AccountId: 011433970860
ContactId: 2dd36bd2-5fed-4221-9401-5fd8add64f68
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 434829 ms
Total Talk Time (AGENT): 177987 ms
Total Talk Time (CUSTOMER): 106052 ms
Interruptions: 1
Overall Sentiment: AGENT=1.2, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/01/31/2dd36bd2-5fed-4221-9401-5fd8add64f68_20250131T16:06_UTC.wav
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[AGENT][NEUTRAL] Hi, thank you for calling APL. This is [PII]. How can I help you today?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] and I'm calling from provider office. I want to know the claim status.
[AGENT][NEUTRAL] OK, yeah, I'd love to help you with claim status today and you said your name was [PII], is that correct?
[CUSTOMER][NEUTRAL] Yeah, it's [PII].
[AGENT][POSITIVE] [PII], OK, perfect, thank you and.
[AGENT][NEUTRAL] Do you mind if I snack a quick call back number for you [PII]?
[CUSTOMER][NEUTRAL] It's [PII].
[CUSTOMER][NEUTRAL] Mhm
[AGENT][NEUTRAL] Thank you. And the policy number?
[CUSTOMER][NEUTRAL] The policy number is 02049543.
[AGENT][POSITIVE] Wonderful, give me just a moment to get that pulled up for you.
[AGENT][POSITIVE] Perfect. And would you be able to verify for me [PII], the first and last name of your member?
[CUSTOMER][NEUTRAL] It's [PII]
[CUSTOMER][NEUTRAL] [PII] and the date of birth is [PII].
[AGENT][NEUTRAL] Perfect. I do see her here. Do you have a particular claim number you're wanting to get information on or you wanting me to search the date of service?
[CUSTOMER][NEUTRAL] The rate of service.
[AGENT][POSITIVE] Perfect. And what is that?
[CUSTOMER][NEUTRAL] And the date of service, um, date of service is [PII].
[AGENT][NEUTRAL] [PII], did I hear that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Perfect. And the billed amount?
[CUSTOMER][NEUTRAL] It's 369 dollars.25 cents.
[AGENT][NEUTRAL] 369.25.
[CUSTOMER][POSITIVE] Yeah, correct.
[AGENT][POSITIVE] OK, perfect. Let me look that up for you.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] Hm.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] And the name on the facility for this claim?
[CUSTOMER][NEUTRAL] All sent home medical.
[AGENT][POSITIVE] All right, perfect.
[AGENT][NEUTRAL] So, I found your claim here. It looks like we received your claim on
[AGENT][NEUTRAL] [PII]. It looks like we processed the claim on [PII], and that claim number listed is 353-9132.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] I'm showing that this claim did have benefits payable in the amount of $7.69 and I do show that paid, mhm, I'm sorry?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Continue, please. Continue.
[AGENT][NEUTRAL] Oh, OK. Um.
[AGENT][NEUTRAL] I show that it states that with the payments of this check, the policy maximum for the benefit has been met and then it's um has a denial code on it for the next procedure code just saying that outpatient benefits for this calendar year have been met.
[AGENT][NEUTRAL] Um, and then I do have your check number listed as 2017616.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And what is the total amount for the calendar year?
[AGENT][NEUTRAL] Um, their total benefit amount?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, yeah, I can pull that up for you. I do wanna let you know any benefit information I give you over the phone is always a verification of coverage and never a guarantee of payment, but it looks like they actually have an inpatient outpatient combined calendar year maximum.
[AGENT][NEUTRAL] And
[AGENT][NEUTRAL] That is $4500.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] But uh as I'm checking, we are receiving only
[CUSTOMER][NEUTRAL] Uh, $2310.15 payments from the insurance side. So at the
[AGENT][NEUTRAL] Yeah, so their outpatient doesn't have to be at one particular facility. That's their maximum at all facilities they go to. So if they went to an urgent care their doctor's office, or they were out of state and had to go somewhere else, so it's not based on your particular facility, it's all the facilities they go to throughout the calendar year. And then it also includes their inpatient stays as well because they have that combined maximum.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] OK. It's so, so can you please give him, give me the other page, other payer details?
[AGENT][NEUTRAL] Give you what details?
[CUSTOMER][NEUTRAL] And yeah.
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] OK. Allow me one second. Let me check the details.
[AGENT][POSITIVE] No, take your time.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm checking. Allow me some time.
[CUSTOMER][NEUTRAL] Can you please provide the other pay details of the insurance paid to the other.
[AGENT][NEGATIVE] No, unfortunately, that would be a violation of their rights. I cannot give you any medical information that doesn't pertain to you.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just give me the call reference number.
[AGENT][NEUTRAL] Yeah, you betcha. It's gonna be my name, [PII].
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Sorry, [PII].
[AGENT][NEUTRAL] And then it's today's date.
[CUSTOMER][POSITIVE] OK. Thank you.
[AGENT][POSITIVE] My pleasure. Thank you for calling APL and you have a fabulous day.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you for that.