AccountId: 011433970860
ContactId: 30ae631e-9ee8-48ab-80ca-be596ca8cf8a
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 376429 ms
Total Talk Time (AGENT): 177822 ms
Total Talk Time (CUSTOMER): 70829 ms
Interruptions: 0
Overall Sentiment: AGENT=0.9, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/03/03/30ae631e-9ee8-48ab-80ca-be596ca8cf8a_20250303T21:40_UTC.wav
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[AGENT][NEUTRAL] Afternoon. Thank you for calling ATL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Um, yes, I just need to check claim status, please.
[AGENT][NEUTRAL] OK, you have one patient to check claim status for, is that correct?
[CUSTOMER][NEUTRAL] Yeah yeah.
[CUSTOMER][NEUTRAL] Yep.
[AGENT][POSITIVE] Yes, ma'am, I can help you with that and who am I speaking with, please?
[CUSTOMER][NEUTRAL] My name is [PII].
[AGENT][NEUTRAL] Thank you and [PII], what is your callback number?
[CUSTOMER][NEUTRAL] [PII] that's a direct line.
[AGENT][NEUTRAL] Thank you. And the member's policy number, please, [PII].
[CUSTOMER][NEUTRAL] Yes, that is 02544610.
[CUSTOMER][NEUTRAL] And what was your name?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK just one moment, [PII] while I get the member's information pulled up.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] And any information [PII] that I do provide would be a verification of benefits and not a guarantee of payment. What type of policy are you calling on for claim status?
[CUSTOMER][NEUTRAL] A medical.
[AGENT][NEUTRAL] OK, the pos, OK.
[AGENT][NEUTRAL] Uh, so first off, the policy number you gave me is for a dental policy. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][NEUTRAL] And any information I do provide would be a verification of benefits and not a guarantee of payment, so I need to locate the correct policy number because again the policy number you gave me is for his dental coverage.
[AGENT][NEUTRAL] Not medical.
[AGENT][NEUTRAL] And it should say dental on his ID card also.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] It just says individual.
[CUSTOMER][NEUTRAL] Oh yep it's this group volunteer.
[CUSTOMER][NEUTRAL] Voluntary dental, that is what it says.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh
[AGENT][NEUTRAL] OK, just one moment.
[AGENT][NEUTRAL] OK, and what is
[CUSTOMER][NEUTRAL] I just, I
[AGENT][NEUTRAL] No, what, what were you about to say?
[CUSTOMER][NEUTRAL] I said I just do the billing. I don't that could have been an admissions problem.
[AGENT][NEUTRAL] OK, so what, um, what is, so I did locate a policy for him, the, the limited benefit plan that he has with APL, that number is 02.
[AGENT][NEUTRAL] 544608.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And what is the data service and total build amount that you're calling about [PII]?
[CUSTOMER][NEUTRAL] 1018 20 $24804.
[AGENT][NEUTRAL] OK, thank you. One moment.
[AGENT][NEUTRAL] OK, so we have received this more than once. The most recently received claim was denied as a duplicate. Do you need the original claims information?
[CUSTOMER][POSITIVE] Yes please.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, so the original claim was received on [PII].
[AGENT][NEUTRAL] 2024.
[AGENT][NEUTRAL] And it was processed on [PII].
[AGENT][NEUTRAL] The claim number is 352.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] 931 6.
[AGENT][NEUTRAL] This claim was denied, [PII].
[AGENT][NEUTRAL] And the reason for the denial on here states.
[AGENT][NEUTRAL] Benefit maximum for this state of service has been met.
[CUSTOMER][NEUTRAL] So this is patient responsibility.
[AGENT][NEUTRAL] We do not determine patient responsibility that would be up to the provider.
[AGENT][NEUTRAL] And if you need a copy of this explanation of benefits status and we do have a portal in which you should be able to print that from.
[AGENT][NEUTRAL] And our portal website is [PII].
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] So you guys are American public as well.
[AGENT][NEUTRAL] All right.
[AGENT][POSITIVE] Yes, ma'am. Uh-huh, we're American Public Life. Yes, ma'am. That is correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEGATIVE] So why what you said this is denied for maximum for data service has been met.
[AGENT][NEUTRAL] Yes ma'am, because this is not a major medical insurance and there was another claim that was received and processed prior to.
[AGENT][NEUTRAL] To your claim.
[CUSTOMER][NEUTRAL] Yes, that was the 1500 claim.
[CUSTOMER][NEUTRAL] So that so his maximum has been met like.
[AGENT][NEUTRAL] For the state of service, yes, ma'am.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Do you have a reference number?
[AGENT][NEUTRAL] Sure, you can use my name along with today's date.
[CUSTOMER][POSITIVE] OK, I will do that thank you.
[AGENT][POSITIVE] OK. OK. Well, you're very welcome. And is there anything else I can help you with?
[CUSTOMER][NEUTRAL] I don't think so.
[AGENT][POSITIVE] OK, well then, thank you very much for calling APL and I hope you have a nice rest of your day.
[CUSTOMER][POSITIVE] You too thanks bye.
[AGENT][POSITIVE] Yes, ma'am. Thank you. Bye-bye.