AccountId: 011433970860
ContactId: 239c5160-d962-4784-9610-f010f1f99932
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1042680 ms
Total Talk Time (AGENT): 224514 ms
Total Talk Time (CUSTOMER): 414218 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/01/239c5160-d962-4784-9610-f010f1f99932_20250501T14:35_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hello [PII], this is [PII] calling for Prodi's office to check on a claim status. How is your day, [PII]? How are you doing today?
[AGENT][POSITIVE] OK good. Thank you for asking. I'm happy to check on a claim for you, [PII]. Can I get the policy number?
[CUSTOMER][NEUTRAL] Uh definitely, [PII]. The policy number is
[CUSTOMER][NEUTRAL] 02141823 M as in Mike Lima number 7.
[AGENT][POSITIVE] Thank you and do you have a good call back number?
[CUSTOMER][NEUTRAL] Yes, I do. It is [PII].
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Extension [PII].
[AGENT][NEUTRAL] Thank you. And patient's name and date of birth?
[CUSTOMER][NEUTRAL] Uh yes, just a second.
[CUSTOMER][NEUTRAL] Member's name will be [PII], it is [PII] for the date of birth, [PII].
[CUSTOMER][NEUTRAL] to do that.
[AGENT][NEUTRAL] Thank you. And what's the date of service?
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK, one moment. The date of service is [PII] for a total charge of $10,000 even.
[CUSTOMER][NEUTRAL] We.
[AGENT][NEUTRAL] All right, thank you. One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, so it looks like we did receive a claim for the state of service, uh, the claim was received on.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And then denied on [PII].
[AGENT][NEUTRAL] Uh, the denial is because patient was not active at the time of service, so.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, can you please tell me, uh, from when the patient is active from? Can you please provide me the effective and termination date?
[AGENT][NEUTRAL] Patient is still active. Effective date is [PII].
[CUSTOMER][NEUTRAL] Um-hum.
[CUSTOMER][NEUTRAL] Policy effective from [PII]. So during the date of service, he's not active, which is for [PII], right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] Mhm. OK, just a second.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK, so this will be the patient's responsible. Can you say is there any other policy active on the date of service from your end?
[AGENT][NEUTRAL] Not that I see on my end, no.
[CUSTOMER][NEUTRAL] Mhm, OK, one second.
[CUSTOMER][NEUTRAL] So no other coverage found. Can you please provide me the claim number?
[AGENT][NEUTRAL] 3561732.
[CUSTOMER][NEUTRAL] 3561732
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. OK. Uh, upon checking, I can see that we have received an EOB, but in that you will be, uh, the denial is not specified as the policy is enacted. Uh, so if you don't mind, can you please fax me a dinner, I will be stating this, uh, uh, policy inactive for the door, please.
[AGENT][POSITIVE] Uh, yes, absolutely. What's a good fax number?
[CUSTOMER][NEUTRAL] Yeah, and before that I want to a confirmation so that you will be that you are going to send is listed as the policy is not active on the date of service as a renewal reason, right?
[AGENT][NEUTRAL] Mhm. Absolutely. It's on page 2 of the EOB.
[CUSTOMER][POSITIVE] Thank you very much and the fax number whenever you are ready.
[AGENT][NEUTRAL] Go ahead.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK. Just to confirm that was [PII]?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Should we mark attention to anybody?
[CUSTOMER][NEUTRAL] Uh yeah, my attention to my name [PII]
[AGENT][NEUTRAL] OK. All right. That'll be there in about 5 minutes. Is there anything else I can check on for you?
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Uh, uh, no, for the, I do have other patient with me. Can you also help me with that please?
[AGENT][NEUTRAL] Mhm let me just notate this and then we can check the next one.
[CUSTOMER][NEUTRAL] Sure, just allow me one moment for me to, and for this one, do you have any duplicate claim on file that uh any other claim?
[AGENT][NEUTRAL] Uh, yes. Do you need those claim numbers?
[CUSTOMER][NEUTRAL] Yeah, I need the duplicate claim number, thanks for asking.
[AGENT][NEUTRAL] So the first one is 357.
[CUSTOMER][NEUTRAL] Have you?
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] 0759.
[CUSTOMER][NEUTRAL] One second, one second. So, uh, provide me with the recent duplicate claim number, that's it.
[AGENT][NEUTRAL] Most recent duplicate is 3581419.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEGATIVE] OK. Received and denied on.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Received on [PII].
[AGENT][NEUTRAL] Denied [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm. And reference number for this patient.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] And can you provide me the reference number for this patient?
[AGENT][NEUTRAL] Uh call reference is my name with the initial to my last name and today's date. My name again is [PII], that's [PII], then today's date.
[CUSTOMER][NEUTRAL] Do you.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][POSITIVE] So, OK, thank you. Yeah, whenever you are ready, I'll provide you the next patient details.
[AGENT][NEUTRAL] Yeah
[AGENT][NEUTRAL] OK, one moment.
[CUSTOMER][POSITIVE] No issues, take your time. No worries.
[AGENT][NEUTRAL] What is the next patient policy number?
[CUSTOMER][NEUTRAL] Uh, definitely it will be 02473403 Mike Lima number 8.
[AGENT][NEUTRAL] Thank you. Patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, just a second. The patient's name is [PII] for the date of birth, [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And then data service.
[CUSTOMER][NEUTRAL] [PII] total charge $2,444 even.
[AGENT][NEUTRAL] Alright, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Mm
[AGENT][NEUTRAL] OK, so it looks like we did receive a claim for this state of service claim was received [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Claim was denied [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Uh, denial, one moment.
[AGENT][NEUTRAL] Max benefit payable for the state of service had been met already.
[CUSTOMER][POSITIVE] Maximum benefits met.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Can I know uh how the maximum benefits met according to the dollar value or the visits uh value?
[AGENT][NEUTRAL] It was $1.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Can you please provide me the amount?
[AGENT][NEUTRAL] Their outpatient benefit amount per calendar day is $300.
[CUSTOMER][NEUTRAL] So OP benefits amount for calendar days is $300.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] Uh-huh. How many calendar days it is?
[AGENT][NEUTRAL] The patient is allowed $300 every day for the calendar year, so 365 days.
[CUSTOMER][POSITIVE] For calendar year. OK, thank you.
[CUSTOMER][NEUTRAL] It's $300 even.
[CUSTOMER][NEUTRAL] So for entire year it is $300 even for 365 days.
[AGENT][NEUTRAL] The patient's benefit max amount is $300 per calendar day.
[AGENT][NEUTRAL] So that's for every day in the year. You asked how many days, there's 365 days in a year.
[CUSTOMER][NEUTRAL] Um-hum.
[CUSTOMER][NEUTRAL] So, for every day, yeah, it is $300 per year for 365 days. Uh-huh.
[AGENT][NEUTRAL] Right.
[AGENT][NEUTRAL] Right.
[CUSTOMER][NEUTRAL] OK, got it. Allow me one moment.
[CUSTOMER][NEUTRAL] And can I know when it was met on?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Uh-huh for the date of service, uh, same date of service.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Is it to the same provider that we billed?
[AGENT][NEUTRAL] No, it's a facility charge.
[CUSTOMER][NEUTRAL] Uh, can I know which facility it is?
[AGENT][NEUTRAL] Baptist Hospital.
[CUSTOMER][NEUTRAL] Uh-huh. Baptist Hospital of Miami.
[AGENT][NEUTRAL] Just show the Baptist Hospital.
[CUSTOMER][NEUTRAL] Mhm sure claim number please.
[AGENT][NEUTRAL] For the denial?
[CUSTOMER][POSITIVE] Mhm. Exactly, got it.
[AGENT][NEUTRAL] 356.
[AGENT][NEUTRAL] 984 7.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, just allow me one moment, please.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] One second, I'm checking some information here, please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thanks for patiently bearing with me.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] 1 2nd.
[CUSTOMER][NEUTRAL] Maximum.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK. Uh, for this one, can you please fax me a copy of your, uh, to the same fax number I will provide you.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm, yeah, the fax number is [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] All right, fax is on its way for that one. Is there anything else I can check for you today?
[CUSTOMER][NEUTRAL] Yeah, just a second. Actually I'm working on something I need, uh, it's pulling up one moment. That's it. Sorry for the delay.
[CUSTOMER][NEUTRAL] So, uh, I have one doubt here. So the total dollar amount is allowed is $300 and total is met uh for this patient on the dose excluding this claim.
[AGENT][NEUTRAL] Correct. The calendar day max was met previously prior to this claim.
[CUSTOMER][NEUTRAL] Prior to this claim, right?
[CUSTOMER][NEUTRAL] No
[AGENT][POSITIVE] Mhm. Correct.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK, sure.
[CUSTOMER][NEUTRAL] OK, no issues. Can you please provide me the
[CUSTOMER][POSITIVE] Reference number you told it will be your name, right? Yeah, then thank you very much for your assistance, [PII]. Have a very nice day.
[AGENT][NEUTRAL] You too, [PII] bye bye.