AccountId: 011433970860
ContactId: 249aa4a4-ced9-44df-bc27-721d31d6fc37
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 331140 ms
Total Talk Time (AGENT): 96543 ms
Total Talk Time (CUSTOMER): 110212 ms
Interruptions: 0
Overall Sentiment: AGENT=0.2, CUSTOMER=0.6
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/07/249aa4a4-ced9-44df-bc27-721d31d6fc37_20250507T19:08_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from provider office and want to check uh claim status and I have a specific question.
[AGENT][POSITIVE] OK, happy to check on a claim for you, [PII]. Do you have a policy number?
[CUSTOMER][NEUTRAL] Yeah, I have the policy number. That is 02588.
[CUSTOMER][NEUTRAL] 663.
[AGENT][NEUTRAL] All right, one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah, the patient name is uh [PII].
[AGENT][NEUTRAL] Date of birth?
[CUSTOMER][NEUTRAL] Yeah, the date of birth is [PII].
[AGENT][NEUTRAL] Data service.
[CUSTOMER][NEUTRAL] Date of service is [PII].
[AGENT][NEUTRAL] In the build out.
[CUSTOMER][NEUTRAL] Yeah, the bill charge I have is.
[CUSTOMER][NEUTRAL] $2,297.
[AGENT][NEUTRAL] Thank you for your patience on that, [PII]. So it looks like we did receive a claim for the state of service. Claim was received on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And there was a benefit payment sent for $50.
[CUSTOMER][NEUTRAL] Uh, the claim is paid.
[AGENT][NEUTRAL] $50 was paid. That was the max benefit for the state of service.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh, there is a denied reason, any denied reason, I think.
[AGENT][NEUTRAL] I'm not showing any denial on the claim.
[CUSTOMER][NEUTRAL] Actually, uh, the claim was denied for, I think, uh,
[CUSTOMER][POSITIVE] Maximum benefit to reach. Am I right?
[AGENT][NEUTRAL] Well I mean the claim was paid that was the max benefit payable for the date of service, yes.
[CUSTOMER][NEUTRAL] OK. Uh, but, uh, here, uh, the claim has, uh,
[CUSTOMER][NEUTRAL] Go for coding review because uh there was uh it uh claim was processed correctly.
[CUSTOMER][NEUTRAL] But you said
[CUSTOMER][NEUTRAL] The maximum benefit is uh
[AGENT][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Next.
[AGENT][POSITIVE] The claim is processed, the claim is processed correctly, yes.
[CUSTOMER][NEUTRAL] Am I right?
[CUSTOMER][NEUTRAL] Yeah, but uh our expected amount is uh $1,241 and you pay only $50.
[AGENT][NEUTRAL] Correct. The patient has a limited benefit plan, so it's only gonna pay the set amount depending upon what they're being seen or treated for. This isn't a major medical.
[CUSTOMER][NEUTRAL] OK, but uh uh we process the claim correctly.
[CUSTOMER][NEUTRAL] And we also uh send it for the view.
[CUSTOMER][NEUTRAL] And per review response, the, you said that the claim was processed correctly and uh
[CUSTOMER][NEUTRAL] Yeah, and they suggest me to connect, connect with you and uh
[CUSTOMER][NEUTRAL] Request for reprocessing. Are you able to reprocess the claim?
[AGENT][NEGATIVE] There's nothing to reprocess. The max benefit payment for an ER visit on this plan is $50. The plan's not gonna pay anything additional.
[CUSTOMER][NEUTRAL] OK, OK, no problem. Thank you. And uh can you give me the call uh appeal address you?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Can you repeat?
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the time of the filing limit?
[AGENT][NEUTRAL] Appeals must be filed within 180 days of the decision.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] And what's the policy number?
[AGENT][NEUTRAL] Call reference is my name.
[AGENT][NEUTRAL] But today's date?
[CUSTOMER][NEUTRAL] Can you spell out your name?
[AGENT][NEUTRAL] My name is spelled [PII] My last name initials [PII], then today's date.
[CUSTOMER][POSITIVE] OK. Thank you.
[CUSTOMER][POSITIVE] Thank you, thank you very much. Have a good day.
[AGENT][NEUTRAL] You too, [PII]. Bye bye.