AccountId: 011433970860
ContactId: 3ee54b41-a40e-4495-ac30-dcf487499044
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 739909 ms
Total Talk Time (AGENT): 242325 ms
Total Talk Time (CUSTOMER): 234401 ms
Interruptions: 2
Overall Sentiment: AGENT=0.6, CUSTOMER=0.5
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/22/3ee54b41-a40e-4495-ac30-dcf487499044_20250522T15:45_UTC.wav
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[AGENT][POSITIVE] Good morning. Thank you for calling APL. My name is [PII]. How may I help you?
[CUSTOMER][NEUTRAL] Hi, [PII]. My name is [PII] and I'm calling from provider's office.
[AGENT][NEUTRAL] Hi, [PII], how are you?
[CUSTOMER][POSITIVE] I'm good. How are you? Thank you for asking.
[AGENT][POSITIVE] I'm well. How may I assist you today?
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] OK. I want to know about the denial status on a claim. Could you please assist?
[AGENT][NEUTRAL] Yes, I can help you with the denied claim. And may I have a good contact number in case we're disconnected and the policy number?
[CUSTOMER][NEUTRAL] Yeah, sure. The callback number is [PII].
[CUSTOMER][NEUTRAL] OK. Now, the policy number is 02030165.
[AGENT][NEUTRAL] Thank you, hold on one moment.
[AGENT][NEUTRAL] And can you verify the member's first and last name and date of birth?
[CUSTOMER][POSITIVE] Take your time.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes, the member's name is [PII].
[CUSTOMER][NEUTRAL] And the patient's date of birth is [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 either the date of service and the total bills or the claim number on the EOB?
[CUSTOMER][NEUTRAL] Uh, yeah, sure.
[CUSTOMER][NEUTRAL] The date of service is [PII].
[CUSTOMER][NEUTRAL] And the total charges are $1,309. OK. What else do you needed?
[AGENT][NEUTRAL] OK, thank you. Hold on one moment.
[AGENT][NEUTRAL] Um, that's all, unless you have the policy number, I'm sorry, the claim number.
[CUSTOMER][NEUTRAL] Yes, I
[CUSTOMER][POSITIVE] totally.
[AGENT][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Hello?
[AGENT][NEGATIVE] Yes, the phone just made a noise and now you sound really far away. Do you have the claim number or no?
[CUSTOMER][NEUTRAL] Hello.
[CUSTOMER][NEUTRAL] No, no, I don't have a claim number.
[AGENT][NEUTRAL] OK. Do you mind if I place you on just a brief hold while I go through these claims um to locate your claim?
[CUSTOMER][POSITIVE] Yeah, sure, no problem.
[AGENT][NEUTRAL] All right, hold on one moment.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEUTRAL] OK, so 358-4123.
[AGENT][NEUTRAL] Yeah 71947.
[AGENT][NEUTRAL] Oh.
[AGENT][POSITIVE] Use this one.
[AGENT][NEUTRAL] And do our MRI.
[AGENT][NEUTRAL] Oh, wait, wait, wait, wait, wait, wait, wait. That's not what I'm trying to do. Mm when I I skip to go.
[AGENT][NEUTRAL] Uh
[AGENT][NEUTRAL] Is this the only one?
[AGENT][NEUTRAL] I feel like
[AGENT][NEUTRAL] 209199.
[AGENT][NEUTRAL] Mhm.
[AGENT][NEUTRAL] Just to be on the safe side.
[CUSTOMER][NEGATIVE] You are on hold.
[AGENT][NEGATIVE] I'd rather have it all and not need it.
[AGENT][NEUTRAL] Than needed and it's not available so we just go.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] 205.
[AGENT][NEUTRAL] 3570934.
[AGENT][NEUTRAL] 70934.
[AGENT][NEUTRAL] Oh
[AGENT][NEUTRAL] Oh.
[AGENT][NEUTRAL] 14 377 30. OK, so it.
[AGENT][NEUTRAL] This one.
[AGENT][NEUTRAL] And what was it the 94, is it the only one, yep, OK, DM.
[AGENT][NEUTRAL] 2306. 00, OK, that's easy, and it's because we paid that.
[AGENT][POSITIVE] Yes right.
[AGENT][NEUTRAL] Hello [PII].
[CUSTOMER][NEUTRAL] Uh yes. Hello?
[AGENT][POSITIVE] All right, thank you so much for holding. I apologize for that wait. Um, so I'm showing the claim number is 3584123.
[CUSTOMER][POSITIVE] No problem.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And um can you verify the name of the provider's office on the claim?
[CUSTOMER][NEUTRAL] Yeah, sure. The provider's office is Perry operative Services of Mississippi.
[AGENT][NEUTRAL] Alright, I'm showing the claim was denied because the um calendar year max has been met.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] OK, so it was denied for TFO.
[AGENT][NEUTRAL] I'm sorry?
[CUSTOMER][NEGATIVE] It is denied for TFO timely filing limit.
[AGENT][NEUTRAL] No, the calendar year maximum for the benefits, so they have $5000 to use per calendar year. By the time this claim came in, the $5000 had been used.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Allow me a moment, please.
[AGENT][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] OK, could you please uh tell me the amount again?
[CUSTOMER][NEUTRAL] Uh.
[AGENT][NEUTRAL] $5000.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] $5000 on me, right?
[AGENT][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK, thank you so much. But uh here uh I have a denial that shows additional information has been requested from the member. So which type of information is, is there any denial? just.
[AGENT][NEUTRAL] What explanation are you looking at an explanation of benefits?
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] What is the claim number on your explanation of benefits?
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] Uh, let me just tell you the claim number. It is.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Hello, my moment is just pulling it up.
[CUSTOMER][NEUTRAL] Yes, the claim number is 507.
[CUSTOMER][NEUTRAL] 262-6800
[AGENT][NEUTRAL] So that might be their primary insurance that is requesting that?
[AGENT][NEUTRAL] Because that is not an APL policy or claim number. The claim number for this claim is the one that I provided you for APL, but we're not denying it, requesting additional information, we're denying it because the max has already been met. So that might be primary, that's.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK, thank
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][POSITIVE] OK, thank you so much. May I have the receipt date of the claim, please?
[AGENT][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] Receive and dena
[CUSTOMER][NEUTRAL] Mhm.
[AGENT][NEUTRAL] And it was denied on [PII].
[CUSTOMER][POSITIVE] OK, thank you so much. And now, could, can you please uh allow me a moment? I'm just checking it up.
[AGENT][NEUTRAL] Sure.
[AGENT][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Yeah, thank you.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] Hey, [PII], are you there?
[AGENT][NEUTRAL] Yes, I'm here.
[CUSTOMER][NEUTRAL] Hello. Yeah, thank you for holding. Actually, I have a question. Uh, could you please tell me from which uh date it the the calendar limits are just started, on which date?
[AGENT][NEUTRAL] Are you asking me when the benefits begin?
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] As in when this policy became effective or the new calendar year?
[CUSTOMER][NEUTRAL] The new calendar year.
[AGENT][NEUTRAL] It's [PII] of every year.
[CUSTOMER][NEUTRAL] OK, then
[CUSTOMER][NEUTRAL] Oh, how do
[CUSTOMER][NEUTRAL] Limit is met and just.
[AGENT][NEUTRAL] Because you all are not the only provider that submitted claims for [PII]. There's another um claim that came in before yours and the the max was paid to that claim.
[CUSTOMER][NEUTRAL] 4 months.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] OK. Thank you so much.
[AGENT][POSITIVE] You're welcome.
[CUSTOMER][NEUTRAL] OK. May I, uh, could you please fax me the EOB of this, uh, claim?
[AGENT][NEUTRAL] Sure, what's a good fax number for you?
[CUSTOMER][NEUTRAL] Yeah, sure. Allow me a moment.
[CUSTOMER][NEUTRAL] The fax number.
[CUSTOMER][NEUTRAL] Yes, the fax number is [PII].
[AGENT][NEUTRAL] And it's [PII]?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK, and what is the attention?
[CUSTOMER][NEGATIVE] Attention is perry operative services.
[CUSTOMER][NEUTRAL] Yeah
[AGENT][NEUTRAL] I'm sorry, can you repeat that, please? It's the provider's name?
[CUSTOMER][NEUTRAL] Yes.
[AGENT][NEUTRAL] OK.
[AGENT][NEUTRAL] So I'll go ahead and fax this over to you now. Was there anything else I could assist you with today, [PII]?
[CUSTOMER][POSITIVE] Uh, no, thank you so much, [PII].
[AGENT][POSITIVE] You're very welcome and thanks for
[CUSTOMER][NEUTRAL] Could you please just
[CUSTOMER][NEUTRAL] Mhm, provide me the call reference please.
[AGENT][NEUTRAL] There's no call reference number, but you can use my name and today's date. The first initial to my last name is [PII].
[CUSTOMER][POSITIVE] OK, thank you so much.
[AGENT][POSITIVE] You're welcome and thanks for calling APL. I hope you have a great day.
[CUSTOMER][NEUTRAL] You too. Bye-bye.
[AGENT][POSITIVE] Thank you. Bye-bye.