AccountId: 011433970860
ContactId: 392b99f5-2b15-46e3-880b-3ab49c09c867
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 674450 ms
Total Talk Time (AGENT): 178354 ms
Total Talk Time (CUSTOMER): 155207 ms
Interruptions: 4
Overall Sentiment: AGENT=0.1, CUSTOMER=0.3
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/04/10/392b99f5-2b15-46e3-880b-3ab49c09c867_20250410T19:07_UTC.wav
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[AGENT][POSITIVE] Good afternoon. Thank you for calling APL. This is [PII]. How may I assist you?
[CUSTOMER][NEUTRAL] Hi, I'm [PII] calling from uh Summit Radiology Services.
[CUSTOMER][NEUTRAL] To check on the claim status, could you please help me with that?
[AGENT][NEUTRAL] Sure, I can assist you with claim status, Ms. [PII]. May I have a callback number just in case we get disconnected?
[CUSTOMER][NEUTRAL] Yes, the callback number is [PII] and the extension is [PII].
[AGENT][NEUTRAL] Thank you. And may I have the name of the facility where you're calling from?
[CUSTOMER][NEUTRAL] Yes, it's uh SummitRadilogy Services.
[AGENT][NEUTRAL] radiology.
[AGENT][NEUTRAL] OK, and what is the patient's policy number?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK, please wait for a moment.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] Thank you for your patience.
[AGENT][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yes, the member's ID is D as in Delta 43732467.
[AGENT][NEUTRAL] And do you see a policy certificate number? It's gonna start with a 0 followed by 7 digits, Ms. [PII].
[CUSTOMER][NEUTRAL] Sorry, I couldn't understand.
[AGENT][NEUTRAL] OK, the policy number with us with APL, it starts with a 0 followed by 7 digits and that the number is not ours, that's just for IMA. Do you see a number starting with a 0 followed by 7 digits?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] No.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] OK. Um,
[AGENT][NEUTRAL] Do you have the social of the member?
[CUSTOMER][NEUTRAL] Are you asking for your SSN number?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Yes, it is [PII].
[AGENT][POSITIVE] OK, thank you.
[AGENT][NEUTRAL] What's the name of the patient?
[CUSTOMER][NEUTRAL] It's [PII].
[AGENT][NEUTRAL] OK, what's the date of birth for Ms. [PII]?
[CUSTOMER][NEUTRAL] Yes, it's [PII].
[AGENT][NEUTRAL] OK, and what is the data of service and the amount of the claim?
[CUSTOMER][NEUTRAL] Yes, the date of service is [PII] and the total charge is $312 even.
[AGENT][NEUTRAL] $312?
[CUSTOMER][NEUTRAL] Yes, $312 even.
[AGENT][NEUTRAL] OK. And let me see if I can find this claim for you, and that was [PII], correct?
[CUSTOMER][NEUTRAL] That
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Do you know what's the procedure codes?
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] The procedure code is 71275.
[AGENT][NEUTRAL] OK, let me pull this EOP one moment.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] I'm still waiting on the EB.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] It was processed on [PII] and the claim was denied. The reason for this denial is that the calendar year maximum on diagnostic testing has been exhausted.
[CUSTOMER][NEUTRAL] The
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] May I know the maximum number of visits that are allowed?
[AGENT][NEUTRAL] The maximum benefit because it was a benefit amount. OK, bear with me just a second, let me pull that information.
[AGENT][NEUTRAL] OK, so this policy has a calendar year maximum of 250 per covered person per calendar year for diagnostic testing.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] No, I just ask, um, may I know what is the uh maximum allowed.
[CUSTOMER][NEUTRAL] Visits, uh, it's visits, right?
[AGENT][NEUTRAL] No, it's not this calendar year maximum benefit on diagnostic service has been met.
[CUSTOMER][NEUTRAL] No it's not.
[CUSTOMER][NEUTRAL] On the.
[AGENT][NEUTRAL] So it's a dollar amount.
[CUSTOMER][NEUTRAL] Dollar
[CUSTOMER][NEUTRAL] OK. This is Annual.
[AGENT][NEUTRAL] Yes, the calendar year maximum is 250.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Could you please wait for a moment?
[AGENT][NEUTRAL] Sure
[CUSTOMER][NEUTRAL] Thank you for your patience. Actually, previously, I contacted our rep and uh uh they stated that uh this maximum benefit met with the all uh with the visits and which is annual, and now we are saying that it's dollars, right?
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] It's an annual maximum dollar amount.
[CUSTOMER][NEUTRAL] Could you please check and tell which is
[AGENT][NEUTRAL] Um, Miss, um, [PII], the annual means that it is an annual maximum benefit. So it is one time per year that is a benefit maximum up to 50.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] to
[AGENT][NEGATIVE] So it's basically the denial reason is calendar your maximum on diagnostic service has been met. That is the denial reason.
[CUSTOMER][NEUTRAL] So it's basically.
[CUSTOMER][NEUTRAL] OK 6 accounts.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] May I know what, uh, may I know what is about the balance amount?
[AGENT][NEUTRAL] What balance amount?
[CUSTOMER][NEUTRAL] The amount on the claim.
[AGENT][NEUTRAL] It's up to the provider's discretion. We don't have any contractual involvement on the remaining of the claim. This is not a major medical, so it's up to the provider's discretion. This is a limited policy.
[CUSTOMER][NEUTRAL] Is that the
[CUSTOMER][NEUTRAL] Let
[CUSTOMER][NEUTRAL] OK. Is the patient's responsibility?
[AGENT][NEGATIVE] It's up to the provider's discretion. We're not the major medical, so it's just denied by us.
[AGENT][NEUTRAL] We don't have any contractual involvement on the remaining on the claim.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Could you please spell out your name?
[AGENT][NEUTRAL] Sure. My name is [PII]. That's [PII], last initial [PII].
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][POSITIVE] OK perfect.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] May I have the call reference number?
[AGENT][NEUTRAL] We don't have reference numbers. You can use my name in today's date if you will.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] Is there anything else I may help you with today, Ms. [PII]?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][POSITIVE] No, thank you. Have a nice day.
[AGENT][POSITIVE] You're welcome. Thank you for calling UPL. You have a good afternoon. Bye-bye.