AccountId: 011433970860
ContactId: 300e09f9-99e5-4ac5-b87c-5431f4dc578e
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 422250 ms
Total Talk Time (AGENT): 138903 ms
Total Talk Time (CUSTOMER): 97136 ms
Interruptions: 1
Overall Sentiment: AGENT=0.7, CUSTOMER=0
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/31/300e09f9-99e5-4ac5-b87c-5431f4dc578e_20250331T12:40_UTC.wav
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[AGENT][NEUTRAL] Thank you for calling APL. This is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII] calling from products on a claim status.
[AGENT][NEUTRAL] Can I help you [PII], what's the policy number?
[CUSTOMER][NEUTRAL] Sure, policy number.
[CUSTOMER][NEUTRAL] 02260096
[AGENT][NEUTRAL] Your phone number in case we're disconnected?
[CUSTOMER][NEUTRAL] [PII] set out of line.
[AGENT][POSITIVE] Thank
[AGENT][POSITIVE] Thank you, one moment.
[AGENT][NEUTRAL] And what is the patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient's name, it is [PII]. Date of birth, [PII].
[AGENT][NEUTRAL] And you said that you're checking claim status?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] And what is the date of service in charge?
[CUSTOMER][NEUTRAL] Date of [PII] built upon is going to be.
[CUSTOMER][NEUTRAL] Just $17,504.18.
[AGENT][NEUTRAL] [PII], 9000.
[AGENT][NEUTRAL] No, $7,504.18.
[CUSTOMER][NEUTRAL] $17,504.18.
[AGENT][NEUTRAL] 0, 17,000. OK.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] Is that for an emergency room visit?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Claim received [PII] processed on the [PII], issuing a payment of $2,422.05. Uh, this amount exhausted the outpatient benefits.
[AGENT][NEUTRAL] Let me know when you're ready for the claim number.
[CUSTOMER][NEUTRAL] Yes, please.
[AGENT][NEUTRAL] 3578036.
[AGENT][POSITIVE] And anything else we can help out with today?
[CUSTOMER][NEUTRAL] Just a moment.
[AGENT][NEUTRAL] Uh-huh.
[CUSTOMER][NEUTRAL] It's 3578036, correct?
[AGENT][NEUTRAL] 3578036
[CUSTOMER][NEUTRAL] But you you have uh denied as outpatient benefits for the access to, right?
[AGENT][NEUTRAL] With the payment of this check or claim, the maximum outpatient benefit is exhausted, so the amount that was paid was what was available.
[CUSTOMER][NEUTRAL] I know when aa.
[AGENT][NEUTRAL] I'm sorry.
[CUSTOMER][NEUTRAL] How much it is allowed.
[CUSTOMER][NEUTRAL] May I know which benefit is exhausted and uh when and how much it is allowed?
[AGENT][NEUTRAL] OK, so it's an outpatient service, so the maximum outpatient benefit is exhausted with this claim. This is the remaining amount when we received your claim.
[CUSTOMER][NEUTRAL] And may I know the maximum benefit amount?
[AGENT][NEUTRAL] So it was exhausted, so the outpatient benefit was exhausted with your claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I'm just asking for the limit how much it is allowed.
[AGENT][NEUTRAL] The maximum outpatient benefit is up to.
[AGENT][NEUTRAL] $2,200,550 per calendar year.
[CUSTOMER][NEUTRAL] OK. May I know when it is lastly accepted?
[AGENT][NEUTRAL] With your claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Just
[AGENT][NEUTRAL] Any other questions?
[CUSTOMER][NEUTRAL] spell your name on the card reference, please.
[AGENT][NEUTRAL] You'll use my name in today's date as reference for today's call?
[CUSTOMER][NEUTRAL] So the total charge.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] It's [PII], first initial and last name is [PII]. Anything else I can help with today?
[CUSTOMER][NEUTRAL] Yes, could you please provide
[CUSTOMER][NEUTRAL] Whether the total charge is going to be the patient responsibility.
[AGENT][NEUTRAL] We do not determine patients responsibility.
[CUSTOMER][NEUTRAL] No, as for it is actually denied, right? So the total claim is going to be the patient responsibility or the provider responsibility.
[AGENT][NEUTRAL] The claim was not denied.
[AGENT][POSITIVE] We paid benefits on it, the remaining benefits.
[AGENT][NEUTRAL] So did you get the amount of the check that I provided earlier? Or do you need that information again?
[CUSTOMER][NEUTRAL] Actually stated the outpatient benefit for excess, sir, right?
[AGENT][NEUTRAL] With this claim, the maximum outpatient benefit is exhausted, so on this claim we paid $2,422.05. That was the remaining benefit.
[CUSTOMER][NEUTRAL] What is the allowed amount, please?
[AGENT][NEUTRAL] OK, we do not have that information. It should be on the claim that was submitted.
[AGENT][NEUTRAL] You should have the primary ELB that you submitted to APL.
[AGENT][NEUTRAL] It's on that document.
[CUSTOMER][MIXED] OK, but the primary, it's more to $4640.
[AGENT][NEUTRAL] And of that amount, the remaining benefit was the amount provided the 2042205 which exhausted the outpatient benefit maximum.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][NEUTRAL] Yeah.