AccountId: 011433970860
ContactId: 2dd29db4-8e77-402c-b8f0-593fe3ee29c0
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 610580 ms
Total Talk Time (AGENT): 152908 ms
Total Talk Time (CUSTOMER): 156861 ms
Interruptions: 0
Overall Sentiment: AGENT=1.5, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/02/24/2dd29db4-8e77-402c-b8f0-593fe3ee29c0_20250224T14:00_UTC.wav
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[AGENT][POSITIVE] Morning, thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, this is [PII] calling from office to check on claim status. Could you spell your name, please?
[AGENT][NEUTRAL] [PII] First [PII], last name, [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And [PII], what is the callback number please, sir?
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Yeah, it's [PII] [PII].
[AGENT][NEUTRAL] You
[AGENT][NEUTRAL] Thank you, [PII]. And what is the policy number for the patient?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah, it's 02344590 M as in Mike, L as in Lima, 7.
[AGENT][NEUTRAL] And the patient's name and date of birth, please.
[CUSTOMER][NEUTRAL] Yeah, the patient's first name is [PII], and the last name is [PII]
[AGENT][NEUTRAL] All right.
[CUSTOMER][NEUTRAL] And the date of birth is [PII].
[AGENT][POSITIVE] Thank you, [PII], and it would be my pleasure to assist you with that claim status. What is the data service?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That is [PII] and the bill amount is $64506456 even.
[AGENT][POSITIVE] Thank you. And the name of the facility, please?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yeah, it's Pediatric Medical Group.
[AGENT][POSITIVE] All right, thank you.
[AGENT][NEUTRAL] [PII], I can help you with that claim status. We did receive that claim on [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the claim was denied as the impatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] OK. May I know the maximum exhausted limit?
[AGENT][NEUTRAL] Yes, so for inpatient hospital, the calendar year max is $3000.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. How are the patients met? May I know the patient's made details?
[AGENT][POSITIVE] Yes, that outpatient benefit.
[AGENT][NEUTRAL] Maximum was paid on 6-13-2024 prior to receiving your claim. Now, I can't disclose any information regarding the claim.
[CUSTOMER][NEUTRAL] OK, the patients have made the $3000.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And it
[CUSTOMER][NEUTRAL] Upon checking here, one moment.
[CUSTOMER][NEUTRAL] Yeah, upon checking here, there is no claim submitted before on.
[CUSTOMER][NEUTRAL] Yeah, [PII]. Could you please check and verify that?
[AGENT][NEUTRAL] It mhm it was for a different provider.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] OK. For this pro uh for this provider, there is no claim was submitted, right?
[CUSTOMER][NEUTRAL] Could you please send the claim for the process?
[AGENT][NEUTRAL] I'm sorry. Uh, no, so.
[CUSTOMER][NEUTRAL] Yeah, for this
[AGENT][NEUTRAL] I got you. So for this provider, that was the first claim that we've received. Now the claim benefit it has already been paid out. It was paid to a different provider.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Therefore, no benefits for the calendar year are remaining.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, it depends on units or dollars.
[AGENT][NEUTRAL] Dollar amount.
[CUSTOMER][NEUTRAL] OK. And the limit of dollars is 3000, right?
[AGENT][NEUTRAL] Yes sir, that's per calendar year.
[CUSTOMER][NEUTRAL] Yeah, OK, 3000 per calendar year, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK. Thank you for that information. OK. The patients already met on [PII], right?
[AGENT][POSITIVE] Yes, sir, that's right.
[CUSTOMER][NEUTRAL] OK. May I know which providers the claim got paid? May I know that information, please?
[AGENT][NEUTRAL] I'm not able to disclose that information.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Well we can, uh, the remaining balance we can build the patient, right?
[AGENT][NEUTRAL] That would be determined by the provider. We're not major medical and do not determine patient responsibility.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] As we can approve the claim.
[AGENT][NEUTRAL] You have a right to an appeal. Now, the appeal time is 180 days from the date of denial. The date of denial was [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK, may I know the ability of time sorry, may I know the mailing address?
[AGENT][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And the zip code is [PII].
[CUSTOMER][POSITIVE] [PII]. OK. Thank you for that information.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] I just need to verify. One moment.
[AGENT][POSITIVE] Take your time.
[CUSTOMER][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] I just need to verify one more time. Could you please help for that?
[AGENT][NEUTRAL] Same patient or different patient?
[CUSTOMER][NEUTRAL] Yeah, for different patients.
[AGENT][NEUTRAL] Alright, bear with me just one second.
[CUSTOMER][NEUTRAL] For, may I know the reason for this claim?
[AGENT][NEUTRAL] It's my name in today's date.
[CUSTOMER][POSITIVE] Yeah, OK, OK, thank you.
[AGENT][POSITIVE] You're very welcome, [PII], and I'm ready for that next policy number whenever you are.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah, the claim number is 735.
[CUSTOMER][NEUTRAL] 940,700.
[AGENT][NEUTRAL] Is that a policy number or a claim number?
[CUSTOMER][NEUTRAL] One moment. It's the policy number?
[AGENT][NEUTRAL] It's too many numbers for an APL policy number.
[CUSTOMER][NEUTRAL] It's American Group of Georgia.
[AGENT][NEUTRAL] We're American Public Life.
[CUSTOMER][POSITIVE] OK. OK. Thank you for that information and uh thank you for your assistance and have a nice day. Bye-bye.
[AGENT][POSITIVE] [PII], it's been a pleasure to assist you and thank you for calling [PII]. I hope you have a wonderful day.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] Thank you. Bye-bye.
[CUSTOMER][NEUTRAL] Bye bye.
[AGENT][NEUTRAL] Oh