[AGENT][NEUTRAL] OK, yes, I can help you with both of them, and [PII], you will use my name along with today's date as your call reference number for each one.
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Also any information that I.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] You, how do you spell your name, [PII]?
[AGENT][NEUTRAL] No, [PII]
[CUSTOMER][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] I
[CUSTOMER][NEUTRAL] All right, [PII].
[AGENT][NEUTRAL] [PII] I don't, yes, the last letter is [PII]
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Got it.
[AGENT][NEUTRAL] And also any information [PII] that I provide for you on the claims will be a verification of benefits and not a guarantee of payment. And lastly, if you need a copy of either explanation of benefits if we have the claim on file, you can print them from our portal by going to secured.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] Yes, sir. And what is your first patient's policy number?
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] 0241
[CUSTOMER][NEUTRAL] 5283.
[CUSTOMER][NEUTRAL] And M as in Mike, L as in Lima, and number 8.
[AGENT][POSITIVE] Thank you.
[CUSTOMER][POSITIVE] You're welcome.
[AGENT][NEUTRAL] And any information that I do, uh, well I've already given you that, so never mind, [PII], I was about to repeat myself to you.
[CUSTOMER][POSITIVE] Mhm no problem.
[AGENT][NEUTRAL] OK, so what is your patient's name please and their date of birth?
[CUSTOMER][NEUTRAL] First name is [PII], last name is [PII]. Date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And what is the date of service and total bill amount for him please?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Date of service is [PII].
[CUSTOMER][NEUTRAL] And uh.
[CUSTOMER][NEUTRAL] I need to calculate the total bill amount because we have this one.
[AGENT][NEUTRAL] OK, that'll be fine.
[AGENT][NEUTRAL] And you did say the service is gonna be 1204, is that correct?
[AGENT][NEUTRAL] 12012, [PII].
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] No, just give me a moment.
[CUSTOMER][NEUTRAL] 60.
[CUSTOMER][NEUTRAL] It should be 1554, 1,554.
[AGENT][NEUTRAL] 1554. Is that correct?
[CUSTOMER][NEUTRAL] Mhm. Yeah.
[AGENT][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] OK, so I do not see a claim on file for him for that data service and that total bill amount.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, actually, uh, we have received a main charge payment from [PII] and uh the remaining leftover balance is billed to your insurance.
[AGENT][NEUTRAL] OK, we do not have a claim on file for $1,554.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Um, what about 1487?
[AGENT][NEUTRAL] One moment, please.
[AGENT][NEUTRAL] Yes, that claim was received on [PII].
[AGENT][NEUTRAL] And it was processed on [PII].
[AGENT][NEUTRAL] The claim number is 3546215.
[AGENT][NEUTRAL] And give me just one moment please.
[CUSTOMER][NEUTRAL] I'm sorry, I missed out the process date.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII], OK.
[AGENT][NEUTRAL] And did you get the claim number?
[CUSTOMER][NEUTRAL] Yeah, 3546215.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And that claim was denied.
[AGENT][NEUTRAL] The reason for the denial, Paul on this one states the maximum benefit payable.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][POSITIVE] For this state of service has been met.
[CUSTOMER][NEUTRAL] And it was met by a visit or is it by uh value?
[AGENT][NEUTRAL] Value
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Maximum visit of value.
[AGENT][NEUTRAL] The exact remark reads as follows the maximum benefit payable.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] For this date of service has been met.
[CUSTOMER][NEUTRAL] And uh if you could help me on which uh claim.
[AGENT][NEUTRAL] Yes, sir. It's another provider's claim and I can't provide information. We just received another claim prior to your claim being received.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] So it was paid to a different provider?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right. And uh the last thing, uh, may I know the member's plan name?
[AGENT][NEUTRAL] This is a supplemental policy and it's called Medlik mhm so Medlink and.
[CUSTOMER][NEUTRAL] Supplement
[CUSTOMER][NEUTRAL] Supplemented.
[AGENT][NEUTRAL] Yes, they're supplemental. We are not a major medical insurance company.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Alright, so as you have already provided me the call reference number, so I have the uh uh so I have the other claim.
[AGENT][NEUTRAL] Mhm. Yes, sir.
[AGENT][NEUTRAL] OK, so just one, and you said it's for a different member, is that correct?
[CUSTOMER][POSITIVE] That's correct.
[AGENT][NEUTRAL] OK, so one moment, please.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] OK, and what is the next patient's policy number?
[CUSTOMER][NEUTRAL] Sure. It's uh 1337.
[CUSTOMER][NEUTRAL] 109.
[CUSTOMER][NEUTRAL] M as in Mike. L as in Lima, the number 8.
[AGENT][POSITIVE] Thank you. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] And your patient's name please and date of birth?
[CUSTOMER][NEUTRAL] Sure. First name is [PII]. Last name is [PII].
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the date of service and total build amount please [PII].
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Um,
[CUSTOMER][NEUTRAL] Data service is showing as [PII] for the bill amount $106 even.
[AGENT][NEUTRAL] 1006. Is that correct?
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][POSITIVE] Thank you. OK, thank you.
[CUSTOMER][NEUTRAL] Yes, it is.
[AGENT][NEUTRAL] OK, so this claim has been received more than once. The most recently received claim was denied as a duplicate of previously submitted expenses. Do you need that information or the original claim information?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Or original claim information.
[AGENT][NEUTRAL] OK, sure, one moment.
[CUSTOMER][NEUTRAL] It
[CUSTOMER][NEUTRAL] We have also sent you the corrected claim.
[AGENT][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so this claim.
[AGENT][NEUTRAL] Just one moment.
[AGENT][NEUTRAL] This claim was received 75 and it was processed on 79.
[CUSTOMER][NEUTRAL] And
[AGENT][NEUTRAL] The claim number is 347.
[AGENT][NEUTRAL] 8307.
[AGENT][NEUTRAL] And the denial on this claim states.
[AGENT][NEUTRAL] Outpatient benefit.
[CUSTOMER][NEUTRAL] Is that what I mean?
[AGENT][NEUTRAL] For this calendar year.
[AGENT][NEUTRAL] has been met.
[CUSTOMER][NEUTRAL] A
[CUSTOMER][NEUTRAL] I know
[CUSTOMER][NEUTRAL] Outpatient benefits for this year.
[AGENT][NEUTRAL] Uh-huh, for this calendar year has been met.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So um
[CUSTOMER][NEUTRAL] Can you, OK, so is it also the, the payment has been made to a different provider and you can't give me the information?
[AGENT][NEUTRAL] Yes, sir. The, the benefit, the calendar year benefits were already exhausted when this claim was received.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] And it was exhausted by the value or a visit.
[AGENT][POSITIVE] I value.
[CUSTOMER][NEUTRAL] Is there any particular amount?
[AGENT][NEUTRAL] The outpatient benefit maximum per calendar year for covered outpatient services is $2500.
[AGENT][NEUTRAL] With no outpatient deductible. Mhm.
[CUSTOMER][NEUTRAL] 2
[CUSTOMER][NEUTRAL] 2500, OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And for the previous claim also it was the value of 2500.
[AGENT][NEUTRAL] I'm not in that policy anymore. No, so I didn't look at that because, yeah, I'm not in that policy anymore.
[CUSTOMER][NEUTRAL] I forgot
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah I, I, I forgot to ask that. OK, no problem.
[AGENT][POSITIVE] I believe that one was, I can look at it if you need me to. I'll be happy to do that.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] That will be great.
[AGENT][NEUTRAL] Once we're finished, OK, once we're completely finished with this one, I will pull that policy back up.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Call reference same [PII] today's date.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes sir, that is correct. And was there any other information on this one, [PII], that you needed?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] OK, so one moment please while I pull that other policy back up.
[CUSTOMER][NEUTRAL] Did you
[AGENT][NEUTRAL] On this number on the original, the first claim that we did, [PII], the outpatient benefit maximum is a per calendar day benefit for covered outpatient services and the max benefit amount per calendar day is $400 per covered person.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] All right.
[AGENT][NEUTRAL] Yes sir, and there was no outpatient deductible per calendar day.
[CUSTOMER][NEUTRAL] All right.
[CUSTOMER][POSITIVE] Thank you so much for all your assistance today, [PII].
[AGENT][POSITIVE] Well, you are very welcome and
[CUSTOMER][NEUTRAL] You may have a mhm.
[AGENT][NEUTRAL] I was gonna ask you just one more time, is there anything else I can help you with?
[CUSTOMER][POSITIVE] Not for today, [PII]. You have been really helpful today.
[AGENT][POSITIVE] Well, you, it was my pleasure in helping you and thank you again [PII] then for calling APL. I hope you have a great afternoon.
[CUSTOMER][NEUTRAL] You too. Bye for now.
[AGENT][POSITIVE] Thank you. Uh-huh. Bye-bye.