AccountId: 011433970860
ContactId: 2a9e1ad5-67cb-42cc-b91f-e4a25ec6861e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 308200 ms
Total Talk Time (AGENT): 81289 ms
Total Talk Time (CUSTOMER): 107614 ms
Interruptions: 1
Overall Sentiment: AGENT=1.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/18/2a9e1ad5-67cb-42cc-b91f-e4a25ec6861e_20250418T14:33_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Uh, hi, my name is [PII] and I'm calling from Pay's office to check on a denial reason.
[CUSTOMER][NEUTRAL] Sorry, I didn't get your name. Could you please repeat for me?
[AGENT][NEUTRAL] Yes, my name is [PII].
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Yeah, of course. And [PII], do you have the policy number?
[CUSTOMER][NEUTRAL] I do.
[CUSTOMER][NEUTRAL] It's 1330836. M as in Mike, L as in Lima, 8.
[AGENT][POSITIVE] OK perfect thank you and then what's a good call back number in case our call gets dropped?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] All right, thank you. And then patient's first and last name and date of birth?
[CUSTOMER][NEUTRAL] It's [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and then do you have a data service and a charge amount?
[CUSTOMER][NEUTRAL] I do. The charge amount is $3,252.75. And the date of service is [PII].
[AGENT][POSITIVE] OK perfect thank you.
[CUSTOMER][NEUTRAL] So, I just want to confirm, uh, is this a member responsibility? Because the claim was denied for maximum dollar amount has met for outpatient benefits.
[CUSTOMER][NEUTRAL] And the member had met $750.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] So we do not determine patient's responsibility.
[CUSTOMER][NEGATIVE] It's not a patient responsibility.
[AGENT][NEUTRAL] Yes, we do not determine patients responsibility.
[CUSTOMER][NEUTRAL] OK. So, uh, can I, I mean, like, can we appeal on this claim?
[AGENT][NEUTRAL] Yes, you have the right to appeal. Mhm.
[CUSTOMER][NEUTRAL] With submitting uh appropriate Medicare.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Let me check uh the denial code really quick so I can tell you why it was denied, OK?
[CUSTOMER][POSITIVE] OK. Take your time.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Yes
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] That.
[AGENT][NEUTRAL] OK, so it looks like we received this claim on [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And we process this claim 10-25, 2024.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then what provider's office are you calling from?
[CUSTOMER][NEUTRAL] I'm calling from Samain Hospital.
[AGENT][POSITIVE] OK, perfect. Thank you.
[AGENT][NEUTRAL] And then the reason why this claim was denied because outpatient benefit for this calendar year has been met.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. Uh, so I just want to confirm, is this a patient responsibility or it's a provider write off?
[AGENT][NEUTRAL] It is this, the patient's responsibility.
[CUSTOMER][NEUTRAL] OK. Thank you. Can I have a reference number?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Yes, it is my first name, H A L E Y.
[AGENT][NEUTRAL] Last initial [PII]
[AGENT][NEUTRAL] And today's date.
[AGENT][NEUTRAL] And then would you like that claim number as well?
[CUSTOMER][NEUTRAL] Uh, I have. I just want to confirm the claim number is 352-2285. Is that right?
[AGENT][POSITIVE] Yes, sir, that is correct.
[CUSTOMER][POSITIVE] Thank you, [PII], for assisting me and thank you for clarifications of my doubts and have a wonderful day. Stay safe. Happy weekend. Bye-bye.
[AGENT][POSITIVE] Thanks for calling APO. Have a good day.