AccountId: 011433970860
ContactId: 2843cef8-1154-4d24-b324-d2e5f4db00a9
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1938810 ms
Total Talk Time (AGENT): 463131 ms
Total Talk Time (CUSTOMER): 450903 ms
Interruptions: 0
Overall Sentiment: AGENT=0.5, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/08/2843cef8-1154-4d24-b324-d2e5f4db00a9_20250108T18:22_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from Nicholas Child's Pediatrics to check on the claim status.
[AGENT][NEUTRAL] I can assist you. What's the policy number?
[CUSTOMER][NEUTRAL] Hello?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Policy number is 1611873 M as in Mary L as in Lima 7.
[AGENT][NEUTRAL] Can you spell your first name for me?
[CUSTOMER][NEUTRAL] And can you
[CUSTOMER][NEUTRAL] Sure. That is [PII].
[AGENT][POSITIVE] OK, thank you. And you said.
[CUSTOMER][NEUTRAL] And can you spell your name for me as well?
[AGENT][NEUTRAL] Oh, [PII]
[CUSTOMER][NEUTRAL] T I sorry?
[AGENT][NEUTRAL] [PII]
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Last termination.
[AGENT][NEUTRAL] [PII], and did you say you're checking on a claim status?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and you, you pronounce your name is [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and what's a good phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Thank you. And what's the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is.
[CUSTOMER][NEUTRAL] [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] Is it [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And what's the date of service and total charge?
[CUSTOMER][NEUTRAL] It's [PII] for the total charge amount.
[CUSTOMER][NEUTRAL] $2970.38.
[AGENT][POSITIVE] Thank you for that.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] One moment, let me pull up the information and then I'll give you the status we have the claim.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And would this be?
[AGENT][NEUTRAL] What are the procedure codes on the claim?
[CUSTOMER][NEUTRAL] It's 99204.
[AGENT][NEUTRAL] I did several?
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] 9,921,426,720 and Q 4012.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Alright, so this claim was received [PII], processed [PII].
[AGENT][NEUTRAL] The two office visit charges are not covered by the patient's policy and the two treatment codes, the explanation of benefits that we received, the primary explanation of benefits that we received, does not indicate the deductible co-insurance and or co-pay amounts, so we need a, a more detailed explanation of benefits which includes those three categories.
[CUSTOMER][NEUTRAL] And can you provide me the claim number?
[AGENT][NEUTRAL] That number is 353-14007 and surely you can also check your status on our online service center at [PII].
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] I just need to confirm the claim number. It's 35304 then.
[AGENT][NEUTRAL] 35314007.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And as I was stating earlier, you can down or check your claim status and download the EOD from our online service center at [PII]. And did you have any other questions, [PII]?
[CUSTOMER][NEUTRAL] Yes, I do have other members too, so could you assist me for that as well?
[AGENT][NEUTRAL] OK, I didn't get the first part of that statement.
[AGENT][NEUTRAL] Could you repeat?
[CUSTOMER][NEUTRAL] Yeah, I do have other claims too, so could you assist me?
[AGENT][NEUTRAL] OK, how many do you have?
[CUSTOMER][NEUTRAL] I do have.
[CUSTOMER][NEUTRAL] 5 more.
[AGENT][NEUTRAL] OK, I can do 2 more and then I can show you how to set up the online service center to check your claim status. Would you like assistance in creating the account?
[CUSTOMER][NEUTRAL] Yeah, I have, but uh it is asking for uh several questions. So, um, like SSN and um other things but I was not able to find the claim status on it.
[AGENT][NEUTRAL] So there is a quick search and it only asks for the claim number which I can provide the patient's first name and the patient's date of birth.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah, that's correct. So I don't have the claim number.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] I know it, so I'll give you the claim number.
[AGENT][NEUTRAL] And then you can pull it up online to check the status. Give me just a second.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] Sure, thank you.
[AGENT][NEUTRAL] And what is the policy number?
[CUSTOMER][NEUTRAL] Yeah, for the next one.
[CUSTOMER][NEUTRAL] Policy number is
[CUSTOMER][NEUTRAL] 021
[CUSTOMER][NEUTRAL] 20103 ML 8.
[AGENT][NEUTRAL] Patient's name and date of birth.
[CUSTOMER][NEUTRAL] Patient's name is [PII].
[CUSTOMER][NEUTRAL] [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] And what's the date of service in charge amount?
[CUSTOMER][NEUTRAL] Data service I'm looking for is [PII]. For the total charge amount $2,603.60.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] 6, OK.
[AGENT][NEUTRAL] And the procedure codes on the claim?
[CUSTOMER][NEUTRAL] Just a second.
[CUSTOMER][NEUTRAL] Procedure codes.
[CUSTOMER][NEUTRAL] R 72148721417214670551.
[AGENT][NEUTRAL] OK, the claim number is 353.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] Yeah, I go at 353.
[AGENT][NEUTRAL] 33534937.
[AGENT][NEUTRAL] And so you can enter that claim number, the patient's date of birth, and their first name.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] In the quick search and it should populate the explanation.
[CUSTOMER][NEUTRAL] Uh, just a second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] And actually that claim number is a duplicate. Let me locate the original one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, the original claim number is.
[AGENT][NEUTRAL] 349.
[AGENT][NEUTRAL] 8101.
[CUSTOMER][NEUTRAL] OK, let me check for that as well.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Still loading.
[AGENT][NEUTRAL] Mhm. No rush.
[CUSTOMER][NEGATIVE] OK. So that is also denied.
[AGENT][NEUTRAL] OK, so, so can you tell me the uh provider tax identification number and the.
[AGENT][NEUTRAL] A patient account number that's on the claim, are you entering that information when you log in?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, so if you can give me the provider tax ID number that you're entering.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] And then the patient account number and box number 26 I believe.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] On the uh-huh.
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, I'm showing a different patient number. Give me a moment.
[AGENT][NEUTRAL] The patient account number and the tax ID number has to match what we have in our system in order for it to populate. One second.
[CUSTOMER][NEUTRAL] Yeah, and I just got the claim number on the portal that is 349-8101.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] Outpatient benefit for this calendar year has been met.
[AGENT][POSITIVE] Correct.
[AGENT][NEUTRAL] That is the that so that is it. So you were able to pull it up?
[CUSTOMER][NEUTRAL] Yes. And may I know um how many visits are allowed as per the plan?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] It's not a number of offices it limits it's a well it's a $1 maximum and the maximum outpatient, yeah, did you want that benefit?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] So the maximum outpatient benefit is up to $1500 per calendar year, so that $1500 max has been exhausted is exhausted.
[CUSTOMER][NEUTRAL] How much dollars?
[AGENT][NEUTRAL] And of course the information provided is verification on a guarantee of payment, and I think that matches what the explanation says.
[CUSTOMER][NEUTRAL] Exhausted.
[CUSTOMER][NEUTRAL] And may I know um when it was met?
[AGENT][NEUTRAL] Sure. One moment.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]. And uh which claim number?
[AGENT][NEUTRAL] It's from a different provider so we do not disclose that information.
[CUSTOMER][NEUTRAL] OK, so this is the patient responsibility, correct?
[AGENT][NEUTRAL] We do not determine patients responsibility [PII]. We can just tell you that the maximum outpatient benefit is exhaustive for the calendar year.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, sure.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And can you provide me the call reference number for this one?
[AGENT][NEUTRAL] Yeah, or it's gonna be my name in today's date.
[AGENT][NEUTRAL] On each, each, yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, let's go to the next game.
[AGENT][NEUTRAL] Give me just a second to document this, please.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK, what's the next policy number?
[CUSTOMER][NEUTRAL] Sure, one moment.
[CUSTOMER][NEUTRAL] Next policy number is
[CUSTOMER][NEUTRAL] 024568
[CUSTOMER][NEUTRAL] 63 ML 7.
[AGENT][NEUTRAL] And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII]. Date of birth is June it's uh [PII].
[AGENT][NEUTRAL] And the data service in charge?
[CUSTOMER][NEUTRAL] The service I'm looking for [PII] for the total charge amount, $517.59.
[AGENT][NEUTRAL] The claim number?
[AGENT][NEUTRAL] Is 353.
[CUSTOMER][NEUTRAL] Just a second.
[CUSTOMER][NEUTRAL] Yeah, go ahead.
[AGENT][NEUTRAL] The claim number is 353.
[AGENT][NEUTRAL] 5409.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Were you able to retrieve that one?
[CUSTOMER][NEUTRAL] 353.
[CUSTOMER][NEUTRAL] Yeah, just a second.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] System is regarding.
[CUSTOMER][NEUTRAL] OK. So, benefits are payable only if your major medical insurance provider provides benefits.
[AGENT][NEUTRAL] That's for the 76882 procedure code.
[CUSTOMER][NEUTRAL] Yeah. And insured, primary insurance provided full benefits. There are no benefits payable.
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] See how easy that is [PII].
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] Let me document this one.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] You can share this with your team members.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Actually, I was trying to pull the claim details. um, as of, I don't have the claim number. It is only possible if we put the claim number then it is getting.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Right, there's 2, yes, there's 2 ways you can search and I believe you tried the long way before which requires you to have the complete social security number of the policy holder, not the patient, and if you don't have that, then you can call us and then we can give you the claim number and then you're able to review it. I wish, yeah, so that is correct.
[CUSTOMER][NEUTRAL] Yeah, so.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, let's see.
[AGENT][NEUTRAL] Hold on one second.
[CUSTOMER][NEUTRAL] So there are 3 more. Could you assist me for?
[AGENT][NEUTRAL] Mhm I'm trying to document this call.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] OK, I'm ready for the next one.
[CUSTOMER][NEUTRAL] Definitely one.
[CUSTOMER][NEUTRAL] So the next member ID number is.
[CUSTOMER][NEUTRAL] 1557778
[AGENT][NEUTRAL] I think one number.
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] OK, the policy number, can you repeat the policy number? It's missing one digit.
[CUSTOMER][NEUTRAL] Date of birth is
[CUSTOMER][NEUTRAL] It's 155778.
[AGENT][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Let me check the member card.
[AGENT][NEUTRAL] The card?
[CUSTOMER][NEUTRAL] Yeah, just a second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, so the
[CUSTOMER][NEUTRAL] Member ID is
[CUSTOMER][NEUTRAL] Loading.
[CUSTOMER][NEUTRAL] Hello.
[AGENT][NEUTRAL] No rush.
[CUSTOMER][NEUTRAL] Yeah, that is 1551778.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So there's a 1 in front of the 7.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII]a. Date of birth is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, the patient for that date, date of birth is, uh, his name is not [PII], I mean, not [PII].
[CUSTOMER][NEUTRAL] OK, one moment. Let me check one second.
[CUSTOMER][NEUTRAL] Is it [PII]?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yeah, I'm showing [PII] with that date of birth.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what's the date of service in charge?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Radio service I'm looking for is [PII] for the total charge amount, $354.42.
[AGENT][NEUTRAL] OK, and is it [PII]'s name on the claim that you have?
[CUSTOMER][NEUTRAL] Um, it is not showing on the.
[CUSTOMER][NEUTRAL] Claim.
[CUSTOMER][NEUTRAL] I just going
[AGENT][NEUTRAL] Whose name is on the claim?
[CUSTOMER][NEUTRAL] [PII]. [PII].
[CUSTOMER][NEUTRAL] So, is this a claim processed or rejected?
[AGENT][NEUTRAL] Give me a second. I'm trying to confirm which is the patient.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so for [PII], I'm showing the patient is [PII], but I'm showing a different date of birth for [PII]. Do you have that?
[CUSTOMER][NEUTRAL] Definitely one moment.
[CUSTOMER][NEUTRAL] Uh, it's [PII] and date of birth is [PII].
[AGENT][NEUTRAL] I'm showing a different date of birth for [PII] and we'll need to get that verified before we can proceed with the status of this claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, so.
[CUSTOMER][NEUTRAL] [PII], it is showing in system and
[AGENT][NEUTRAL] Yeah, we show a different date for a date of birth for [PII], so we can go ahead and move to your last claim status because it has to be verified. The date of birth has to be verified.
[CUSTOMER][NEUTRAL] A one
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um, [PII].
[AGENT][NEUTRAL] That's father.
[CUSTOMER][NEUTRAL] Yeah, it's father's name is [PII].
[AGENT][NEUTRAL] But the claim is for dependent son [PII]. I need the dependent son's date of birth.
[CUSTOMER][NEUTRAL] Yeah, that is only [PII]. That's it.
[AGENT][NEUTRAL] Yeah, and I'm saying that's incorrect and so we cannot proceed with this one because I have to get the correct date of birth for the patient that you have.
[AGENT][NEUTRAL] Which is [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] So if you locate the correct date of birth, you can call us back and we can status that one for the dependent son [PII] we can go ahead and move to the to the last one.
[AGENT][POSITIVE] And I, I'm ready for the policy number.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Sure, just a second.
[CUSTOMER][NEUTRAL] One moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Next, member ID number is [PII].
[AGENT][NEUTRAL] And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name is [PII].
[CUSTOMER][NEUTRAL] [PII]. Date of birth is [PII].
[AGENT][NEUTRAL] OK, date of service in charge?
[CUSTOMER][NEUTRAL] Detail service is [PII] for the total charge amount, $245.28.
[AGENT][NEUTRAL] OK, I show that the claim was not payable. Office visits are not covered under the patient's policy, and the claim number.
[AGENT][NEUTRAL] You ready for the claim number?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] It's 353.
[AGENT][NEUTRAL] 5571.
[CUSTOMER][NEUTRAL] OK, let me check just a moment.
[AGENT][NEUTRAL] Mhm. Mhm.
[CUSTOMER][NEUTRAL] Still loading.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you do you find the online service center helpful Shalish?
[CUSTOMER][NEUTRAL] Yes, office visits are not allowed under the above number policy, OK.
[AGENT][POSITIVE] OK. Good.
[AGENT][POSITIVE] Mhm. Correct.
[CUSTOMER][NEUTRAL] Yeah, I do have last one more, so could you assist me for, so that we can close this call.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, the policy number?
[CUSTOMER][NEUTRAL] OK, one moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Policy number is
[CUSTOMER][NEUTRAL] 1091645
[AGENT][NEUTRAL] And the patient's name and date of birth?
[CUSTOMER][NEUTRAL] OK, just a second.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Patient's name is [PII]. Date of birth is.
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the date of service?
[CUSTOMER][NEUTRAL] And I'm
[CUSTOMER][NEUTRAL] D of service I'm looking for is [PII] for the total charge amount $518.28.
[AGENT][NEUTRAL] OK, give me one moment.
[CUSTOMER][NEUTRAL] Sure.
[AGENT][NEUTRAL] Thank you so much for holding. So this claim was denied because the date of service is after the policy termination date and the policy number is, I mean the claim number is 352-7352.
[CUSTOMER][NEUTRAL] That's the same. Let me check.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And may I know the effective and termination date?
[AGENT][NEUTRAL] Mhm, I'll get that for you just a second.
[AGENT][NEUTRAL] So the policy effective date is [PII].
[AGENT][NEUTRAL] And the policy termination date is [PII].
[CUSTOMER][NEGATIVE] OK. And then patient never got.
[CUSTOMER][NEUTRAL] This plan after [PII].
[AGENT][POSITIVE] Yeah, no other coverage, yeah, correct.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank you. Thank you so much for your assistance.
[AGENT][POSITIVE] Oh, you're welcome.
[AGENT][POSITIVE] You're welcome, [PII]. Any, all right, if no other questions, thanks for calling APL. Have a good day.
[CUSTOMER][POSITIVE] And have a great day.
[CUSTOMER][NEUTRAL] You too as well. Bye-bye.
[AGENT][NEUTRAL] Mhm bye.