AccountId: 011433970860
ContactId: 29843c37-7b7f-4aa3-bbd1-24d958419d4b
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 378709 ms
Total Talk Time (AGENT): 206489 ms
Total Talk Time (CUSTOMER): 104948 ms
Interruptions: 1
Overall Sentiment: AGENT=0.8, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/16/29843c37-7b7f-4aa3-bbd1-24d958419d4b_20250416T18:35_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling A. This is [PII].
[CUSTOMER][NEUTRAL] What?
[AGENT][NEUTRAL] Can I help you?
[CUSTOMER][NEUTRAL] Uh, hi there.
[AGENT][POSITIVE] Hello, what can we do for you?
[CUSTOMER][NEUTRAL] No, sorry about that. I'm calling about a claim for a patient.
[AGENT][NEUTRAL] That's OK.
[AGENT][NEUTRAL] OK, I could check on a claim for you. uh, what was your name?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][POSITIVE] OK [PII], can I get a good call back number from you in case we're disconnected?
[CUSTOMER][NEUTRAL] Yeah it's [PII].
[AGENT][NEUTRAL] Thank you. And do you have that policy number?
[CUSTOMER][NEUTRAL] Uh yes, policy number 02506661.
[AGENT][NEUTRAL] OK and then what was the name and date of birth for the member please?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] Perfect, thank you for verifying that and what was the date of service for this client, please?
[CUSTOMER][NEGATIVE] Um, so I actually have a couple of claims. I got the EOB for claim date of service [PII], and it said that pay maintenance is only payable once in every 6 months and then I have an outstanding claim from uh [PII] that never got paid.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, um, do you happen to have that claim number for the [PII]?
[CUSTOMER][NEUTRAL] I do, yes, the claim number is 3587319.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK thank you one moment.
[AGENT][NEUTRAL] OK, yes, I do see that periodontal maintenance.
[AGENT][NEUTRAL] Once every 6 months, so are we just needing to make sure that that's accurate?
[CUSTOMER][NEGATIVE] Uh, well, when I looked into that I realized that I still have this outstanding claim from December so it shows that it was accepted through our online portal, uh, but we never got payment for that December claim.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Oh, OK. Is that where that, uh, other periodontal maintenance was?
[CUSTOMER][NEUTRAL] I assume so, yes, because that's the only one she's got on file, yeah.
[AGENT][NEUTRAL] OK, got you. OK, one moment, let me get that.
[CUSTOMER][NEUTRAL] So I'm guessing since y'all show it completed that it must have been a check that got lost in the mail.
[AGENT][POSITIVE] Possibly, we can definitely take a look.
[CUSTOMER][NEUTRAL] OK
[AGENT][NEUTRAL] Yeah, [PII] and procedure code 4910, yes. Um, so,
[AGENT][NEUTRAL] Well, we didn't pay that one either.
[AGENT][NEUTRAL] Um, we paid the, we paid the 0120, uh, was $68 and I can still look into that if you've not received that check, um, but looks like we didn't make a payment for this other one either, so give me just a moment, let me get this first.
[CUSTOMER][NEUTRAL] Yeah yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And let me take a look at what this denial reason is just to make sure that this is all.
[AGENT][NEUTRAL] Accurate.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEGATIVE] Oh, OK. So this one was denied, as the policy's required waiting period of 12 months for major services has not been met. So I'd imagine.
[AGENT][NEUTRAL] When was the effective date? Let's see.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] So 4910 is major.
[AGENT][NEUTRAL] Yes, um.
[AGENT][NEUTRAL] So the effective date was [PII].
[AGENT][NEUTRAL] So March would have been.
[AGENT][NEUTRAL] No, it's 12 month waiting period, so I'm not sure why it would put that to no reason that's where the confusion is. OK, yeah, I'm sorry, I was trying to just make sure that that's right, um, OK, so yes, that's, that's accurate, um, and if you need that EOB I can send that to you if you need that for your records and then of course I can also um.
[CUSTOMER][NEUTRAL] It's 12 months, so yeah.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Che, take a look at this chart.
[CUSTOMER][NEUTRAL] Well, you said the um.
[CUSTOMER][NEUTRAL] OK, yeah.
[CUSTOMER][NEUTRAL] Yes, if you can send me a copy of that just so I have an accurate denial reason that would be great.
[AGENT][POSITIVE] Absolutely, yes.
[AGENT][NEUTRAL] OK, give me just a moment. Let me take a look. OK, yes, so the check for this claim, uh, was $68. That was for procedure code 0120, uh, that was issued [PII], and I am showing that that is still outstanding. It has not been cleared. Uh, let me verify the address we have is correct. I have [PII].
[AGENT][NEUTRAL] In [PII], is that right?
[CUSTOMER][POSITIVE] Correct, yes it is.
[AGENT][NEUTRAL] OK, OK, so I can go ahead and put this in to have this check uh voided and reissued to you um do you have a fax number that I can send this EOB to you?
[CUSTOMER][NEUTRAL] Yes, it is um 8 sorry.
[AGENT][NEUTRAL] That's OK.
[CUSTOMER][NEUTRAL] Yeah [PII].
[AGENT][NEUTRAL] I'm so sorry, would you mind repeating that for me?
[CUSTOMER][NEUTRAL] Sure, [PII].
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] OK, I'm gonna read that back to make sure I heard that correctly. That was [PII].
[CUSTOMER][POSITIVE] Correct.
[AGENT][NEUTRAL] Alrighty, I will get this sent to you now. You should get it within about 10 minutes or so, um, and of course I will put this in, um, to have this check voided and reissued to you.
[CUSTOMER][NEUTRAL] OK, and then tell me your name again please.
[AGENT][NEUTRAL] Sure, it's uh [PII]
[CUSTOMER][NEUTRAL] OK and then do you have a reference number for a call?
[AGENT][NEUTRAL] Yeah, it would just be my first name, last initial and today's date, uh, so my last initial is [PII] and was there anything else I could help you with, [PII]?
[CUSTOMER][POSITIVE] That is all thank you so much I appreciate your help.
[AGENT][POSITIVE] Alright, yeah, thanks for calling APL. I hope you have a great rest of your day.
[CUSTOMER][NEUTRAL] You too bye bye.
[AGENT][POSITIVE] Thank you. Bye-bye.