AccountId: 011433970860
ContactId: 37437f77-9d0e-423f-ac02-96f312e3fcc5
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 346880 ms
Total Talk Time (AGENT): 170915 ms
Total Talk Time (CUSTOMER): 113646 ms
Interruptions: 3
Overall Sentiment: AGENT=0.3, CUSTOMER=0.4
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/06/06/37437f77-9d0e-423f-ac02-96f312e3fcc5_20250606T19:43_UTC.wav
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[AGENT][NEUTRAL] Afternoon. Thank you for calling ATL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, so my name is [PII] and I was calling to make sure that you guys received our claim that was submitted in April.
[AGENT][POSITIVE] OK, sure, I can assist you with claims, Miss [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] OK, and may I have the patient's policy number?
[CUSTOMER][NEUTRAL] It is 02300415.
[AGENT][NEUTRAL] OK, thank you. May I have the name and date of birth of the patient?
[CUSTOMER][NEUTRAL] [PII] [PII].
[AGENT][POSITIVE] Perfect, thank you. May I have the date of service and the amount of the claim?
[CUSTOMER][NEUTRAL] [PII].
[AGENT][NEUTRAL] Alright, and may I have the name of the facility you're calling from from my notes?
[CUSTOMER][NEUTRAL] Faculty physicians and surgeons.
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] See.
[AGENT][NEUTRAL] 124.
[AGENT][NEUTRAL] OK, yeah, here it is. Let me pull the EOB on this one, OK, one moment.
[CUSTOMER][POSITIVE] Thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] And then if you don't mind, can you start with the claim number just because I don't have any any information on this.
[AGENT][NEUTRAL] Mhm, sure. The claim number is 359-8009.
[CUSTOMER][NEUTRAL] And it is for billing provider [PII], right?
[AGENT][NEUTRAL] Um, let me check the paperwork make sure.
[AGENT][NEGATIVE] Yeah, unfortunately, that's not on the ELB.
[CUSTOMER][NEGATIVE] I made that mistake a couple times already where.
[AGENT][NEUTRAL] Yeah.
[CUSTOMER][NEGATIVE] Oh it's not OK.
[AGENT][NEUTRAL] Mm, yeah, that's not on the AOB so yeah, let me just pull the paperwork and make sure it's, it's that, uh.
[CUSTOMER][NEUTRAL] Oh, OK.
[AGENT][NEUTRAL] At least, OK, let's see, let me pull up your claim.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] [PII]
[AGENT][NEUTRAL] OK, T R U O N G. OK, yes. Mhm. Yeah, it is for [PII] and let's see.
[AGENT][NEGATIVE] Um, it was processed on [PII] and it was denied. The reason for this denial is
[AGENT][NEUTRAL] Let's see.
[CUSTOMER][NEUTRAL] You said it was denied what date?
[AGENT][NEUTRAL] On [PII].
[CUSTOMER][NEUTRAL] 6 what?
[CUSTOMER][NEUTRAL] Oh, [PII].
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, the reason is the calendar year maximum for outpatient accident and sick treatment has been exhausted for the year.
[CUSTOMER][NEUTRAL] How many um does the patient have?
[AGENT][NEUTRAL] Mm, let's see.
[AGENT][NEUTRAL] OK, this is not a guarantee of payment, just a verification of coverage and let me see.
[AGENT][NEUTRAL] Mm.
[AGENT][NEUTRAL] Um, bear with me. This one is terminated, so I have to go a different route. One moment.
[AGENT][NEUTRAL] OK, so this one had a maximum benefit of $75 per visit, maximum of 6 visits per year.
[CUSTOMER][NEUTRAL] OK, so it's maximum of 6 visits, OK.
[CUSTOMER][POSITIVE] And the patient exceeded that already at that time.
[AGENT][POSITIVE] Correct. Mhm. Yes.
[CUSTOMER][NEUTRAL] I see. So would it be considered patients responsibility?
[CUSTOMER][NEUTRAL] After they maxed out
[AGENT][NEUTRAL] Um, we don't have, yeah, we don't have any contractual involvement on the remaining on the claim because this is just a limited policy and we don't know if they have any other policies out there. So it's up to the provider's discretion.
[CUSTOMER][NEUTRAL] Well, what do you mean other policies like under under APL?
[AGENT][NEUTRAL] No, not with APL. We don't know if they have any other major medical policies or any other medical policies that they may use, but with us, they don't have anything. Yes. Uh-huh. Yeah.
[CUSTOMER][NEUTRAL] Oh, like if they have like a secondary year or something like that, yeah, yeah, yeah. No, no, I was just talking specifically about yours.
[AGENT][NEGATIVE] Yeah, this is not a major medical, so it's just not covered and it's because it's already been exhausted.
[CUSTOMER][POSITIVE] Wow
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] Um
[CUSTOMER][NEUTRAL] Is this
[CUSTOMER][NEUTRAL] I'm just trying to figure it out because I don't see a max amount of time that the patient has seen the facilities here or like the doctor's visits here for this one.
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] But do you does that go all across the board?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] It is all across the board. It's for any any.
[CUSTOMER][NEUTRAL] Like 66 visits for like any specialty, any visit, anything at all, right?
[AGENT][NEUTRAL] Mhm. PCP. Correct, any PCP, any uh specialist, correct.
[CUSTOMER][NEUTRAL] OK, doesn't doesn't necessarily mean ours.
[AGENT][NEUTRAL] No.
[CUSTOMER][NEUTRAL] OK, that's because that's why I was asking like what's the max because I only see like 3 or 4 so I'm like, uh, OK, so then I think, OK, perfect. May I have your reference number please?
[AGENT][NEUTRAL] Yeah.
[AGENT][NEUTRAL] We don't have reference numbers now you can use my name and today's date if you will.
[CUSTOMER][POSITIVE] Perfect thank you so much for your time.
[AGENT][POSITIVE] You're welcome and thank you for calling APL. Have a good day, Miss [PII].
[CUSTOMER][POSITIVE] Thank you very much.