AccountId: 011433970860
ContactId: 40266509-06a3-4f5a-845b-9ef8d37f8230
Channel: VOICE
LanguageCode: en-US
Total Conversation Duration: 711119 ms
Total Talk Time (AGENT): 267955 ms
Total Talk Time (CUSTOMER): 335908 ms
Interruptions: 23
Overall Sentiment: AGENT=0.4, CUSTOMER=0.1
Redaction Types: PII
Input Audio S3: s3://apl-connect-contactcenter-data-prod/connect/apl-prod/CallRecordings/2025/05/12/40266509-06a3-4f5a-845b-9ef8d37f8230_20250512T17:27_UTC.wav
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[AGENT][NEUTRAL] Afternoon, thank you for calling APL. This is [PII]. How can I help you?
[CUSTOMER][NEUTRAL] Hi, [PII], this is [PII] calling from MAC physicians to check on the claim status.
[AGENT][NEUTRAL] OK, can you please spell your name for me?
[CUSTOMER][NEUTRAL] Name of the spelling is [PII], and my last name initial is [PII].
[AGENT][NEUTRAL] Thank you and can you have one claim to check status on, is that correct?
[CUSTOMER][NEUTRAL] I have 2 claims today.
[AGENT][NEUTRAL] Are they for the same patient or different patients?
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Different patient.
[CUSTOMER][NEUTRAL] Just one moment, I will.
[AGENT][NEUTRAL] OK, I can help you. And what is your callback number?
[CUSTOMER][NEUTRAL] Oh
[CUSTOMER][NEUTRAL] Callback number is [PII].
[CUSTOMER][NEUTRAL] [PII] direct line.
[AGENT][NEUTRAL] Thank you. So [PII], you will use my name along with today's date as each call reference number. Again, my name is [PII].
[AGENT][NEUTRAL] Any information that I provide for you on the claims will be a verification of benefits and not a guarantee of payment and lastly, if we do have the claims on file and you need a copy of the explanation of benefits, once you have the claim number, you should be able to print that yourself by going to our portal it's secured.
[CUSTOMER][NEUTRAL] You got it, [PII].
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mm, got it.
[AGENT][NEUTRAL] [PII].
[AGENT][NEUTRAL] And what is your first patient policy number to you?
[CUSTOMER][NEUTRAL] Policy number is
[CUSTOMER][NEUTRAL] 01979937.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] I don't.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] On.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] That.
[CUSTOMER][NEUTRAL] Then we get.
[CUSTOMER][NEUTRAL] I yeah.
[CUSTOMER][NEUTRAL] I think you.
[CUSTOMER][NEUTRAL] Well
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] OK, and [PII] again any information provided is a verification of benefits and not a guarantee of payment. What is your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Patient name is [PII] and date of birth, [PII].
[AGENT][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] What's the date of service and total bill amount, please?
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] Data services.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] For the bill amount of
[CUSTOMER][NEUTRAL] $548 even.
[AGENT][NEUTRAL] 548, is that correct?
[CUSTOMER][NEUTRAL] No.
[CUSTOMER][POSITIVE] Mm, that's right.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] Mm
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Uh
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, so I do see that this claim was received. It was received on [PII].
[CUSTOMER][NEUTRAL] I think the 4.
[AGENT][NEUTRAL] Processed and denied on [PII].
[CUSTOMER][NEUTRAL] the
[AGENT][NEUTRAL] The claim number is going to be 358-534-6.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Oh
[AGENT][NEUTRAL] And the reason for the denial states the maximum amount payable for this occurrence has been met.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][POSITIVE] Thank.
[CUSTOMER][NEUTRAL] I.
[AGENT][NEUTRAL] Per-occurrence means treatment for the same or related condition unless separated by a period of 90 days. Treatment for the same or related conditions separated by 90 days, or an unrelated condition will be considered a new occurrence.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] I.
[CUSTOMER][NEUTRAL] So the maximum dollar amount made for this account, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEUTRAL] Can I have a loan amount for this account?
[AGENT][NEUTRAL] The maximum amount per occurrence on this policy is $1000 for covered outpatient services.
[CUSTOMER][NEUTRAL] $1000 right? And may I know when it was met?
[AGENT][NEUTRAL] Uh per current.
[AGENT][NEUTRAL] The same data service for with a claim that was received prior to yours.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Mhm.
[CUSTOMER][NEUTRAL] Oh.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] What
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Can I have a mailing address?
[AGENT][NEUTRAL] And is there any other information, Chan you need on this? I'm sorry, what was your question?
[CUSTOMER][NEUTRAL] Can I have the mailing address?
[AGENT][NEUTRAL] It's the same as the claims address.
[CUSTOMER][NEUTRAL] Please.
[AGENT][NEUTRAL] Attention appeals department.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And an appeal must be filed within 180.
[CUSTOMER][NEUTRAL] Can I have the timely quality limit for mobile?
[AGENT][NEUTRAL] Uh-huh. 180 days from the date of the decision.
[CUSTOMER][NEUTRAL] Bass from the date of the denial, right?
[AGENT][POSITIVE] Correct.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Can we go to the next claim when you're ready.
[AGENT][NEUTRAL] One moment.
[CUSTOMER][NEUTRAL] I
[AGENT][NEUTRAL] OK, and the next member's policy number, please?
[CUSTOMER][NEUTRAL] Just give me one quick moment.
[AGENT][NEUTRAL] Uh-huh. Sure.
[CUSTOMER][NEUTRAL] The system is loading.
[AGENT][NEUTRAL] That's fine.
[CUSTOMER][NEUTRAL] The next policy number is?
[CUSTOMER][NEUTRAL] 025
[CUSTOMER][NEUTRAL] 44,110.
[AGENT][NEUTRAL] OK thank you one moment.
[CUSTOMER][NEUTRAL] Yeah.
[AGENT][NEUTRAL] OK, and your patient's name and date of birth?
[CUSTOMER][NEUTRAL] Patient name is [PII] and date of birth [PII].
[AGENT][POSITIVE] Thank you.
[AGENT][NEUTRAL] And the date of service and total build amount please.
[CUSTOMER][NEUTRAL] Data services.
[CUSTOMER][NEUTRAL] [PII].
[CUSTOMER][NEUTRAL] For the amount of $277 even.
[AGENT][POSITIVE] OK, thank you.
[CUSTOMER][NEUTRAL] People.
[AGENT][NEUTRAL] OK, so this claim was also received one moment and I'll provide that information to you.
[CUSTOMER][NEUTRAL] Um.
[CUSTOMER][NEUTRAL] Sure.
[CUSTOMER][NEUTRAL] Oh.
[AGENT][NEUTRAL] OK, this claim was received [PII].
[CUSTOMER][NEUTRAL] And
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] And.
[AGENT][NEUTRAL] Processed and denied on [PII].
[CUSTOMER][NEUTRAL] But
[CUSTOMER][NEUTRAL] You.
[AGENT][NEUTRAL] Claim number is 3,583,430.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] OK.
[AGENT][NEUTRAL] And the reason for the denial states benefit payable under this certificate, excuse me, benefits payable under this certificate are limited to those outlined on the schedule of benefits. This is not a covered loss under the plan. Therefore, no amount is payable this expense.
[CUSTOMER][NEUTRAL] A.
[CUSTOMER][NEUTRAL] And.
[CUSTOMER][NEUTRAL] So the claim for not covered as for the patient's plan, right?
[AGENT][POSITIVE] Correct, yes sir.
[CUSTOMER][NEUTRAL] Yeah
[CUSTOMER][NEUTRAL] Could you repeat me why it's not covered?
[AGENT][NEUTRAL] Benefits payable under this certificate are limited to those outlined on the schedule of benefits. This is not a covered loss under the plan. Therefore, no amount is payable for this expense.
[CUSTOMER][NEUTRAL] OK
[CUSTOMER][NEUTRAL] No
[CUSTOMER][NEGATIVE] This is not good under this law, right?
[AGENT][NEGATIVE] Under the under the member's plan, this is not covered.
[CUSTOMER][POSITIVE] Thank you.
[CUSTOMER][NEUTRAL] OK.
[CUSTOMER][NEUTRAL] Mhm
[CUSTOMER][NEUTRAL] I'm repeating the reason the benefits for the services is not covered under the nation, but I'm, I'm asking why it's not covered, uh.
[AGENT][NEUTRAL] The member's plan.
[AGENT][NEGATIVE] It's not covered. I mean, that is the reason. It's not covered under the plan. This is not a covered loss under this plan.
[CUSTOMER][NEUTRAL] Yes.
[CUSTOMER][NEUTRAL] I can.
[AGENT][NEGATIVE] Therefore, there is no payable amount for this expense.
[CUSTOMER][NEUTRAL] Yeah.
[CUSTOMER][NEUTRAL] Got it. Can I have a patient plan type?
[CUSTOMER][NEUTRAL] We go.
[AGENT][NEUTRAL] This is a supplemental Medlink, M E D L I N K. It's a supplemental policy. Office visits are not covered under this policy.
[CUSTOMER][NEUTRAL] You.
[CUSTOMER][NEUTRAL] 758.
[CUSTOMER][NEUTRAL] 50 got it.
[CUSTOMER][NEUTRAL] I
[CUSTOMER][NEUTRAL] Any other discount?
[AGENT][NEUTRAL] Mhm
[AGENT][NEUTRAL] Uh-huh. The same as the other one, my name and today's date. And if you need a copy of the EOB, you can also print that from the portal that I gave you.
[CUSTOMER][POSITIVE] Mm. Got it. Thank you. Thank you so much for patiently assisting me. Have a great rest of your day. Stay there. Take care.
[AGENT][POSITIVE] Are you, you're welcome, [PII]. I hope you have, yes, you too. Is there anything else I can help you with today?
[CUSTOMER][NEUTRAL] No, that's not.
[AGENT][POSITIVE] OK, well then thank you very much for calling APL. Have a great rest of your day.
[CUSTOMER][NEUTRAL] Bye-bye.
[CUSTOMER][NEUTRAL] March.
[CUSTOMER][NEUTRAL] You too bye bye.