AccountId: 011433970860
ContactId: 3119e87f-8cbc-4fed-83ca-635145643487
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 1021710 ms
Total Talk Time (AGENT): 301576 ms
Total Talk Time (CUSTOMER): 256095 ms
Interruptions: 3
Overall Sentiment: AGENT=0.7, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/03/3119e87f-8cbc-4fed-83ca-635145643487_20250403T18:07_UTC.wav
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[AGENT][NEUTRAL] Good afternoon. Thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. This is [PII] calling from doctor's office to get the denial clarification.
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, so you're needing to get clarification on a denied claim, is that correct?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] Yes, I can help you with that and I'm so sorry. Could you give me your name again?
[CUSTOMER][NEUTRAL] Yeah, which is [PII], and my last name is [PII].
[AGENT][POSITIVE] OK, [PII], thank you. And what is a good call back number for you please?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] [PII]. Is that correct for the extension?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you. And then [PII], what is your um
[AGENT][NEUTRAL] Patient's policy number?
[CUSTOMER][NEUTRAL] Yes, it's going to be.
[CUSTOMER][NEUTRAL] 013
[CUSTOMER][NEUTRAL] 066
[CUSTOMER][NEUTRAL] 81 M. Mary L. Lima 8.
[AGENT][NEUTRAL] OK thank you one moment please.
[AGENT][NEUTRAL] And checking the information that I provide today would be a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Which is [PII].
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] I do.
[AGENT][NEUTRAL] And what is the date of service and total bill amount for her that you're calling about?
[CUSTOMER][NEUTRAL] When
[CUSTOMER][NEUTRAL] Yes, which is uh [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] The amount of
[CUSTOMER][NEUTRAL] $174 even.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and do you already have the claim number check or do you also need that?
[CUSTOMER][NEUTRAL] Yeah, I already have a you'll be on file.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And the claim number should be 3571846.
[CUSTOMER][NEUTRAL] So,
[CUSTOMER][POSITIVE] Exactly.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] And yes, this claim has been denied.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] The reason for the denial on the claimhake excuse me, states benefits payable under this certificate are limited to those outlined on the schedule of benefits.
[AGENT][NEUTRAL] This is not a covered loss under the plan, therefore no amount is payable for this expense.
[AGENT][NEGATIVE] This is not covered by the member's plan.
[CUSTOMER][NEUTRAL] OK. So, these services are not covered under the patient's plan, right?
[AGENT][POSITIVE] That is correct.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] OK. And uh may I know what type of plan whether the patients have?
[AGENT][NEUTRAL] Uh, this is the only plan that the patient has with our company.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And then Shake, um, you said that you already have the explanation of benefits, however, if you were to need an additional copy of that, you can print it directly from our portal as well by going to [PII].
[CUSTOMER][NEUTRAL] Hey
[CUSTOMER][NEUTRAL] Yes. Yeah.
[CUSTOMER][NEUTRAL] OK. Uh, [PII], thank you so much for that. And uh can I get uh the plan information one more time? You said, right, the benefits are not payable under the certificate, and this is not a covered plan, right? What's the exactly the plan name?
[AGENT][POSITIVE] You're welcome.
[AGENT][NEGATIVE] This is not a, this is not covered. This
[AGENT][NEUTRAL] This is a supplemental policy. This is a supplement to her primary insurance.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] We are not a major medical insurance carrier.
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] OK. I'll make a note on that, uh, [PII]. And uh can I have the car reference number for this, and I do have a few more claims in order to review today.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] How many total claims do you have? I didn't know that you had more than one. You, you didn't tell me you had more than one shake.
[CUSTOMER][NEUTRAL] Actually,
[CUSTOMER][NEUTRAL] Yeah, I have, uh,
[CUSTOMER][NEUTRAL] Yeah. Uh, I have, uh, actually 3 claims. The next claim under the same patient for the different date of service, and the last name would be a totally different patient.
[AGENT][NEUTRAL] OK, so you have one more data service for this number and then
[AGENT][NEUTRAL] You have one claim for a different number?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] Is that correct? OK, so the information that I gave you about using my name in today's date as your call reference number, that will be used for each claim that I check.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Yes, exactly.
[CUSTOMER][NEUTRAL] Can you
[AGENT][NEUTRAL] My name is [PII]. Mhm.
[CUSTOMER][NEUTRAL] Sure, right, and uh, could you
[CUSTOMER][NEUTRAL] Yes, sir. Could you spell that for me, please?
[AGENT][NEUTRAL] [PII]
[AGENT][NEUTRAL] First initial to last name [PII]
[CUSTOMER][NEUTRAL] OK. And your last name is?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][POSITIVE] Oh, OK. Great. Thank you so much for that. And shall I provide you the next, uh,
[AGENT][NEUTRAL] And uh-huh and then any information provided.
[AGENT][NEUTRAL] Yes, but any information on any claim that I checked will be a verification of benefits and not a guarantee of payment. And again, the online service center at secure. Amublic is where you can print copies of any of the explanation of benefits if you need them. So what is the next data service for this number and total bill amount?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Which is [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] And the amount is $174 even.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] OK, and the claim number for this one is 3571854.
[AGENT][NEGATIVE] And it was denied and it was denied for the same reason.
[CUSTOMER][NEUTRAL] OK, I'll make a note on that, uh, [PII], thank you so much for that. And shall we move for the last claim?
[AGENT][NEUTRAL] OK, just, uh, but it's a different member, correct?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, thank you. One moment and let me finish this one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK. And what is the next patient's policy number, [PII]?
[CUSTOMER][NEUTRAL] Yes, which is 02344566.
[AGENT][POSITIVE] Thank you. One moment.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And your patient's name and date of birth for this claim?
[CUSTOMER][NEUTRAL] [PII], [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] And the date of service and total bill amount for her please?
[CUSTOMER][NEUTRAL] [PII]. And the amount is $3,877.20.
[AGENT][NEUTRAL] Uh-huh.
[AGENT][NEUTRAL] 203877.20.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] Uh.
[AGENT][NEUTRAL] And do you already have the claim number for this data service?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Actually, yeah, it ends with 4779.
[CUSTOMER][NEUTRAL] Is that right?
[AGENT][NEUTRAL] Uh, I, yeah, one moment. I'm waiting on something. Just one second.
[CUSTOMER][NEUTRAL] OK.
[AGENT][POSITIVE] OK, yes, that is the correct um claim number for this member, yes, and there we do show a benefit being paid.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. Give me a moment. Uh let me pull up the UV.
[AGENT][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Yeah, right. Can I get the information about that?
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK, it states the maximum amount payable for this occurrence has been met.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Per occurrence means treatment.
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] For the same or related condition.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Unless separated by a period of 90 days, treatment for the same or related condition separated by 90 days, or an unrelated condition.
[CUSTOMER][NEUTRAL] OK. So,
[AGENT][NEUTRAL] Will be considered a new per occurrence.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK. So maximum amount payable has been made for this claim. Uh,
[AGENT][NEUTRAL] For for this occurrence.
[CUSTOMER][NEUTRAL] Well,
[CUSTOMER][NEUTRAL] Oh, OK.
[CUSTOMER][NEUTRAL] For this occurrence of 90 days, right?
[AGENT][NEUTRAL] Yes, sir. The explanation of benefits does have the exact remark that I just read to you on page 2.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Of the of the explanation of benefits.
[CUSTOMER][NEUTRAL] Actually, uh,
[CUSTOMER][NEUTRAL] Yeah, we do have, but, uh, you know, unfortunately, we have only the, you know, benefit maximum has been passed. This is the only reason we have on the claim, uh, on the, as well as the UOB. That's why the call is regarding about sorry I you know.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Uh, ask me again and uh.
[CUSTOMER][NEUTRAL] So, there is no further payment has been uh no provide from your side, right, for this claim?
[AGENT][NEUTRAL] There was a benefit paid in the amount of $373.65.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, Trish.
[AGENT][NEUTRAL] Yes.
[CUSTOMER][POSITIVE] Thank you so much for that. So and uh that's all for the day.
[AGENT][NEUTRAL] OK. Well,
[CUSTOMER][POSITIVE] And once again, thank you so much for valuable assistance and you have a great day, right?
[AGENT][NEUTRAL] Oh
[AGENT][POSITIVE] Well, you're welcome, [PII]. I hope you do too. If that is all then that I can help you with. Thank you again for calling APL. Have a great day.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][POSITIVE] OK. Take care and stay safe. Bye. Bye-bye.
[AGENT][POSITIVE] All right, thank you. You too. Bye-bye.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][NEUTRAL] Yeah.
[AGENT][NEGATIVE] Oh it hurts with everything I eat.
[AGENT][NEUTRAL] Hello?