AccountId: 011433970860
ContactId: 36bbd4b9-d0a8-4156-b3e6-74e1a8f2116d
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 526799 ms
Total Talk Time (AGENT): 228716 ms
Total Talk Time (CUSTOMER): 109986 ms
Interruptions: 0
Overall Sentiment: AGENT=0.1, CUSTOMER=0.2
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/11/36bbd4b9-d0a8-4156-b3e6-74e1a8f2116d_20250611T14:30_UTC.wav
--------------------------------------------
[AGENT][POSITIVE] Good morning thank you for calling APL name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, my name is [PII], and I'm calling from Memorial Hospital for Cancer and Alla to check the claim status.
[AGENT][NEUTRAL] OK, well, I'll be more than happy to help you with the claim status, [PII], and how many claims do you have in total today?
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I have one.
[AGENT][NEUTRAL] OK, may I have a good contact number in case we're disconnected?
[CUSTOMER][NEUTRAL] It's [PII] direct line.
[AGENT][NEUTRAL] Thank you. May I have the member's policy number?
[CUSTOMER][NEUTRAL] Sure. It's 02334237.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] that
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] So first name is [PII]. Last name is [PII]. Date of birth [PII].
[AGENT][NEUTRAL] Thank you for that and all the information provided is a verification of benefits, not a guarantee of payment. And may I have the date of service and the total bills for the claim?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] It's [PII] with the amount of uh $7,169.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] And can you verify the name of the provider's office on the claim?
[CUSTOMER][NEGATIVE] I can't even
[CUSTOMER][NEUTRAL] It's Memorial Hospital for Cancer and disease.
[AGENT][NEUTRAL] Can you verify your tax ID?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, for some reason it came over [PII], so I wasn't sure if it was the same. Sorry about that. Um, but I do, it's the same tax ID number. So we received the claim on
[CUSTOMER][NEUTRAL] It's OK.
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] The claim number is 358.
[CUSTOMER][NEUTRAL] Hey
[AGENT][NEUTRAL] 0031.
[AGENT][NEUTRAL] And on [PII], the claim was denied because the outpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] When it was denied? [PII], right?
[AGENT][POSITIVE] Yes, that's correct.
[CUSTOMER][NEUTRAL] Yes. Uh, can you repeat the denied reason?
[AGENT][NEUTRAL] The outpatient benefit for the calendar year has been met.
[CUSTOMER][NEUTRAL] The patient benefits of the calendar.
[CUSTOMER][NEUTRAL] Calendar year?
[AGENT][NEUTRAL] Yes, the calendar year max has been met.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] In me. So what is the exact uh denial of this?
[AGENT][NEUTRAL] OK, again, the outpatient calendar year max.
[AGENT][NEUTRAL] has been met.
[CUSTOMER][NEUTRAL] OK. What, uh, we need to send, we send a current claim or appeal for this?
[AGENT][NEUTRAL] Um, there's no need for an, I mean, you have the right to an appeal, but there's no need. This is just saying that the max that they have. Hold on one moment.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] So the outpatient calendar year max for this policy is $6650.
[AGENT][NEUTRAL] So this now reason is saying that that $6650 had been was completely used by the time your claim came in, they didn't have any more money to pay out. So you can appeal it if you like, but they've already used all their benefits for the year, so we can't give them anymore.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK, one second. I'll just check.
[CUSTOMER][NEUTRAL] So, so, uh, you said like $650 was met, right? Like uh which date of service it was met?
[AGENT][NEUTRAL] Hold on one moment.
[AGENT][NEUTRAL] Um, I can't give you the date of service because it's another claim, but I can let you know we
[AGENT][NEGATIVE] The fund, the, the max was exhausted on on.
[AGENT][NEUTRAL] [PII]. Hold on one second.
[CUSTOMER][NEUTRAL] I'm
[AGENT][NEUTRAL] [PII], that maxed out the the um maximum for the year.
[CUSTOMER][NEUTRAL] Only one data service?
[AGENT][NEUTRAL] OK, so there's a total.
[CUSTOMER][NEGATIVE] Only one day of service it was with uh.
[AGENT][NEUTRAL] There's a total that we have to pay out for outpatient balances.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] By the time your claim came in, the total, the
[AGENT][NEUTRAL] The amount, the 6000 had already been used, so they used all of their benefits.
[AGENT][NEUTRAL] Before you filed your claim. So there's no more benefits to give out because they used it all.
[CUSTOMER][NEUTRAL] So
[AGENT][NEUTRAL] Back in June.
[CUSTOMER][NEUTRAL] But, uh, [PII], we have a date of service for this patient. We don't have [PII].
[AGENT][NEUTRAL] It was claim. OK, I'm gonna get a claims examiner on the line for you so they can explain this for to you further, OK?
[CUSTOMER][NEUTRAL] What is the call reference?
[AGENT][NEUTRAL] There's no call reference number. It'll be my name and today's date.
[CUSTOMER][NEUTRAL] Could you please spell your name?
[AGENT][NEUTRAL] Name is [PII].
[CUSTOMER][POSITIVE] Thank
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] All right, and before I transfer you over to claims, was there anything else I can assist you with today?
[CUSTOMER][NEUTRAL] Uh, what is the appeal timely filing limit for this?
[AGENT][NEUTRAL] An appeal is 180 days from the denial date?
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK, fine.
[CUSTOMER][NEUTRAL] OK, that's it.
[AGENT][NEUTRAL] Alright, OK, before I transfer you over to claims, did you have any other questions or was there anything else I can assist you with?
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] All right thank you hold on one moment, OK?
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEGATIVE] You are on hold.
[CUSTOMER][NEUTRAL] Transferring.
[CUSTOMER][POSITIVE] Good morning. Thanks for calling APL. This is [PII]. How can I help you?
[AGENT][NEUTRAL] Hey [PII], this is [PII] on the care team. How are you doing?
[CUSTOMER][POSITIVE] I'm good how are you?
[AGENT][NEUTRAL] I'm doing good. I have a provider on the other line um that needs to speak with you. Um, can I give you the policy number?
[CUSTOMER][NEUTRAL] Uh, ready.
[AGENT][NEUTRAL] Alright, it's 233-423-7.
[CUSTOMER][NEUTRAL] Part 12.
[AGENT][NEUTRAL] Part
[AGENT][NEUTRAL] There's only one.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, and the claim number is 3580031.
[AGENT][NEUTRAL] Actually, they just hung up, but basically we have paid the max and she didn't understand why we couldn't pay out on her claim, and I'm like we've already paid on another claim previously, so, but they hung up, so I guess they're OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Um, but she was asking to speak to someone, I guess, to give a different answer, but we paid the max, so maybe they'll call back. I'll just note the policy. Thank you.
[CUSTOMER][POSITIVE] OK, no problem.
[AGENT][NEUTRAL] Alright, bye-bye.
[CUSTOMER][NEUTRAL] Bye.